HESI 700 499 to 814 to print

A client is receiving an IV solution of nitroglycerin 100mg/500ml D5W at 10 mcg/ minute. The nurse should program the infusion pump to deliver how many ml/hour? ( Enter numeric value only)

3 ml/hour Rationale : 0.01 x 500 x 60 / 100 = 3

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother... During the assessment, the mother asks the nurse why her child is at the 5th percent...response is best for the nurse to provide?

"His smaller size is probably due to the heart disease"

While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond?

"We need to stay focused on the topic."

An adolescent receives a prescription for an injection of s-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.

0.33 mL Rationale: 4mg x 0.5 ml=2/6=0.33 ml

A client admitted to the telemetry unit is having unrelieved chest pain after receiving 3 sublingual nitroglycerin tablets and morphine 8 mg IV. The electrocardiogram reveals sinus bradycardia with ST elevation. In what order should the nurse implement the nursing actions? (Arrange first to last

1. Call the rapid response team to assist 2. Move the crash cart to the client room 3. Notify the client's healthcare provider 4. Inform the family of the critical situation

After receiving lactulose, a client with hepatic encephalopathy has several loose stools. What action should the nurse implement?

Monitor mental status.

The nurse is collecting a sterile urine specimen using a straight catheter tray for culture.... (Arrange from first action to last).

1. Drape the client in a recumbent position for privacy 2. Open the urinary catheterization tray 3. Don sterile gloves using aseptic technique 4. Use forceps and swaps to clean the urinary meatus

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

1. Place stethoscope in suprasternal area to auscultate from bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds

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.

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 HCP prescribes methotrexate 7.5 mg PO weekly, in 3 divides doses for a child with rheumatoid arthritis whose body surface area (BSA) is 0.6 m2. The therapeutic dosage of methotrexate PO is 5 to 15 mg/m2/week. How many mg should the nurse administer in each of the three doses given weekly? (Enter the numeric value only. If round is required, round to the nearest tenth.)

1.5

A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only)

18 Rationale: 450000/25000=18

The nurse notes the client receiving heparin infusion labeled, Heparin Na 25,000 Units in 5% Dextrose injection 500 ml at 50ml/hr. What dose of Heparin is the client receiving per hour?

2500

The nurse mixes 250 mg of debutamine in 250 ml of D5W and plans to administer the solution at rate client weighing 110 pounds. The nurse should set the infusion pump to administer how many ml per hour only. If rounding is required, round the nearest whole number.)

45

Dopamine protocol is prescribed for a male client who weigh 198 pounds to maintain the mean arterial pressure (MAP) greater than 65 mmHg. His current MAP is 50 mmHg, so the nurse increases the infusion to 7 mcg/kg/minute. The infusion is labeled dextrose 5% in water (D5W) 500 ml with dopamine 400 mg. The nurse should program the infusion pump to deliver how many ml/hour?

47

A client is receiving an IV of heparin sodium 25000 units in 5% dextrose injection 500 ml at 14 ml/hour...verify that the client is receiving the prescribed amount of heparin. How many units is the client receiving

700 Rationale: 25000/500x14=700

A female client reports that she drank a liter of a solution to cleanse her intestines... immediately. How many ml of fluid intake should the nurse document? Whole number

760 Rationale: 1L=1000ml Subtract the emesis, 1 cup (8 oz)=240ml 1000-240=760 ml

The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?

A client with congestive heart failure who reports a 3 pound weight gain in the last two days

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.

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

When organizing home visits for the day, which older client should the home health nurse plan to visit first?

A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools

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.)

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

A client with multiple sclerosis is receiving beta-1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply)

A. Platelet count B. Red blood cell count (RBC) C. White blood cell count (WBC).

The nurse is assessing the thorax and lungs of a client who is having respiratory difficulty. Which finding is most indicative of respiratory distress?

Contractions of the sternocleidomastoid muscle

A female client comes to the clinic complaining of fatigue and inability to sleep because she is the full-time caretaker for 22-year-old son who was paralyzed by a motor vehicle collision. She adds that her husband left her because he says he can't take her behavior any more since all she does is care for their son. What intervention should the nurse implement?

