HESI 799 RN Exit Exam (301-400)

A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth). 0.4

0.4 Rationale: Convert pounds to kg 42lbs = 19.09 kg Next calculate to prescribed dose, 0.5 mg x 1909 kg = 9.545 Then use the desired dose/ dose on hand x volume on hand (9.545/25x1ml =0.3818=0.4 ml) Or use ratio proportion (9.545 mg: x ml = 25 mg: 1ml 25x = 9.545 X= 0.3818 = 0.4)

A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? a. 0.9% sodium chloride solution (normal saline) b. 0.45% sodium chloride solution (half normal saline) c. 10% Dextrose in 0.45% sodium chloride d. 5% dextrose in 0.2% sodium chloride

0.9% sodium chloride solution (normal saline) Rationale: Normal range = 135-145

A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit? 1. Discuss the importance of continuing the usual at-home activities 2. Encourage the family to plan daily activities to keep the client busy 3. Have friends and family visit the client at a welcome party. 4. Instruct family to monitor the client's choice of television programs.

1. Discuss the importance of continuing the usual at-home activities Rationale: Week-end pass are schedules to help the client ease back into the family's routine, so the client can back to normal activities.

The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.) 1.9

1.9 Rationale: 38/20x1=1.9 m

A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour? 1000

1000 units/hour Rationale:20000/500=40x25=1000

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? a. Altered consciousness within the first 24 hours after injury. b. Cushing reflex and cerebral edema after 24 hours c. Fever, nuchal rigidity and opisthotonos within hours d. Headache and pupillary changes 48 hours after a head injury

Altered consciousness within the first 24 hours after injury.

The healthcare provider prescribes heparin protocol at 18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium 25,000 units in 5% dextrose 250 ml. the nurse should program the pump to deliver how many ml/hr? (Enter numeric value only. If rounding is require round to the nearest whole number.) 12

Answer 12 Rationale: 144/2.2= 65kg 18units/kg/hr 65 kg x 18units/kg/hr= 1170 units/hr 25000 units heparin/250 ml of D5W = 100 units heparin per ml of solution

The nurse observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What action should the nurse perform first? A. determine the client's blood pressure and apical pulse B. observe the amount of urine in the clients urinary drainage bag C. obtain a pulse oximeter to assess the client's oxygen saturation D. review the medication record for recently administered medications

B. observe the amount of urine in the clients urinary drainage bag. Rationale: If blood clots are present, the nurse should first determine if urinary output has become obstructed by observing the amount of urine in the urinary drainage bag (B) Continuous bladder irrigation is performed to prevent blood clots that may form and obstruct the outflow of urine

The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is _____. Which action should the nurse take to ensure adequate filling of the drip chamber? a. Lower the IV bag to a flat surface b. Compress the drip chamber c. Open the roller clamp d. Squeeze the bag of IV solution

Compress the drip chamber

A client is admitted with a wound on the right hand and associated cellulitis. In assessing the client's hand, which finding required most immediate follow-up by the nurse? a. Cyanotic nailbeds

Cyanotic nailbeds

One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement? a- Encourage use of analgesics before position change b- Assess anxiety about transferring to commode chair c- Assist client during transfer on the first two days d- Review use of assistive devices for weight bearing.

Encourage use of analgesics before position change

The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement? a. Examine the genitalia as the last part of the total exam. b. Use soothing statements to facilitate cooperation c. Allow the child to keep underpants on to examine genitalia d. Work slowly and methodically so not to stress the child

Examine the genitalia as the last part of the total exam. Rationale: Examination of a child's genitalia is particularly stressful to toddles, so this assessment is best left as the last part of the examination. B are best done by a parent, not the nurse. The genitals must be completely visualized and sometimes palpates underwear for a brief period of.

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? a. Initiate intravenous fluid as prescribed b. Notify the HCP of the need to reposition the catheter c. Remove the catheter and apply direct pressure for 5 minutes. d. Secure the catheter using aseptic technique

Initiate intravenous fluid as prescribed Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C)

A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse? a. Urinary incontinence b. Left forearm hematoma c. Disorientation to surroundings d. Dislodge intravenous site

Left forearm hematoma Rationale: The left forearm hematoma may be indicative an injury, such as broken bone, that requires immediate intervention. A may be likely be due to the inability to use the toilet due to the fall. Disorientation is a common symptom of Alzheimer's disease. IV Dislodged is not an urgent concern.

