HESI 1

A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? 0800, 1200, 1600, 2000. 0800. Every other day at 0800. 0800, 1200, 1600, 2000, 0000, 0400.

0800, 1200, 1600, 2000.

When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? Confirm the finding by further assessing the client for jugular vein distention. Offer the client high protein snacks between regularly scheduled mealtimes. Continue the planned nursing interventions to restore the client's fluid volume. Change the plan of care to include a nursing diagnosis of impaired skin integrity

Continue the planned nursing interventions to restore the client's fluid volume.

An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? The nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. The nurse assigned to care for the client who was at lunch at the time of the fall. The nurse who transferred the client to the chair when the fall occurred. The charge nurse who completed rounds 30 minutes before the fall occurred.

The nurse who transferred the client to the chair when the fall occurred.

A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? Continue gabapentin. Discontinue ibuprofen. Add aspirin to the protocol. Add oral methadone to the protoco

Continue gabapentin.

A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? Give an around-the-clock schedule for administration of analgesics. Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities.

Give an around-the-clock schedule for administration of analgesics.

A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? The responses to biofeedback have not been well established and may be a waste of time and money. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. Although biofeedback is easily learned, it is most often used to manage exacerbation of symptoms. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation.

Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? Removing the empty food tray from a client with a urinary catheter. Washing and combing the hair of a client with a fractured leg in traction. Administering oral medications to a cooperative client with a wound infection. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, which action should the nurse take next? Clamp the tube for 20 minutes. Flush the tube with water. Administer the medications as prescribed. Crush the tablets and dissolve in sterile water.

Flush the tube with water.

A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? Amount of liquid protein supplements consumed daily. Foods and liquids consumed during the past 24 hours. Usual weekly intake of milk products and red meats. Grains and legume combinations used by the client.

Foods and liquids consumed during the past 24 hours.

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? Thalamus. Hypothalamus. Frontal lobe. Parietal lobe.

Frontal lobe

A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? Generativity. Ego integrity. Identification. Valuing wisdom.

Generativity.

An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? Massage any reddened areas for at least five minutes. Encourage active range of motion exercises on extremities. Position the client laterally, prone, and dorsally in sequence. Gently lift the client when moving into a desired position.

Gently lift the client when moving into a desired position.

While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement?v Advise the client to continue to bear down without holding his breath. Gently insert the lubricated suppository four inches into the rectum. Perform a digital exam to determine if a fecal impaction is present. Instruct the client to take slow deep breaths and stop bearing down.

Instruct the client to take slow deep breaths and stop bearing down

Which action is most important for the nurse to implement when donning sterile gloves? Maintain thumb at a ninety degree angle. Hold hands with fingers down while gloving. Keep gloved hands above the elbows. Put the glove on the dominant hand first.

Keep gloved hands above the elbows

When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the client's ability to perform which action? Locate the perineum. Transfer to a commode. Attach the catheter to a drainage bag. Manipulate a syringe to inflate the balloon.

Locate the perineum.

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? Loosen the right wrist restraint. Apply a pulse oximeter to the right hand. Compare hand color bilaterally. Palpate the right radial pulse.

Loosen the right wrist restraint.

In providing care for a terminally ill resident of a long-term care facility, the nurse determines that the resident is exhibiting signs of impending death and has a "do not resuscitate" or DNR status. What intervention should the nurse implement first? Request hospice care for the client. Report the client's acuity level to the nursing supervisor. Notify family members of the client's condition. Inform the chaplain that the client's death is imminent.

Notify family members of the client's condition.

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client's silence? "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." "It is OK if you don't want to talk about your surgery. I will be available when you are ready." "I will ask a woman who has had a mastectomy to come by and share her experiences with you."

"It is OK if you don't want to talk about your surgery. I will be available when you are ready."

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? "That means you have derived the maximum benefit, and the heat can be removed." "Your blood vessels are becoming dilated and removing the heat from the site." "We will increase the temperature 5 degrees when the pad no longer feels warm." "The body's receptors adapt over time as they are exposed to heat."

"The body's receptors adapt over time as they are exposed to heat."

What client statement indicates to the nurse that the client requires assistance with bathing? "I wasn't able to pack a bag before I left for the hospital." "I don't understand why I'm so weak and tired." "I only bathe every other day." "I left my eyeglasses at home."

"I don't understand why I'm so weak and tired."

A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? Encourage the client to take several slow, deep breaths while ambulating. Help the client to remain standing by the bedside until the dizziness is relieved. Instruct the client to remain on bedrest until the healthcare provider is contacted. Advise the client to sit on the side of the bed for a few minutes before standing again.

Advise the client to sit on the side of the bed for a few minutes before standing again.