Acknowledge the client's stress and suggest that she consider respite care.

What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?

Achieve satisfactory pain control.

To reduce the risk of being named in malpractice lawsuit, which action is most important for the nurse to take?

Adhere consistently to standards of care.

After checking the fingerstick glucose at 1630, what action should the nurse implement

Administer 8 units of insulin aspart SubQ

A primigravida client is 36 weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks:

Administer Oxygen via face mask

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 toddler presents to the clinic with a barking cough, strider, refractions with respiration, the child's skin is pink with capillary refill of 2 seconds. Which intervention should the nurse implement?

Administered Nebulized Epinephrine

A client with a traumatic brain injury becomes progressively less responsive to stimuli. 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

The nurse provides feeding tube instructions to the wife of a client with end stage cancer. The client's wife performs a return demonstration correctly, but begins crying and tells the nurse, "I just don't think I can do this every day." The nurse should direct further teaching strategies toward which learning domain?

Affective

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

A male Korean-American client looks away when asked by the nurse to describe his problem. What is the best initial nursing action?

Allow several minutes for the client to respond

The nurse observes a newly hired unlicensed assistive personnel (UAP) performing a fingestick to obtain a client's blood glucose. Prior to sticking the client's finger, the UAP explains the procedure and tell the client that it I painless. What action should the nurse take

Allow the UAP to complete the procedure, then discuss the painless comment privately with the UAP.

A nurse is preparing to feed a 2-month-old male infant with heart failure who was born with congenital heart defect. Which intervention should the nurse implement

Allow the infant to rest before feeding

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

In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

An older client post-stroke who is aphasic with right-sided hemiplegi

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

Which class of drugs is the only source of a cure for septic shock?

Antiinfectives

The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy the client's serum blood potassium is elevated, which finding requires immediate action by the nurse?

Anuria for the last 12 hours.

A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effect he stopped taking the medication 6 year ago. Which finding warrants immediate intervention by the nurse?

Anxiety and restlessness.

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

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

The nurse requests a meals tray for a client follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply)

Apple juice Chicken broth

A multigravida, full-term, laboring client complains of "back labor". Vaginal examination reveals that the client's 3 cm with 50% effacement and the fetal head is at -1 station. What should the nurse implement?

Apply counter-pressure to the sacral area

The nurse is teaching a male client with multiple sclerosis how to empty his bladder using the Crede Method. When performing a return demonstration, the client applies pressure to the umbilical areas of his abdomen. What instruction should the nurse provide?

Apply downward manual pressure at the suprapubic regions.

A client present at the clinic with blepharitis. What instructions should the nurse provide for home care?

Apply warm moist compresses then gently scrub eyelids with dilute baby shampoo

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

An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive...medication therapy, the nurse notices the client has more energy, is giving her belongings...mood. Which intervention is best for the nurse to implement?

Ask the client if she has had any recent thoughts of harming herself

An older female client tells the nurse that her muscles have gradually been getting weak...what is the best initial response by the nurse?

Ask the client to describe the changes that have occurred

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

The healthcare provider prescribes oxycodone/ aspirin 1 tab PO every 4h as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question?

Aspirin content.

A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next?

Assess client's knowledge of an allergy response

Which nursing intervention has the highest priority for a multigravida who delivered

Assess fundal tone and lochia flow

A male client with rheumatoid arthritis is schedule for a procedure in the morning. The... unable to complete the procedure because of early morning stiffness. Which intervention... implement?

Assign a UAP to assist the client with a warm shower early in the morning

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?

Avoid exposure to large crowds

A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

Assist the client to sharply flex her thighs up again the abdomen.

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 removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, what action should the nurse implement?

Attempt to distract the client with general conversation

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

Auscultate bilateral breath sounds

Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider?

Avoid administration of oxygen at high levels for extended periods.