A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement? a. Overlook the client's behavior. b. Distract client to interfere with the ritual. c. Ask why the client checks the pulse. d. Hold client's hand to stop the behavior.

Overlook the client's behavior.

The nurse has received funding to design a health promotion project for AfricanAmerican women who are at risk for developing breast cancer. Which resource is most important in designing this program? a. A listing of African-American women so live in the community b. Participation of community leaders in planning the program c. Morbidity data for breast cancer in women of all races d. Technical assistance to produce a video on breast self-examination.

Participation of community leaders in planning the program

The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? a- Opening the package b- Picking up the second glove c- Picking up the first glove d- Positioning of the table

Picking up the second glove

During a cardiopulmonary resuscitation of an intubated client, the nurse detects a palpable pulse throughout the two minutes cycle chest compression and absent breath sounds over the left lung. What action should the nurse implement? a- Instruct the compressor to stop chest compression. b- Advise ventilator to increase bag-mask ventilation rate. c- Plan to suction endotracheal tube at two-minute check. d- Prepare for the endotracheal tube to be repositioned

Prepare for the endotracheal tube to be repositioned

A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition? a. Pulmonary hypertension b. Left ventricular hypertrophy c. Renal failure d. Stroke

Stroke

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? a. Supervised a newly hired graduate nurse during an admission assessment

Supervise a newly hired graduate nurse during an admission assessment

A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective? a. The nurse note that no pills remain in the prescription bottle. b. The client serum Depakote level is 125 mcg/ml c. The family reports a great reduction in client's maniac behavior d. The client denies any occurrence of suicidal ideation.

The family reports a great reduction in client's maniac behavior

A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include? a. Wash hands before cleaning exit site b. Keep the head of the bed flat at night c. Feel for a thrill and a distal pulse nightly d. Do not get up if fluid is left in the abdomen

Wash hands before cleaning exit site Rationale: meticulous hand hygiene is essential when performing care for a peritoneal dialysis, infections is a common complication of peritoneal dialysis.

After teaching a male client with chronic kidney disease (CKD) about therapeutic diet... which menu of foods indicates that the teaching was effective? Select all that apply a- A slice of whole grain toast b- Half cup of black beans c- A ham and cheese sandwich d- A bowl of cream of wheat e- Two bananas.

a- A slice of whole grain toast d- A bowl of cream of wheat Rationale: Patient with CKD have elevated serum potassium, sodium and protein levels. A and D are low in potassium, sodium and protein, Beans are rich in proteins. C are high in sodium and potassium and E are rich in potassium.

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) a- Apple juice b- Chicken broth. c- Hot chocolate d- Orange juice e- Black coffee

a- Apple juice b- Chicken broth.

An 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 a- History of hypertension. b- Homosexual lifestyle c- Vegetarian diet d- Excessive aerobic exercise e- Family heath history.

a- History of hypertension. e- Family heath history. Rationale: Based on the client's family history and medication for management of hypertension, the nurse should further explore these risk for ischemic heart disease.

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? a- Instruct the client to keep the left leg straight b- Keep the head of bed at 60-degree angle. c- Observe the insertion site for a hematoma d- Manually flush the arterial sheath hourly e- Circle first noted drainage on the dressing

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

A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher? a- The child should avoid eating homemade cookies and cupcakes during parties. b- No products containing any form of peanuts should be allowed in the classroom c- Report a runny nose or head cold to the nurse immediately for further revaluation. d- Avoiding direct contact sports and games will reduce the child's risk of bruising.

a- The child should avoid eating homemade cookies and cupcakes during parties. Rationale: Celiac disease is an intolerance to products containing gluten. Wheat flour,

When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has: a- A collapsed lung b- A history of COPD c- A chronic lung infection d- Normally functioning lungs

a. A collapsed lung Rationale: Unilateral absence of chest movement (or unequal lung expansion because one lung is not moving at all) may be indicative previous surgical removal of that lung, a bronchial obstruction, or a collapsed lung caused by air or fluid in the pleural space.