What is the rationale for using the nursing process in planning care for clients? As a scientific process to identify nursing diagnoses of a clients' healthcare problems. To establish nursing theory that incorporates the biopsychosocial nature of humans. As a tool to organize thinking and clinical decision making about clients' healthcare needs. To promote the management of client care in collaboration with other healthcare professionals.

As a tool to organize thinking and clinical decision making about clients' healthcare needs.

A client is demonstrating a positive Chvostek's sign. What action should the nurse take? Observe the client's pupil size and response to light. Ask the client about numbness or tingling in the hands. Assess the client's serum potassium level. Restrict dietary intake of calcium-rich foods

Ask the client about numbness or tingling in the hands.

A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? Document the client's request in the medical record. Ask the client if this decision has been discussed with his healthcare provider. Inform the client that a written, notarized advance directive, is required to withhold resuscitation efforts. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.

Ask the client if this decision has been discussed with his healthcare provider.

The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? Portable syringe pump. Cassette infusion pump. Volumetric controller. Nonvolumetric controller.

Cassette infusion pump.

What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? Check capillary refill of toes on lower extremity with Unna's paste boot. Apply dressing to wound area before applying the Unna's paste boot. Wrap the leg from the knee down towards the foot. Remove the Unna's paste boot q8h to assess wound healing.

Check capillary refill of toes on lower extremity with Unna's paste boot.

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? Client. Healthcare provider. A family member. Previous medical records.

Client.

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? Restatement of responses. Open-ended questions. Closed-ended questions. Problem-seeking responses.

Closed-ended questions, b/c they focus directly

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? Determine the etiology of the problem. Prioritize nursing care interventions. Plan appropriate interventions. Collaborate with the client to set goals.

Determine the etiology (cause) of the problem.

An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? Apply flannel pajamas to provide warmth. Administer a PRN dose of ibuprofen. Perform range of motion exercises in a warm tub. Drape the sheets over the footboard of the bed.

Drape the sheets over the footboard of the bed.

The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the elderly is accurate? Bewilderment is to be expected, and progresses with age. Disorientation often follows relocation to new surroundings. Uncertainty is a result of irreversible brain pathology. Being perplexed can be prevented with adequate sleep.

Disorientation often follows relocation to new surroundings.

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? Notify the charge nurse that a medication error occurred. Submit a medication variance report to the supervisor. Document the events that occurred in the nurses' notes. Discard the original medication administration record.

Document the events that occurred in the nurses' notes.

In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? Elevate the head of the bed and attempt to palpate the site again. Document the presence and volume of the pulse palpated. Use a thigh cuff to measure the blood pressure in the leg. Record the presence of pitting edema in the inguinal area.

Document the presence and volume of the pulse palpated

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? Empty the client's urinary drainage bag. Draw up the irrigating solution into the syringe. Secure the client's catheter to the drainage tubing. Use aseptic technique to instill the irrigating solution.

Draw up the irrigating solution into the syringe.

After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? Notify the surgeon that the consent form has not been signed. Read the consent form to the client before witnessing the client's signature. Determine if the client's spouse is willing to sign the consent form. Administer an opioid antagonist prior to obtaining the client's signature.

Notify the surgeon that the consent form has not been signed.

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? Observe the appearance of the skin under the ice pack. Instruct the client regarding the need for the covering. Reapply the covering after filling with fresh ice. Ask the client how long the ice was applied to the skin

Observe the appearance of the skin under the ice pack.

Which nursing intervention is most beneficial in reducing the risk of urosepsis in a hospitalized client with an indwelling urinary catheter? Ensure that the client's perineal area is cleansed twice a day. Maintain accurate documentation of the fluid intake and output. Encourage frequent ambulation if allowed or regular turning if on bedrest. Obtain a prescription for removal of the catheter as soon as possible

Obtain a prescription for removal of the catheter as soon as possible

The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? Stage 1 pressure sore draining sero-sanguineous drainage. Pressure sore at bony prominence with exudate noted. One-inch pressure sore draining serous fluid. Pressure sore on heel with a small amount of purulent drainage

One-inch pressure sore draining serous fluid.

The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? Tossed salad, low-sodium dressing, bacon and tomato sandwich. New England clam chowder, no-salt crackers, fresh fruit salad. Skim milk, turkey salad, roll, vanilla ice cream. Macaroni and cheese, diet Coke, a slice of cherry pie.

Skim milk, turkey salad, roll, vanilla ice cream.

The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first? Determine when the IV solution was started. Slow the IV infusion to keep vein open rate. Assess the IV insertion site for swelling. Report the finding to the healthcare provide

Slow the IV infusion to keep vein open rate.