The nurse is teaching a client with atrial fibrillation about a newly prescribed medication, dronedarone. Which information should the nurse include in client interactions? (Select all that apply)

Avoid eating grapefruit or drinking grapefruit juice. Report changes in the use of daily supplements Notify you heal care provider if your skin looks yello

Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome?

Avoid exposure to respiratory infection

A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care?

Avoid foods that caused gas before the colostomy

The nurse assesses a female client with obstructive sleep apnea syndrome (OSAS) who is 5 feet tall (152 cm) and weighs 155 pounds (70 kg), the client's 24 hour diet history includes: no breakfast, cheeseburger and fries for lunch; lasagna, chocolate ice cream and a cola drink for dinner, and 2 glasses of wine in the evening before going to bed for a total caloric intake of 3500 calories. What instructions should the nurse provide? (Select all that apply)

Avoid use of alcohol as a sleep aide at bedtime Start a weight loss program

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 male client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client states he plans to take a multivitamin. What teaching should the nurse provide?

Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness

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 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 charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse?

Bronchodilators

A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?

Collect a clean-catch specimen

The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, what actions should the nurse take before inserting the catheter? (Select all that apply)

C. Gently palpate the client's bladder for distention D. Hold the catheter 3 - 4 inches (7.5 - 10 cm) from its tip E. Secure the urinary drainage bag to the bed frame

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 prescriptions. What actions should the charge nurse take?

Call the healthcare provider who wrote the prescription

Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)?

Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema

A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information?

Catheterize for residual urine after next voiding

When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first

Check for a distended bladder

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

After diagnosis and initial treatment of a 3 year old with Cystic fibrosis, the nurse provides home care instructions to the mother, which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?

Chest physiotherapy should be performed twice a day before a meal.

The nurse is administering a 750 ml cleansing enema to an adult client. After approximately150 ml of enema has informed, the client states, 'stop I can't hold anymore." What action should the nurse take

Clamp the tubing and instruct the client to breathe deeply before continuing.

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 for the nurse to implement?

Clarify end of life desires

The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply)

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

The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse?

Cloudy dialysate output and rebound abdominal 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

A 7-year-old boy is brought to the clinic because of facial edema. He reports that he has been voiding small amounts of dark, cloudy, tea-colored urine. The parents state that their son had a sore throat 2 weeks earlier, but it has resolved. After assessing the child's vital signs and weight, what intervention should the nurse implement next?

Collect a urine specimen for routine urinalysis

A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important time the infusion rate is increases?

Contraction pattern

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client?

Come to the clinic to be seen by a healthcare provider

The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

Complain of headaches and stiff neck

An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior?

Compulsion

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

A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy... Which action should the nurse instruct the parents to take if the child begins to vomit

Continue giving ORS frequently in small amounts

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 client is complaining of intermittent, left, lower abdominal pain that began two days ago...implement the following interventions?

Correct orders: (DPIA) 1. Determine when the client had last bowel movement 2. Position client supine with knees bent 3. Inspect abdominal contour 4. Auscultate all four abdominal quadrants

Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective?

Decrease abdominal girth

A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet?

Demonstrates willingness to adhere to the diet consistently

A newly hired home health care nurse is planning the initial visit to an adult client who has had multiple sclerosis (MS) for the past 20 years and is currently bed-bound and is lifted by a hoist. And unlicensed caregiver provides care 8 hours/ daily, 5 days/week. During the initial visit to this client, which intervention is most important to the nurse to implement?

Determine how the client is cared for when caregiver is not present

An adult male who lives alone is brought to the Emergency Department by his daughter who is unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and... Which nursing intervention has the highest priority?

Determine if the client has an executed living will

The nurse is caring for four clients...postoperative hemoglobin of 8.7 mg/dl; client C, newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention...

Determine the availability of two units of packed cells in the blood bank for client B

An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant tachypneic, and hypotonic. What is the first action that the nurse should take?

Determine the infant's blood sugar level

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

A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amount of liquid stool. Which action should the nurse implement?

Digitally check the client for a fecal impaction

The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?