While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first? a. Ask the client when a family member last visited her. b. Determine the client's orientation to time and space c. Review the client's record regarding social interactions d. Reassure the client of her family's love for her

a. Ask the client when a family member last visited her.

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? a- Aspirin content. b- Dose c- Route d- Risk for addiction

a. Aspirin content. Rationale: Aspirin content medication are contraindicated for client with polycystic kidney disease because the risk for bleeding.

The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three days ago. The client plans to live with a family member. Which action should the nurse implement? Select all that apply A.)Assess the client for self-care ability B.)Provide pain medication instructions C.)Teach care of ostomy to care provider D.)Instruct client to Look up a video E.)Give client a pamphlet

a. Assess the client for self-care ability b. Provide pain medication instructions c. Teach care of ostomy to care provider

A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement? a. Auscultate all quadrants of the abdomen. b. Perform a digital rectal exam c. Palpate the liver and spleen d. Obtain a hemoccult of the client's stool

a. Auscultate all quadrants of the abdomen.

The home care nurse provide self-care instruction for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply a. Avoid prolonged standing or sitting b. Use a recliner for long periods of sitting c. Continue wearing elastic stockings d. Maintain the bed flat while sleeping e. Cross legs at knee but not at ankle

a. Avoid prolonged standing or sitting b. Use a recliner for long periods of sitting c. Continue wearing elastic stockings

A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding... the client? a. Blood pressure 149/101 b. Irregular pulse rate of 80 c. Oral temperature is 98.9 F (37.1 C) d. Pain rated 7 on scale 1-10

a. Blood pressure 149/101

Which information is more important for the nurse to obtain when determining a client's risk for Obstructive Sleep Apnea Syndrome (OSAS)? a- Body mass index b- Level of consciousness c- Self-description of pain d- Breath sounds

a. Body mass index

The nurse is administering a 750 ml cleansing enema to an adult client. After approximately 150 ml of enema has informed, the client states, 'stop I can't hold anymore." What action should the nurse take? a. Clamp the tubing and instruct the client to breathe deeply before continuing. b. Discontinue infusing the enema and record the client's response. c. Slow infusion of the enema and instruct the client to use paint breathing d. Place the client on the bedpan and continue infusion of the enema.

a. Clamp the tubing and instruct the client to breathe deeply before continuing. Rationale: Clamping the tube momentarily allows the muscle to relax and prevents expulsion of the solution prematurely. B may be eventually necessary but A should be tried first.

A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribed medications? a. Clopidogrel (Plavix), an antiplatelet agent, given orally b. Methylprednisolone (solu-medrol), a corticosteroid, to be given IV c. Nitroglycerin (Nitro-Dur) an antianginal, to be given transdermally. d. Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous. e. Furosemide (Lasix), a loop diuretic, to be given intravenously.

a. Clopidogrel (Plavix), an antiplatelet agent, given orally Rationale: Because of the emesis is coffee brown appearance, which is an indicator of bleeding in GI tract, the nurse should consult the health care provider because increase the risk of bleeding.

A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take? a- Contact the regional organ procurement agency b- Convene a multidisciplinary care conference c- Explain that client may not be an organ donor candidate d- Discontinue feeding and fluids per the family's request.

a. Contact the regional organ procurement agency

A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement? a. Determine current sexual practices b. Prepare a female client for an ultrasound c. Request a sperm sample for ovulation d. Evaluate hormone levels on both clients

a. Determine current sexual practices Rationale: First a history should be obtained including practices that might be related to the infertility, such as douching, daily ejaculation or the male partner's exposure to heat, such as frequent sauna or work environment which can decrease sperm production (A B or C) may be indicated after a complete assessment is obtained.

A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first? a. Determine the client's responsiveness and respirations b. Bring the crash cart to the room to defibrillate the client. c. Immediately initiate chest compressions. d. Notify the emergency response team

a. Determine the client's responsiveness and respirations Rationale: Activities, such as brushing teeth, can mimic the waveform of VI, so first he client should be assessed (A) to determine if the alarm is accurate. The crash cart can be brought to the room by someone else and defibrillation (B) delivered as indicated by the client's rhythm. Based on as assessment of the client, CPR© as summoning the emergency response team (D) may be indicated.