The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first? Determine when the IV solution was started. Slow the IV infusion to keep vein open rate. Assess the IV insertion site for swelling. Report the finding to the healthcare provider

Slow the IV infusion to keep vein open rate.

Which statement best describes durable power of attorney for health care? The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so. The healthcare decisions made by another person designated by the client are not legally binding. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding.

The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so.

The home health nurse visits an elderly female client who had a stroke three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. The client tells the nurse that she does not have much of an appetite today. The nurse notes that there are numerous scatter rugs throughout the house. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

The nurse notes that there are numerous scatter rugs throughout the house.

Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? The nurse will provide client instruction for daily foot care. The client will demonstrate proper trimming toenail technique. Upon discharge, the client will list three ways to protect the feet from injury. After instruction, the nurse will ensure the client understands foot care rationale.

Upon discharge, the client will list three ways to protect the feet from injury.

A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? Use distraction techniques during times of spiritual stress and crisis. Reassure the client that his faith will be regained with time and support. Consult with the staff chaplain and ask that the chaplain visit with the client. Use reflective listening techniques when the client expresses spiritual doubts.

Use reflective listening techniques when the client expresses spiritual doubts.

The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? Fiber. Folate. Ascorbic acid. Vitamin B12

Vitamin B12

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? Hydrogel. Exudate absorber. Wet to moist dressing. Transparent adhesive film.

Wet to moist dressing.

Which technique is most important for the nurse to implement when performing a physical assessment? A head-to-toe approach. The medical systems model. A consistent, systematic approach. An approach related to a nursing model.

A consistent, systematic approach.

A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? Accused of diversion. Reported for stealing. Reported for a HIPAA violation. Accused of unprofessional conduct.

Accused of diversion.

A client's spouse is learning passive range-of-motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement? Acknowledge that the spouse is supporting the arm correctly. Encourage the spouse to keep the joint covered to maintain warmth. Reinforce the need to grip directly under the joint for better support. Instruct the spouse to grip directly over the joint for better motion.

Acknowledge that the spouse is supporting the arm correctly.

The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? Withdraw the tube and apply additional lubricant to the tube. Encourage the client to bear down and continue to insert the tube. Remove the tube and check the client for a fecal impaction. Ask the client to relax and run a small amount of fluid into the rectum.

Ask the client to relax and run a small amount of fluid into the rectum.

What action by the nurse demonstrates culturally sensitive care? Asks permission before touching a client. Avoids questions about male-female relationships. Explains the differences between Western medical care and cultural folk remedies. Applies knowledge of a cultural group unless a client embraces Western customs.

Asks permission before touching a client.

A signed consent form indicated a client should have an electromyogram, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent what infraction? A quasi-intentional tort because a similar mistake can happen to anyone. Failure to respect client autonomy to choose based on intentional tort law. Assault and battery with deliberate intent to deviate from the consent form. An unintentional tort because the client benefited from having the myelogram.

Assault and battery with deliberate intent to deviate from the consent form.

A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? Help the client to accept the final stage of life. Assist and support the client in establishing short-term goals. Encourage the client to make future plans, even if they are unrealistic. Instruct the client's family to focus on positive aspects of the client's life

Assist and support the client in establishing short-term goals.

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings? Complains of inability to empty bladder. Temperature of 99.8 ??F and pulse of 108. Post-voided residual volume of 750 ml. Specimen collection for culture and sensitivity.

Complains of inability to empty bladder.

The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? Talk directly to the child instead of the mother. Continue asking the mother questions about the child. Ask another nurse to interview the mother now. Tell the mother politely to look at you when answering.

Continue asking the mother questions about the child.

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? Does not check capillary blood glucose as directed. Occasionally forgets to take daily prescribed medication. Cannot identify signs or symptoms of high and low blood glucose. Eats anything and does not think diet makes a difference in health.

Eats anything and does not think diet makes a difference in health.

A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? Review the client's medical record for an advance directive. Determine if a do-not-resuscitate prescription has been obtained. Document that the client is being discharged against medical advice. Evaluate the client's mental status for competence to refuse treatment.

Evaluate the client's mental status for competence to refuse treatment.

What activity should the nurse use in the evaluation phase of the nursing process? Ask a client to evaluate the nursing care provided. Document the nursing care plan in the progress notes. Determine whether a client's health problems have been alleviated. Examine the effectiveness of nursing interventions toward meeting client outcomes.

Examine the effectiveness of nursing interventions toward meeting client outcomes.

A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical." What response should the nurse provide first? Ask the nursing supervisor to meet with the students. Notify the student's clinical instructor of the situation. Ask the student if permission was obtained from the client. Explain that the records are hospital property and may not be removed.