Direct the UAP to measure the emesis while the nurse irrigates the NGT

The nurse is caring a client with NG tube. Which task can the nurse delegate to the UAP

Disconnect the NG suction so the client can ambulate in the hallway

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

The nurse assesses a 78-year-old male client who has left sides heart failure. Which symptoms would the nurse expect this client to exhibit?

Dyspnea, cough, and fatigue.

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity?

Distal pulse intensity

A woman just received the Rubella vaccine after a delivery of a normal new born, has two children at home, ages 13 months and 3 years. Which instruction is most important to provide to the client?

Do not get pregnant for at least 3 months

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 the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

Document the finding in the infant's record

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain?

Does your pain occur when walking short distances?

A client in her first trimester of pregnancy complains of nausea. Which complementary therapy should the nurse recommend?

Drink chamomile tea at breakfast and in the evening.

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 Loosen restrictive clothing Note the duration of the seizure

A male client with cancer, who is receiving antineoplastic drugs, is admitted to the... what findings is most often manifest this condition?

Ecchymosis and hematemesis

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 should the nurse implement?

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

An adult woman who is seen in the clinic with possible neuropathic pain of the right leg rates her pain as a 7 on a 10 point scale. What action should the nurse take

Encourage the client to describe the pain.

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?

Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elev ated blood pressure. Which intervention should the nurse implement first?

Ensure client takes a diuretic q AM

The nurse plans to use an electronic digital scale to weight a client who is able to stand. Which intervention should the nurse implement to ensure that measurement of the client's weight is accurate?

Ensure that the scale is calibrated before a weight is obtained

he nurse manager is conducting an in-services education program on the fire evacuation of the newborn recovery. What intervention should the nurse manager disseminate to the staff?

Evacuate each infant with mother via wheelchair

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 young adult male was admitted 36 hours ago for a head injury that occurred as the result of a motorcycle accident. In the last 4 hours, his urine output has increased to over 200 ml/H. Before reporting the finding to the healthcare provider, which intervention should the nurse implement?

Evaluate the urine osmolality and the serum osmolality values.

Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul...Which finding warrants immediate intervention by the nurse?

Evidence of hypoventilation

The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide?

Exercise at least three times weekly

A 2-year-old girl is brought to the clinic for a routine assessment and all findings are within the normal limits. However, the mom expresses concern over her daughter's protruding abdomen and tells the nurse that she is worry that her child is becoming overweight. How should the nurse respond to the mother's comment?

Explain that a protruding abdomen is typical for toddler

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

The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based clean...tray to the room. The UAP rub both hands thoroughly for 2 minutes while standing at the...should the nurse take?

Explain that the hand rub can be completed in less than 2 minute

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 should the nurse implement first?

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

Which assessment finding indicates to the nurse a client's readiness for pulmonary function tests

Expresses an understanding of the procedure

Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication?

Fat embolism

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 caring for a client with dysphagia is attempting to insert an NG tube, but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus?

Flex the client's head with chin to the chest and insert.

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 of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history

Frequency of laxative use for chronic constipation

A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer?

Fresh horseradish

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 raw unsalted almonds and apples

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

When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do

Get a blood pressure cuff.

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

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

During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond?

Give me specific examples to support your statements.

The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement?

Give the prescribed antiemetic.

A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.)

Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. T3 and T4 hormone levels are increased Large protruding eyeballs are a sign of hyperthyroid function

Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is... the priority?

Have a meconium aspirator available at delivery

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

Have the client vocalize the instructions provided.

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

Have you had any difficulty in starting your urinary stream"

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 that apply)

Headache and tremors Postural hypotension Pallor and diaphoresis Irregular heart beat

A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse she is. What information for the nurse to obtain?

History of alcohol use,

n adult man reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging in the neighborhood. He expresses concern because both of his deceased parents had heart disease and his father was a diabetic. He lives with his male partner, is a vegetarian, and takes atenolol which maintain his blood pressure at 138/74. Which risk factors should the nurse explore further with the client? Select all that apply

History of hypertension. Family heath history

An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive...medication therapy, the nurse notices the client has more energy, is giving her belongings...mood. Which intervention is best for the nurse to implement

Hold the thermometer in place.