The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion? a- Increase the oxygen flow via nasal cannula if dyspnea is present. b- Place in a Trendelenburg position to increase cerebral blood flow c- Monitor capillary glucose measurements hourly during transfusion. d- Encourage increased intake of oral fluid to improve skin turgor.

a. Increase the oxygen flow via nasal cannula if dyspnea is present.

The nurse is teaching a client about the antiulcer medications ranitidine which was... statement best describes the action of this drug? a- It blocks the effects of histamine, causing decreased secretion of acid b- Ranitidine will neutralize gastric acid and decrease gastric pH c- This drug provides a protective coating over the gastric mucosa d- It effectively blocks 97% of the gastric acid secreted in the stomach

a. It blocks the effects of histamine, causing decreased secretion of acid

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? a- Long distance runner since high school. b- Lactose intolerant since childhood c- Photosensitive to a drug currently taking d- Recently treated for deep vein thrombosis.

a. Long distance runner since high school. Rationale: Osteoarthritis is a degenerative joint disease of the cause by traumatic or repetitive stress to weight-bearing joint such as high impact sport like running.

The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? a. Monitor for an elevated temperature b. Measure the abdominal girth daily c. Report the onset of sclera jaundice d. Keep a record of daily urinary output

a. Monitor for an elevated temperature Rationale: The client should be instructed to monitor or elevated temperature because immunosuppressant agents, which are prescribed to reduce rejection after transplantation, place the client at risk for infection. The client should recognize sign of liver rejection, such as sclera jaundice and increasing abdominal girths, but fever may be the only sign of infection. A is not as important and monitoring for signs of infection.

An older female who ambulates with a quad-cane prefers to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply) a. Move personal items within client's reach b. Lower bed to the lower possible position c. Raise all bed rails when the client is resting d. Give directions to call for assistance e. Assist client to the bathroom in 2 hours. f. Encourage the use of the wheelchair

a. Move personal items within client's reach b. Lower bed to the lower possible position d. Give directions to call for assistance e. Assist client to the bathroom in 2 hours. Rationale: A client who needs assistive devices, such as quad-cane is at risk for falls. Precautions that should implement include ensuring that personal items are within reach the bed is in the lowest position and directions are given to call assistance to minimize the risk for falls. Frequently assisting the client to the bathroom help ensure this client does not go the bathroom by herself, thereby decreasing the possibility of falling.

When changing a diaper on a 2-day-old infant, the nurse observes that the baby's legs are... this finding, what action should the nurse take next? a- Notify the healthcare provider b- Continue care since this is a normal finding c- Document the finding in the record d- Perform range of motion to the joint.

a. Notify the healthcare provider

The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement? a. Observe the wound for dehiscence b. Teach the client to splint the incision while coughing c. Assess the skin surrounding the wound for maceration d. Obtain a culture of the wound drainage.

a. Observe the wound for dehiscence

A client whose wrists are sutured from a recent suicide attempt has been transferred from a medical unit. Which nursing diagnosis is of the highest priority? a- Risk for self-directed violence related to impulsive actions b- Risk for violence related to feeling of guilt and failure c- Low self-esteem related to feeling of loss of control d- Ineffective coping related to violent actions towards self.

a. Risk for self-directed violence related to impulsive actions

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? a. The client has asymmetrical chest wall expansion b. The clients complain of pain at the insertion site c. The client chest's x-ray indicates decreased pleural effusion d. The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26

a. The client has asymmetrical chest wall expansion Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal limits.

A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions? a- Turkey salad sandwich. b- Clam chowder c- Macaroni and cheese d- Bacon, lettuce, and tomato sandwich

a. Turkey salad sandwich.

A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/ hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement? a. Use a secondary port of the Normal Saline solution to administer the antibiotic. b. Add the antibiotic to the TPN solution, and continue the normal saline solution. c. Stop the TPN infusion for the time needed to administer the prescribed antibiotic. d. Add the antibiotic to the Normal Saline solution and continue both infusions.

a. Use a secondary port of the Normal Saline solution to administer the antibiotic.

