Exit Hesi 700-799

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms?

Destruction of joint cartilage.

A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement?

• Assist the client's to a bedside commode every two hours

While taking vital signs, a critically ill male client grabs the nurse's hand and ask the nurse not to leave. What action is best for the nurse to take?

• Pull up a chair and sit beside the client's bed

A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention?

•Maintain contact transmission precautions

An adult client comes to the clinic and reports his concern over a lump that "just poppedup on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. This suggests what?

•Malignancy

When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top last action on bottom.)

1. Rub hands palm to palm. 2. Interlace the fingers, 3. Dry hands with paper towel. 4. Turn off the water faucet.

When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate?

Neurologically stable without indications of an increased ICP

732. Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.)

Place stethoscope in suprasternal area to auscultate from bronchial sounds lOMoARcPSD|12755628 Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds Document normal breath sounds and location of adventitious breath sounds

During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices should the nurse encourage? (Select all apply)

Plain, air-popped popcorn. Natural whole almonds.

During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement?

Stop the transfusion start a saline

A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement?

• Administer PRN dose of albuterol

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/d (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications?

• Hydrocortisone

After an elderly female client receives treatment for drug toxicity, the HCP prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3mg/dl. What action should the nurse implement?

• Notify the HCP of the results.

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement?

• Obtain a clean catch mid-stream specimen

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). Request a referral for speech therapy if there is which finding?

• Persistent coughing while drinking

The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?

• Viral meningitis whose temperature changed from 101 F to 102 F.

The nurse is assessing a female client's BP b/c she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated, a knockoff sound is heard. Best intervention?

• Wait 1 minute and palpate the systolic pressure before auscultating again.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

• Watery diarrhea

In early septic shock states, what is the primary cause of hypotension?

•. Peripheral vasodilation

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

• Ask the client about gastrointestinal pain

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning?

• Cold sensitivity

The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

• Fetal heart rate of 200 beats/minute

The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention implement?

•Talk directly to the adolescent while providing care

The mother of a child recently diagnosed w/ asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions are provided? SATA

Close car windows and use air conditioner Avoid sudden changes in temperature Keep away from pets with long hair Stay indoors when grass is being cut

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?

Document the ongoing wound healing.

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

Ineffective coping related to denial

The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? (Arrange from first on top to last on the bottom)

Verify the drug and dose with the label on the vial Inject the volume of air to be aspirated from each vial Aspirate the desired volume from vial A Aspirate the desired volume from vial B

An elderly male client is admitted to the urology unit with acute renal failure due to a post renal obstruction. Which questions best assists the nurse in obtaining relevant historical data?

• "Have you had any difficulty in starting your urinary stream"

An adolescent, whose mother recently died, comes to the school nurse complain headache. Which statement made by the students should warrant further explanation nurse?

• "I miss Mon and would like to go see her'".

The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed?

• "On left thigh with arrow pointing to inner thigh"

An IV antibiotic is prescribed for a client with a postoperative 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 caring for 4 clients on the rehabilitation unit, which client should the nurse assess first?

• A client who is receiving a continuous tube feeding and is now vomiting.

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply).

• A full pitcher of water is on the bedside table • The client is lying in a supine position in bed

A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours?

• Agitation and threats to harms staff

The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?

• An 11-year-old with a headache, nausea, and projectile vomiting

An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse?

• Antacids will neutralize the acid in your stomach

The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, "She says it is OK." What action should the nurse take next?

• Ask for a full explanation from the interpreter of the witnessed discussion

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?

• Asses for contraindications for thrombolytic therapy

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%. What action should the nurse take first?

• Begin manual ventilation immediately.

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?

• Bone marrow transplantation

A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?

• Chest pain and dysrhythmia

An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important to implement?

• Clarify end of life desires

A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make?

• Contact the healthcare provider immediately to report the laboratory value regardless of the advice

During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide?

• Dialysis would need to be resumed if chronic rejection becomes a reality

While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement?

• Discontinue the painful IV after a new IV is inserted

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?

• Document the extend of the bruising in the medical record

During a staff meeting, a nurse verbally attacks nurse manager stating, "you always let your favorites have holidays off. You are unfair and prejudiced" how should the nurse- manager respond Give me specific examples to support your statements.