The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take?

Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.

When obtaining a rectal temperature with an electronic thermometer, which action is most important for the nurse to perform?

Hold the thermometer in place

A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client

Human source grafts require monitoring for signs of graft rejection

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/dl (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

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse?

Hypernatremia

A male client arrives at the clinic with a severe sunburn and explains that he did not use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse

Hypotension

The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child's diagnosis

I couldn't get my son's socks and shoes on this morning"

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 Mom and would like to go see her'".

A newly graduated female staff nurse approaches the nurse manager and request reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

I'll change your assignment, but let's talk about you a nurse should respond to this kind of client.

An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?

Identify pills in the bag

The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate

Inability of the SA node to initiate an impulse at the normal rate

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

A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L or 12 mmol/L (SI), and blood glucose is 310 mg/dl or 17.2 mmol/L (SI). Which action should the nurse implement?

Infuse sodium chloride 0.9% (normal saline)

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first? pH 7.50; PaCo2 42; HCO3 33; pO2 92

Infuse 0.9 % sodium chloride 500 ml bolus

Sublingual nitroglycerin is administered to a male client with unstable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his bloods pressure drops to 60/40. Which intervention should the nurse implement?

Infuse a rapid IV normal saline bolus

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 should the nurse implement first?

Initiate a prescribed IV for parental fluid

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.

An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-side weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement?

Install a bed exit safety monitoring device

A male infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant?

Instill beractant 100 mg/kg in endotracheal 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

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate...through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?

Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing

An adolescent's mother calls the clinic because the teen is having recurrent vomiting and...Combative in the last 2 days. The mother states that the teen takes vitamins, calcium, mag...With aspirin. Which nursing intervention has highest priority?

Instruct the mother to take the teen to the emergency room

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

During the intraoperative phase of care, the circulating nurse observes that the client is not adequately client's privacy. What is the best initial nursing action for the nurse to implement

Instruct the scrub nurse to re-drape the client

A male client with impaired renal function who takes ibuprofen daily for chronic arthritis...gastrointestinal (GI) bleeding. After administering IV fluids and a blood transfusion, his blood pressure is 100/70, and his renal output is 20 ml / hour. Which intervention should the nurse include in hours?

Irregular pulse

An infant born to a heroin-addicted mother is admitted to the neonatal care unit. What behaviors can...to exhibit?

Irritability and a high-pitched cry

The mother of a one-month-old boy born at home brings the infant to his first well...was born two weeks after his due date, and that he is a "good, quiet baby" who almost... hypothyroidism, what question is most important for the nurse to ask the mother?

Is your son sleepy and difficult to feed?

A client with a new diagnosis of Raynaud's disease lives alone. Which instruction should the nurse include in the client's discharged teaching plan?

Keep room temperature 80

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

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

During a 26-week gestation prenatal exam, a client reports occasional dizziness...What intervention is best for the nurse to recommend to this client?

Lie on the left or right side when sleeping or resting

The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis?

Long distance runner since high school.

The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter?

Long-term care facility Home health agency

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

An adult female client with chronic kidney disease (CKD) asks the nurse if she can continue...Medications. Which medication provides the greatest threat to this client?

Magnesium hydroxide (Maalox)

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

A 16-year-old male is admitted to the pediatric intensive care unit after being involved in a house fire. He has full thickness burns to his lower torso and extremities. Before a dressing change to his legs, which intervention is most important for the nurse to implement?

Maintain strict aseptic technique.

A 59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up 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 not overlying tissue inflammation. What do these findings suggest

Malignancy

An adult client comes to the clinic and reports his concern over a lump that "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these finding suggest?

Malignancy

What is the nurse's priority goal when providing care for a 2-year-old child experiencing seizure...

Manage the airway

A client delivers a viable infant, but begins to have excessive uncontrolled vaginal... notifying the health care provider of the clients' condition, what information is most....

Maternal blood pressure

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?

Moderate amount of foul-smelling lochia.