A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? a. creatinine clearance 25 mL/ minute b. calcium 9 mg/dl c. hemoglobin 12 grams/dl d. partial thromboplastin time (PTT) 30 seconds

a. creatinine clearance 25 mL/ minute

When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat? a- Nuts b- Yogurt. c- Fresh turkey d- Fresh chicken e- Processed cheese.

b- Yogurt. e- Processed cheese. Rationale: In hypoparathyroidism, the client's diet should be supplemented with calcium rich foods which include dairy products.

The nurse is conducting health assessments. Which assessment finding increases a 56 year-old woman's risk for developing osteoporosis? a. Body mass index of (BMI) of 31 b. 20 pack-year history of cigarette smoking c. Birth control pill usage until age 45 d. Diabetes mellitus in family history

b. 20 pack-year history of cigarette smoking Rationale: Cigarette smoking (2 packs/day x 10 years = 20 packs-year) increases the risk of osteoporosis. BMI of 30 or greater falls in the category of obesity which increase weight bearing that is protective against osteoporosis. C contain estrogens and are also protective against development of osteoporosis. D is not related to the development of osteoporosis.

A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond? a. Affirm that the client is effectively performing the double voiding. b. Advise the client to empty her bladder fully when she first voids c. Suggest that the client drink water between the two voiding. d. Explain that Kegel exercises help promote full bladder empty.

b. Advise the client to empty her bladder fully when she first voids

The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first? a. Attached de IV tubing to the central line. b. Check the TPN solution for cloudiness c. Set the infusion PUMP at the prescribed rate. d. Prime the IV tubing with the TPN solution.

b. Check the TPN solution for cloudiness

During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media? a. Varicella Virus Vaccine Live b. Hemophilic Influenza Type B (HiB) vaccine c. Pneumococcal vaccine d. Palivizumab vaccine for RSV

b. Hemophilic Influenza Type B (HiB) vaccine

A male client is admitted with burns to his face and neck. Which position should the nurse place the client to prevent contract? a. Flexed with the chin toward the chest. b. Hyperextended with neck supported by a rolled towel. c. Side-lying with the head on a pillow d. Prone with face supported by an inflated rubber ring.

b. Hyperextended with neck supported by a rolled towel.

A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include: intubation with controlled mechanical ventilation to PaCO2...what is the pathophysiological basis for this ventilator settings? a- Hypoxemia reduces ICP. b- Hypocapnea reduces ICP. c- Hyperventilation reduces need for temperature control. d- Controlled ventilation reduces need for oxygen to brain.

b. Hypocapnea reduces ICP

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restraints are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care? a. Understand pain management scale b. Maintain effective breathing patterns c. Absence of ventilator associated pneumonia d. No injuries refer to soft restrains occur

b. Maintain effective breathing patterns Rationale: Basic airway management (B) is the priority. Pain management (A), risk of infection (C), and prevention of injury (D) do not have the same priority as (C)

A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care? a. Implements decisions about future hospices services within the next 3 months. b. Maintaining pain level below 4 when implementing outpatient pain clinic strategies. c. Request home health care if independence become compromised for 5 days. d. Arranges for short term counseling stressors impact work schedule for 2 weeks.

b. Maintaining pain level below 4 when implementing outpatient pain clinic strategies. Rationale: An outpatient pain clinic provides the interdisciplinary services needed to manage chronic pain. Also, the client has a terminal disease and is being discharge home, hospice and health care are not indicating currently. Short term counseling is not an option.