• Does anyone else on the staff fell the same way

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care?

• Evaluate daily blood clotting factors.

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first?

• Evaluate the oxygen saturation

A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention is implemented first?

• Explore the client's reasons for wanting to be discharged.

A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first?

• Furosemide

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all apply)

• Headache and tremors • Postural hypotension Pallor and diaphoresis • Irregular heart beat

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 lOMoARcPSD|12755628 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?

• Inform her that some antianxiety medications are safe to take while breastfeeding

An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first?

• Insertion of a left- sided chest tube.

A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results?

• Institute coughing and deep breathing protocols

A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse?

• Leakage around catheter insertion site

A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture?

• Lower the left arm below the level of the heart

While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

• Place a portable toilet next to the bed

The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first?

• Place the side rails in an up position

An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity best establish rapport and accomplish goal?

• Play a board game with the client and begin taking about stressors

733. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation?

• Recommend weigh bearing physical activity

To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement?

• Review the staff nurse job description to ensure that it is clear, accurate, and current

A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

• Sitting up and leaning forward

A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement?

• Suggest the use of alternative sources of protein such as dairy products and nuts

A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan?

• Take on an empty stomach with a full glass of water

A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• Total calcium 5.0 mg/dl

Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% nonrebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately?

• Upper airway stridor

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?

•. Leave the room and close the door quietly

The nurse suspect may be hemorrhaging internally. Which findings of an orthostatic test may indicate to the nurse of major bleed?

•A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20.

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply.)

•Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). •Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty •Perform daily surgical dressing change for a client who had an abdominal hysterectomy

A client with a traumatic brain injury becomes progressively less responsive tostimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously schedules. What action should the nurse take?

•Advise the UAP to resume positioning the client on schedule

Which client should the charge nurse on the oncology unit assign to an RN, rather than a PN?

•An elderly female client with cancer whose children who are trying to decide whether to change to palliative care measures or continue disease control

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

The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?

•Appearance of wound

A preoperative client states he is not allergic to any medications. Most important implement next?

•Assess client's knowledge of an allergy response

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? SATA

•Avoid exposure to large crowds •Do not take any over-the-counter medications

A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

•Blood pressure 90/76 mm Hg

The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the rescriptions. What actions should the charge nurse take? SATA

•Call the HCP wrote the prescription •Report the situation to the house supervisor

A client's subjective data includes dysuria, urgency, and urinary frequency. Best implemention next?

•Collect a clean-catch specimen

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply)

•Ease the client to the floor lOMoARcPSD|12755628 •Loosen restrictive clothing •Note the duration of the seizure

A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention be implemented?

•Elevate the head of the bed 60 to 90 degrees

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

•Elevated blood pressure must be anticipated and identified quickly

734. The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take?

•Explain that memory loss and confusion are common with vitamin B12 deficiency

During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy? SATA

•Family history of adult onset diabetes. • Three year history of taking oral contraceptives

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause, what information is most important to obtain?

•Frequency of laxative use for chronic constipation

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply).

•Fresh turkey slices and berries • Chicken bouillon soup and toast

A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, and after another minute of compression, the client's rhythm converts to SVT on the monitor, at this point, what is priority intervention for the nurse?

•Give IV dose of adenosine rapidly over 1-2 seconds.

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention implement first?

•Initiate a prescribed IV for parental fluid

The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take?

•Instruct the nurse to use a transparent dressing over the site

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care?

•Monitor for secondary infections.

A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement?

•Notify the healthcare provider

Following an open reduction of the tibia, nurse notes bleeding on the client's cast. Best implementation?

•Outline the area with ink and check it every 15 minutes to see if the area has increased

The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system?

•Plastic tubing located at the chest insertion site

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming, what action should the nurse take?

•Review the client's serum calcium level

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse?

•Serum creatinine of 4.5 mg/dl (398 mcmol/L SI)

To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply).

•Space activities to allow for rest periods •Take warm baths before starting exercise

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?

•Tented skin turgor

An alert older client with diabetes mellitus type 1 is admitted with a serum glucose of 420 mg/dl (23.31 mmol/L (SI)). As the nurse administers 10 units of regular insulin intravenous(IV), the client immediately begins to vomit. What action should the nurse implement first?

•Turn the client to a lateral position

A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity?

•Vomiting