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 acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply)

Monitor heart, lung, and kidney function. Notify healthcare provider of serum amylase and lipase levels. Review client's abdominal ultrasound findings.

A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a JacksonPratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care?

Monitor urine output hourly.

The nurse teaches an adolescent male client how to use a metered dose inhaler. Seen in the picture. What instruction should the nurse provide?

Move the device one to two inches away from the mouth

A male client with an antisocial personality disorder is admitted to an in-patient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior this client's history is most likely to include which finding?

Multiple convictions for misdemeanors and class B felonies.

A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the health care provider

Muscle cramping

A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement?

Negative pressure environment

The nurse should observe most closely for drug toxicity when a client receives a medication that has which characteristic?

Narrow therapeutic index.

A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication?

Nausea and indigestion.

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 about the client?

Neurologically stable without indications of an increased IC

The nurse is caring for a toddler with a severe birth anomaly that is dying. The parents... holding the child as death approaches. Which intervention is most important for the nurse?

Notify nursing supervisor and hospital chaplain of the child's impending death.

While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?

Notify the employee health nurse.

A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Notify the healthcare provider

An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. Which action should the nurse take?

Notify the healthcare provider of the client's refusal

One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

Observe for unilateral swelling

A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD)... which breakfast selection by the client indicates effective learning?

Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee

In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next?

Observe the amount and dose of morphine in the PCA pump syringe

A client presents to the labor and delivery unit, screaming "THE BABY IS COMING" which action should the nurse implement first.

Observe the perineum

The father of 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care?

Obtain a detailed report from the nurse transferring the client.

Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?

One with the clamp

A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive...rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take?

Obtain a pulse oximeter reading

A client with a postoperative wound that eviscerated yesterday has an elevated temperature...most important for the nurse to implement?

Obtain a wound swab for culture and sensitivity

A client who has a suspected brain tumor is schedules for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement?

Obtain the client's food allergy history

The family of a client who just died arrives on the nursing unit after receiving telephone notification of the death. Several family members state they would like to view the body. How should the nurse respond?

Offer to go with the family members to view the body

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? (Mark the location on one of the images.)

On left thigh with arrow pointing to inner thigh"

A-12-years old boy has a body mass index (BMI) of 28, a systolic pressure and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicated that his mother understands the management of his diet

One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice.

A young adult female client with recurrent pelvic pain for 3 year returns to the clinic for relief of severe dysmenorrhea. The nurse reviews her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this client?

Oral contraceptives increase the symptoms of endometriosis.

In determine the client position for insertion of an indwelling urinary catheter, it is most important for the nurse to recognize which client condition?

Orthopnea

Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement?

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

A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus?

Oxygen saturation

To obtain an estimate of a client's systolic B/P. What action should the nurse take first?

Palpate the client's brachial pulse

A health care provider continuously dismisses the nursing care suggestions made by staff nurses. As a result...dealing with the healthcare provider. What action should the nurse manager implement?

Plan an interdisciplinary staff meeting to develop strategies to enhance client care

The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-yearol client with... Infected pseudomonas aeruginosa. Which assessment data warrants further intervention by the nurse?

Peak and through levels has not been drawn since the tobramycin was started

A client who has been in active labor for 12 hours suddenly tells the nurse that she has a strong urge to have a bowel movement. What action should the nurse take?

Perform a sterile vaginal exam

A 17-year -old male is brought to the emergency department by his parents because he has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first?

Place a mask on the client's face.

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 is caring for a client immediately after inserting a PICC line. Suddenly, the client becomes anxious and tachycardiac, and loud churning is heard over the pericardium upon auscultation. What action should the nurse take first?

Place client in Trendelenburg position on the left side

After applying an alcohol-based hand rub to the palms of the hand and rubbing the hand together, what action should the nurse do next?

Place one hand on top of the other and interlace the fingers

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

Which intervention should the nurse implement for a client with a superficial (first degree) burn?

Place wet cloths on the burned areas for short periods of time.

During discharge teaching, an overweight client 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? (Select all that apply)

Plain, air-popped popcorn. Natural whole almonds.