Which intervention should the nurse include in the plan of care for a client with leukocytosis? a. Avoid intramuscular injections b. Monitor temperature regularly c. Assess skin for petechiae or bruising d. Implement protective isolation measures

b. Monitor temperature regularly

A client with superficial burns to the face, neck, and hands resulting from a house fire... which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...? a. Expiratory stridor and nasal flaring b. Mucous membranes cherry red color c. Carbonaceous particles in sputum d. Pulse oximetry reading of 80 percent

b. Mucous membranes cherry red color

The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating? a. A paced rhythm with 100% capture after pacemaker replacement b. Normal sinus rhythm and complaining of chest pain c. Atrial fibrillation with congestive heart failure and complaining of fatigue d. Sinus tachycardia 3 days after a myocardial infarction

b. Normal sinus rhythm and complaining of chest pain

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? a. Reassure the client that his child will be allowed to visit b. Obtain a detailed report from the nurse transferring the client. c. Mark the chart with client's request for no heroic measure d. Provide the client whitening information about end-of-life care

b. Obtain a detailed report from the nurse transferring the client. Rationale: To maintain continuity of care, it is important for the nurse working on the palliative care unit to obtain a detailed "situation, background, assessment, recommendation (SBAR) report, which provide clinical and no clinical information, as well as further information about the client may need. A, C and D are important intervention but not have priority at this time.

An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement? a- Inform the family of the client's wishes b- Obtain a prescription for DNR c- Clergy consultation d- Ask the patient why he made this choice

b. Obtain a prescription for DNR

A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/hr current labor....sodium level of 155 mEq/L, a serum potassium level of 4mEq/L.... what nursing intervention is most important? a. Provide a high-potassium snack, such as bananas. b. Obtain a prescription to increase the IV rate c. Administer the next scheduled dose of antibiotic d. Review the report of the most recent chest x-ray.

b. Obtain a prescription to increase the IV rate

In assessing a pressure ulcer on a client's hip, which action should the nurse include? a. Determine the degree of elasticity surrounding the lesion b. Photograph the lesion with a ruler placed next to the lesion c. Stage the depth of the ulcer using the Braden numeric scale d. Use a gloved finger to palpate for tunneling around the lesion

b. Photograph the lesion with a ruler placed next to the lesion Rationale: An ulcer extends into the dermis or subcutaneous tissue and is likely to increase in size and depth, so assessment should include photograph with measuring device to document the size of the lesion.

The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client with...daily leaving. When making this assignment, which instruction is most important for the nurse to do? a- Do not remove the dentures, but instead brush them within the mouth b- Place a washcloth in the sink while cleaning the dentures. c- Use tepid, not hot, water to clean the dentures d- Avoid damaging the dentures using a soft-bristled toothbrush.

b. Place a washcloth in the sink while cleaning the dentures

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? a. Examine the victim's body surfaces for arterial bleeding b. Stabilize the victim's neck and roll over to evaluate his status c. Return to the car to call emergency response 911 for help d. Open the airway and initiate resuscitative measures

b. Stabilize the victim's neck and roll over to evaluate his status

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? a. Advise the client's spouse to consider inpatient hospice care as an alternative b. Suggest that each rotation last one week, rather than two, to prevent caregiver fatigue c. Use active listening to allow the client and spouse to express their feelings about the plan d. Suggest enrolling the client in adult daycare instead of rotating among family.

b. Suggest enrolling the client in adult daycare instead of rotating among family Rationale: Suggesting a viable alternative, such as adult daycare provides an option to allow the spouse respite the least disruption to routines and environment.

A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action I the treatment plan should the nurse implement? a. Tell the client to drive over the bridge until fear is manageable b. Teach client to listen to music or audio books while driving c. Encourage client to have spouse drive in stressful places. d. Recommend that the client avoid driving over the bridge.

b. Teach client to listen to music or audio books while driving

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? a. The loop-diuretic furosemide (Lasix) for a client with a serum potassium level of 4.2 mEq/L b. The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease. c. The antiplatelet agent aspirin, for a client who is scheduled to be discharged within the hour d. The antifungal nystatin (mycostatin) suspension, for a client who has just brushed his teeth.

b. The mucosal barrier, sucralfate (Carafate), for a client diagnosed with peptic ulcer disease Rationale: Carafate coats the mucosal lining prior to eating a meal, so this medication should be held until prior to the next meal.

The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? a. High salt can damage the lining of the blood vessels b. Too much salt can cause the kidneys to retain fluid c. Excessive salt can cause blood vessels to constrict d. Salt can cause information inside the blood vessels

b. Too much salt can cause the kidneys to retain fluid Rationale: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension.