Explain that the records are hospital property and may not be removed.

The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? Disturbed sleep pattern. Caregiver role strain. Impaired skin integrity. Fluid volume imbalance.

Fluid volume imbalance.

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? Flush the lumen with the saline solution and administer the medication through the lumen. Determine if a PRN prescription for a thrombolytic agent is listed on the medication record. Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the tubing. Withdraw the aspirated blood into the syringe and use a new syringe to administer the medication.

Flush the lumen with the saline solution and administer the

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? At the beginning, middle, and end of the shift. After client priorities are identified for the development of the nursing care plan. At the end of the shift so full attention can be given to the client's needs. Immediately after the assessments are completed.

Immediately after the assessments are completed.

When caring for an immobile client, what nursing diagnosis has the highest priority? Risk for fluid volume deficit. Impaired gas exchange. Risk for impaired skin integrity. Altered tissue perfusion.

Impaired gas exchange.

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? Bradycardia. Increase in pulse rate. Peripheral vasodilation. Increase in cardiac output.

Increase in pulse rate.

An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? Use a mechanical lift to transfer from the bed to a chair. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.

How should the nurse handle linens that are soiled with incontinent feces? Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. Place an isolation hamper in the client's room and discard the linens in it. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room.

Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.

What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? Maintain in a lateral position using protective wrist and vest devices. Position prone with a small pillow below the diaphragm. Raise the head and knee gatch when lying in a supine position. Transfer into a wheelchair close to the nurse's station for observation.

Position prone with a small pillow below the diaphragm.

On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? Remind the client to turn every two hours while lying in bed. Provide warm prune juice before the client goes to bed at night. Teach the client to splint the incision while walking to the bathroom. Administer an analgesic before the client attempts to defecate.

Provide warm prune juice before the client goes to bed at night

What action is most important for the nurse to implement when placing a client in the Sim's position? Raise the bed to a waist-high working level. Elevate the head of the bed 45 degrees. Place a pillow behind the client's back. Bring the client to one edge of the bed.

Raise the bed to a waist-high working level.

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? Encourage the client to cough to help loosen secretions. Advise the client to increase the intake of oral fluids. Rotate the suction catheter to obtain any remaining secretions. The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? Encourage the client to cough to help loosen secretions. Advise the client to increase the intake of oral fluids. Rotate the suction catheter to obtain any remaining secretions. Re-oxygenate the client before attempting to suction again.

Re-oxygenate the client before attempting to suction again.

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? Review the steps in the procedure manual. Ask another nurse to assist while implementing the procedure. Follow the agency's policy and procedure. Refuse to perform the task that is beyond the nurse's experience.

Refuse to perform the task that is beyond the nurse's experience.

The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? Remain calm with the client and record abnormal results in the chart. Notify the medication nurse immediately if the pulse or blood pressure is low. Report the results of the vital signs to the nurse. Reassure the client that the vital signs are normal.

Report the results of the vital signs to the nurse

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? Position the client on the right side of the bed in reverse Trendelenburg. Fill the enema container with 1000 mL of warm water and 5 mL of castile soap. Reposition in a Sims' position with the client's weight on the anterior ilium. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Reposition in a Sims' position with the client's weight on the anterior ilium.

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? Check for a blood return. Reposition the client's arm. Remove the IV site dressing. Flush the lock with saline.

Reposition the client's arm.

A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? Sensory pattern, area, intensity, and nature of the pain. Trigger points identified by palpation and manual pressure of painful areas. Schedule and total dosages of drugs currently used for breakthrough pain. Sympathetic responses consistent with onset of acute pain.

Sensory pattern, area, intensity, and nature of the pain.

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? Transferrin. Prealbumin. Serum albumin. Urine urea nitrogen.

Serum albumin.

A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? Take measures to promote as much comfort as possible. Report any signs of drug addiction to the nurse immediately. Wait until the client's pain is gone before assisting with personal care. This client's pain will be difficult to manage, since the cause is unknown.

Take measures to promote as much comfort as possible.

A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client? Obtain an interpreter to explain the procedure to the client. Encourage the client to make her own decision regarding surgery. Ask the family members to provide a clarification of the surgeon's explanation to the client. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow (culturally senitive

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? The drainage tubing is secured over the siderail. The clamp on the urinary drainage bag is open. There are no dependent loops in the drainage tubing. The urinary drainage bag is attached to the bed frame.

The clamp on the urinary drainage bag is open.

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? Can you describe where your pain is the most severe? What is your pain intensity on a scale of 1 to 10? Is your pain best described as aching, throbbing, or sharp? Which activities during a routine day are impacted by your pain?

Which activities during a routine day are impacted by your pain?