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 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 is best to establish rapport and accomplish this therapeutic goal?

Play a board game with the client and begin taking about stressor

The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats / minute. Which action should the nurse take?

Postpone the feeding until the infant's vital signs and stable

A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first?

Provide immediate defibrillation

When checking a third grader's height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement?

Refer child to the family healthcare provider

While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition?

Psoriasis

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

The nurse determines that a client's pupils constricts as they change focus from a far object. What documentation should the nurse enter about this finding?

Pupils reactive to accommodation

The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin... medication?

Push the undiluted Dextrose slowly through the currently infusion IV

The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider?

Rebound tenderness in the upper quadrants

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

The nurse is assessing and elderly bedridden client. Which finding indicates that the turning and positioning schedule is effective in protecting the client's skin?

Reddened skin areas disappear within 15 minutes of being turned and positioned.

Which interventions should the nurse include in a long-term plan of care for a client with COPD

Reduce risk factors for infection

Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client?

Reduce the risk for injury

When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client?

Reflection

Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis?

Remain upright after taking the medication

The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take?

Remind the client to hold his breath after inhaling the medication

The nurse is preparing to discharge an older adult female client who is at risk for hy... nurse include with this client's discharge teaching?

Report any muscle twitching or seizures Take vitamin D with calcium daily Low fat yogurt is a good source of calcium Keep a diet record to monitor calcium intake

The nurse is reinforcing home care instructions with a client who is being discharged following...prostate (TURP). Which intervention is most important for the nurse to include in the client...

Report fresh blood in the urine

A client with hypertension receives a prescription for enalapril, an angiotensin... instruction should the nurse include in the medication teaching plan?

Report increased bruising of bleeding

A female client is taking alendronate, a bisphosphate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond

Report the client's jaw pain to the healthcare provider.

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 should the nurse implement?

Talk directly to the adolescent while providing care

A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client's mothers enter the labor suite and says in a loud voice, "I've had 8 children and I know she's in labor. I want her to have her cesarean section right now!" what action should the nurse take?

Request the mother to leave the room

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 the presence of spams 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 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 client who had a gestational trophoblastic disease (GTD) evacuated 2 days ago is being...18 months-old child and lives in a rural area. Her husband takes the family car to work daily...transportation during the day. What intervention is most important for the nurse to implement?

Schedule a weekly home visit to draw hCG values

A client with multiple sclerosis (MS) is admitted to the medical unit. The client reports... which action should the nurse implement to reduce the client's risk for falls?

Schedule frequent rest periods Provide assistance to bedside commode Teach to patch one eye when ambulating

A male client recently released from a correctional facility arrives at the clinic with a cough, fever, and chills. His history reveals active tuberculosis (TB) 10 years ago. What action should the nurse implement? (Select all that apply)

Schedule the client for the chest radiograph Obtain sputum for acid fast bacillus (AFB) testing Place a mask on the client until he is moved to isolation.

A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority?

Signs a no-self-harm contract.

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

An infant is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant's heart rate drops to 80 beats / minute. What action should the nurse take

Slow the feeding and monitor the infant's response.

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

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

When administering ceftriaxone sodium (Rocephin) intravenously to a client before... most immediate intervention by the nurse?

Stridor

The nurse is making a home visit to a male client who is in the moderate stage of Alzheimer's diseases. The client's wife is exhausted and tells the nurse that the family plans to take turns caring for the client in their home, each keeping him for two weeks at a time. How should the nurse respond?

Suggest enrolling the client in adult daycare instead of rotating among family

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

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

Supervised a newly hired graduate nurse during an admission assessment

A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10), two hours ago, he received hydrocodone / acetaminophen 7.5/7.50 mg his vital signs are elevated from reading of a previous hour: temperature 97.8 F, heart rate 102 beats / minute, respiration 20 breaths/minutes. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but left is greater than right. Preoperatively, clopidrogel was prescribed for a history of previous peripheral stents. Another nurse is holding manual pressure on the femoral arterial access site which may be leaking into the abdomen. What data is needed to make this report complete

Surgeon needs to see client immediately to evaluate the situation

While attempting to stablish risk reduction strategies in a community, the nurse notes that the regional studies have indicated....persons with irreversible mental deficiencies due to hypothyroidism. The nurse should seek funding to implement which screening measure?