An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? a. Rebound abdominal tenderness b. nausea and projectile vomiting c. rib pain with deep inspiration d. diminished bilateral breath sounds

b. nausea and projectile vomiting Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture.

During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply) a- Situation b- Background c- Assessment d- Recommendation e- Rationales.

c- Assessment d- Recommendation e- Rationales.

The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention? a. A young adult with Crohn's disease who reports having diarrheal stools b. An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late. c. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. d. A teenager who reports continued pain 30 minutes after receiving an oral analgesic.

c. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping Rationale: The nurse should immediately assess the child whose infusion pump is alarming during chemotherapy administration because infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalance. Diarrhea is a common occurrence for Crohn's disease. Late consumption of food for a diabetic is of concern, but 20 minutes late is usually not life-threatening. Treatment of pain is most important but has been only 30 mints since the client was medicated and this issue can be assessed in 10 mints or delegated to another nurse.

When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first? a. Include the family in client's care b. Request the chaplain's presence c. Ask the family to identify a specific spokesperson d. Page the healthcare provider to speak with family.

c. Ask the family to identify a specific spokesperson

On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take? a. Encourage the nurse purchase the reading glasses in the hospital gift shop b. Request another nurse to assist the staff nurse with her documentation c. Ask the nurse to return home and get her prescription eyeglasses for work. d. Tell the staff nurse to take a day off and change her weekly work schedule.

c. Ask the nurse to return home and get her prescription eyeglasses for work

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a. Review the heart rhythm on cardiac monitors b. Check urinary catheter for obstruction c. Auscultated bilateral breath sounds d. Give PRN dose of lorazepam (Ativan)

c. Auscultated bilateral breath sounds Rationale: Restlessness often results from decreased oxygenation, so breath sounds should be assessed first. Giving an anxiolytic such as lorazepam, might be indicated but first the client should be assessed for the cause of the restlessness. An obstruction in the urinary drainage system can cause a distended bladder that may result in restlessness, but patent airway is the priority intervention. The client should be assessed before evaluating the cardiac rhythm on the monitor.

The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs? a- Stares straight ahead without blinking b- Face does not convey any emotion c- Cries frequently during the interview d- Uses a monotone when speaking

c. Cries frequently during the interview

The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take? a- Check the client's temperature, blood sugar, and urine output. b- Transport the client for laboratory client for laboratory test and electrocardiogram (EKG) c- Delegate care of the crying client to an unlicensed assistant d- Send the client to the shelter's nutrient center to obtain water and food.

c. Delegate care of the crying client to an unlicensed assistant

The nurse is presenting information about fetal development to a group of parents with...when discussing cephalocaudal fetal development, which information should the nurse gives the parents? a- set order in fetal development is expected b- Growth normally occurs within one organ at a time c- Development progress from head to rump d- Organ formation is directed by brain development

c. Development progress from head to rump

The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? a- Fruity breath odor b- Polyphagia c- Diaphoresis d- Polydipsia

c. Diaphoresis

The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? a. Decreased white blood cell count b. Pruritus and muscle aches c. Elevated liver function tests d. Vomiting and diarrhea

c. Elevated liver function tests Rationale: Valacyclovir is an antiviral agent of acyclovir which is used in therapy of herpes simplex and varicella-zoster virus infections (shingles). Valacyclovir has been associated with rare instances mild, clinically apparent liver injury.

The 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? a. Place infants on a blanket for evacuation via stairwell b. Secure three infants on a stretcher for transport c. Evacuate each infant with mother via wheelchair d. Use the bassinet in evacuate two infants at a time.

c. Evacuate each infant with mother via wheelchair Rationale: Rooming-in and newborn babies are counted with their mothers. To exposure safety and accountability during the evacuations newborns should be evacuated with their mother in a wheelchair while maneuver with fire extinguisher are performed (PASS)...

A client with severe full-thickness burns is scheduled for an allografting procedure. Which information should the nurse provide the client? a. The donor site will be painless a few days after the surgery b. Allografts are made from human and nonhuman material sources. c. Human sources graft require monitoring for signs of graft injection d. Something about scarring occurring under the graft?

c. Human source grafts require monitoring for signs of graft rejection Rationale: Allograft is a graft created from the client's own skin, which is called harvest site. All types of grafts, from human and nonhuman sources should be monitor for signs of rejection. Graft site are painful. (A). Allografts are obtained from the client, which is a human source (B). scaring does occur under the graft (D)

The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective? a. These warts are caused by a fungus b. Early treatment is very effective c. I need to have regular pap smears d. I will clean my hot tub better

c. I need to have regular pap smears

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? a. Evaluate the client's ability to use an incentive spirometer b. Monitor the amount of drainage from the client's incision c. Observe both lower extremities for redness and swelling d. Palpate all peripheral pulse points for volume and strength

c. Observe both lower extremities for redness and swelling Rationale: Intermittent compression devices (ICDs) are used to reduce venous stasis and prevent venous thrombosis in mobile and postoperative clients and its effectiveness is best assessed by observing the client's lower extremities for early signs of thrombophlebitis.

A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important? a- Review record of recent analgesia b- Provide frequent pulmonary toilet c- Prepare the client for intubation d- Obtain STAT arterial blood gases

c. Prepare the client for intubation

The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? a. Tell the UAP to offer more choices during the personal care to prevent anxiety b. Meet with the UAP later to role model more assertive communication techniques c. Assume care of the client to ensure that effective communication is maintained. d. Affirm that the UAP is using an effective strategy to reduce the client's anxiety.

d. Affirm that the UAP is using an effective strategy to reduce the client's anxiety. Rationale: Reduction is an effective technique is managing the anxiety of client with Alzheimer's disease, so the nurse should affirm the UAP is using an effective strategy (A). Nurse assertive communication and offering more choices (B) may increase... an agitation (C) is not indicated since the UAP is using redirection, an effective strategy.

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse? a. Transfer a client to another unit b. Monitor the central telemetry c. Perform the admission d. Assist cardiac nurses with their assignments

d. Assist cardiac nurses with their assignments

After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? a. Dark, rust-colored urine b. Urine output 300 ml/hr c. Joint and muscle aches d. Blood pressure 170/98

d. Blood pressure 170/98 Rationale: SLE can result in renal complication such as glomerulonephritis, which can cause a critically high blood pressure that necessitates immediate intervention. A, B and C are symptoms of glomerulonephritis and should be treated once the blood pressure is under control

A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status? a. A 24-hour diet history b. History of a recent weight loss c. Status of current petite d. Condition of hair, nails, and skin

d. Condition of hair, nails, and skin Rationale: The assessment of hair, nails and skin is most indicative of long-term nutritional status, which is important in the healing process.

The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? a. Lip smacking and frequent eye blinking b. Shuffling gait and stooped posture c. Rocks back and forth in the chair d. Muscle spasms of the back and neck

d. Muscle spasms of the back and neck

During an Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar syndrome in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? a. Urine ketones b. Urine albumin c. Serum protein d. Serum potassium

d. Serum potassium Rationale: Electrolyte shifts are common during correction of hyperosmolar and hyperglycemic states. Monitor electrolyte levels at least every 4 hours, or every 2 hours if needed. Monitor serum sodium and potassium levels closely. If needed, use isotonic and hypotonic saline solutions to adjust the patient's sodium level. Despite major potassium loss during diuresis in early HHS stages, many patients initially present in a hyperkalemic state due to dehydration. When fluid and insulin therapy begin, the serum potassium level may drop dramatically.

A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM? a- Immune antibodies attack pancreatic beta cells resulting in no insulin b- The body cells develop resistance to the action of insulin. c- Body organs produce less insulin and more glucagon d- The liver produces excess glucose in response to excess glycotrophic hormones

d. The body cells develop resistance to the action of insulin

The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately? a. headache, photophobia, and nuchal rigidity b. high fever, skin rash, and a productive cough c. nausea, vomiting, and poor skin turgor d. malaise, fever, and stiff, swollen joints

headache, photophobia, and nuchal rigidity Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so this client should immediately be referred to the health care provider. AC D do not have priority of B

In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis? a. Infectious process b. Metastatic process c. Autoimmune disorder d. Inflammatory disorder

infectious process

The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image). right upper chest, left midaxillary

right upper chest, left midaxillary