T4 levels in newborns

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

An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply)

Teach client to use incentive spirometer q2 hours while awake. Remove urinary catheter as soon as possible and encourage voiding.

A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement?

Teach the client how to use a dry heating pad over the painful area

An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first?

Tell the client that the nurse will be back to talk to her after medications are given

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

Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. 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

A 35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery?

The client will be restricted from eating seafood

The husband of a client with advanced ovarian cancer wants his wife to have every treatment available. When the husband leaves, the client tells the nurse that she has had enough chemotherapy and wants to stop all treatments but knows her husband will sign the consent form for more treatment. The nurse's response should include which information?

The husband cannot sign the consent for the client, her signature is required The client's specific wishes should be discussed with her healthcare provider The healthcare team will formulate a plan of care to keep the client comfortable

Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medication should be held until a later time?

The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease

A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain?

Therapeutic exercise included in daily routine

A 2-year-old is bleeding from a laceration on the right lower extremity that occurred as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size?

Thready brachial pulse.

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?

Three year history of taking oral contraceptives

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

A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation... is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip what?

Two FHR accelerations of 15 beats/minute x 15 seconds are recorded

Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first?

Transfuse packed red blood cells

A woman who takes pyridostigmine for myasthenia gravis (MG) arrives at the emergency department complaining of extreme muscle weakness. Her adult daughter tells the nurse that since yesterday her mother has been unable to smile, which assessment finding warrants immediate intervention by the nurse?

Uncontrollable drooling

After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that applied.)

Unrelieved back and flank pain. Cool and pale left leg and foot. Left groin egg-size hematoma.

A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk?

Unresponsive to painful stimuli

A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. which assessment finding should the nurse report to the healthcare provider?

Urinary output of 25mL per hour

A client who is at 36 weeks gestations is admitted with severe preclampsia. After a 6 gram loading dose of magnesium sulfate is administered, an intravenous infusion of magnesium sulfate at a rate of 2 grams/hour is initiated. Which assessment finding warrants immediate intervention by the nurse?

Urine output 20 ml/hour

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement

Use a water soluble lubricant on affected oral and nasal mucosa

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

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.

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

Vomiting

In caring for a client receiving the amino glycoside antibiotic gentamicin, it is most important for the nurse to monitor which diagnostic test?

What food does your baby usually eat in a normal day?

The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next

Wait 1 minute and palpate the systolic pressure before auscultating again

The nurse is conducting the initial assessment of an ill client who is from another culture.... What response should the nurse provide?

What practices do you believe will help you heal?"

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

An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?

Weak palpable distal pulses

After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life- threatening condition?

Widening QRS complexes and flat waves

A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications?

Withhold the preoperative medication

A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother

Withhold this dose

An African-American man come into the hypertension screening booth at a community fair. The nurse finds that is blood pressure is 170/94 mmHg. The client tells the nurse that he has never been treated for high blood pressure. What response should the nurse make?

Your blood pressure is a little high. You need to have it rechecked within one wee

During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen in the video. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?

infection

A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement?

allow time for the behavior and then redirect the clients to other activities

In conducting a health assessment, the nurse determines that both parents of a child with asthma smoke cigarettes. What recommendation is best to the nurse to recommend to the parents?

avoid smoking in the house

The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement?

corner of the mouth to the tip of the ear

A client has both primary IV infusion and a secondary infusion of medication. An infusion pump is not available. The nurse needs to determine the current rate of infusion of the primary IV. Where should the nurse observe to determine the rate of infusion?

drip chamber

The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

medication port

A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide?

oatmeal cookies

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room?

place the id bands on the infant and mother

A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide?

you need to seek immediate medical assistance to evaluate the cause of these symptoms"