HESI Case Studies Fall 2023

When using an 8-ounce glass, the client should drink how many glasses per day to ingest 3081 mL of fluid in 1 day?

13

Prior to administering the first dose of the antibiotic, the nurse asks the client about any drug allergies. The nurse explains to the client that this precaution reduces the risk for what potential problem? Anaphylactic reaction. Idiosyncratic response. Synergistic effect. Drug incompatibility. Submit

Anaphylactic reaction. An anaphylactic reaction is a severe allergic response that can be life threatening.

To reduce the effects of moisture on the client's skin, which intervention should be implemented? Apply a moisture-repellent ointment to intact skin areas. Rinse ulcerated areas with an alcohol-based irrigating solution. Position a plastic-lined pad under the buttocks. Apply moist heat to the area following exposure to feces. Submit Previous Section

Apply a moisture-repellent ointment to intact skin areas. After the skin is cleaned and dried, a moisture-repellent ointment should be applied to protect and moisturize the skin. Fecal toxins are damaging to tissue, and excessive moisture causes skin maceration and damage.

The nurse prepares a written positioning schedule and places it in the client's room as a reminder for the unlicensed assistive personnel (UAP) assigned to help with the client's care. The charge nurse removes the schedule and states that it violates the client's privacy. What action should the nurse take? Provide verbal instructions about positioning to the UAP and document the instructions in the nurse's notes. Ask the charge nurse to assist with verbal communication to all of the staff involved in the client's care to ensure continuity of care. Advise the charge nurse that client confidentiality is secondary to continuity of care. Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights.

Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights. A written, individualized schedule is the most effective method to ensure consistent positioning and may be placed in the client's room without compromising client confidentiality.

Dressing Change After the client ambulates with the physical therapist, the nurse prepares to change the surgical dressing. While obtaining supplies, the nurse reviews the sterile procedure to be followed. At what step in the procedure should the nurse don sterile gloves? Prior to removing the dressing on the client's hip. Before opening the new sterile dressing package. Before cleansing the client's hip incision. After cleansing the client's hip incision.

Before cleansing the client's hip incision. When using surgical asepsis for wound care, the sterile gloves should be donned prior to cleaning the wound and applying the new sterile dressing.

The nurse notes that the client takes oral (PO) gabapentin every day when he is at home to treat his peripheral neuropathy. It is most important for the client to report which potential adverse or side effect associated with gabapentin? Restlessness. Diarrhea with black stool. Dry mouth. Flatulence.

Diarrhea with black stool. Diarrhea with tarry or black stool may be an indication of a gastrointestinal bleed, a potentially life-threatening complication.

Preoperative Teaching The nurse talks with the client about what to expect the day of surgery and during the immediate postoperative period. The nurse provides instructions regarding cough and deep breathing exercises. The client performs a return demonstration by breathing in deeply through their mouth and exhaling forcefully and rapidly through pursed lips. What action should the nurse implement? Advise the client to avoid pursing her lips when exhaling. Remind the client to cough after taking 2 to 3 breaths. Demonstrate the deep breathing and coughing technique again. Document successful completion of the return demonstration.

Demonstrate the deep breathing and coughing technique again. The client has demonstrated incorrect technique. When performing deep breathing exercises, the client should inhale through the nose and exhale slowly through the mouth without pursing the lips. The nurse should demonstrate the entire procedure again for best learning by the client.

The nurse prepares to administer the first dose of vitamin B12 via intramuscular (IM) injection. Which technique is correct? Inject into the dorsogluteal site, the preferred injection site. Aspirate after injecting medication into the muscle. Inject into the fatty tissue of the abdomen. Use a 1 to 1½ inch needle. Submit

Use a 1 to 1½ inch needle. For a male client who weighs 130 to 260 lb (59 to 118 kg), a 1 to 1½ inch needle is recommended.

A wound culture indicates that the client's wound is infected with methicillin-resistant Staphylococcus aureus (MRSA). After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client? Standard precautions. Droplet precautions. Airborne precautions. Contact precautions.

Contact precautions. The client should be cared for using contact precautions when there is potential for wound drainage and debris to splatter during care. The mode of transmission of MRSA includes direct contact, as well as contact with infected surfaces.

As the nurse documents the client's assessment, the nurse is correct to question which activity of a client with type II diabetes mellitus? (Select all that apply. One, some, or all options may be correct.) Client's frequency for checking blood glucose. Quantity of Ensure taken per day. Reason for lack of appetite. Amount of water and other fluids taken daily. Last blood glucose result obtained by client.

Client's frequency for checking blood glucose. Quantity of Ensure taken per day. Reason for lack of appetite. Amount of water and other fluids taken daily.

The nurse determines that the client's bowel sounds are hypoactive. What action should the nurse implement in response to this finding? Document the assessment finding in the chart. Notify the surgeon of the assessment finding. Review the client's serum electrolyte values. Administer a laxative prescribed for PRN use.

Document the assessment finding in the chart. Hypoactive bowel sounds are an expected finding following general anesthesia, so the nurse should document this finding in the chart and continue to monitor the client.

Upon learning that the client has a pressure-reducing gel chair cushion for their wheelchair, which action should the nurse take? Encourage them to continue to use this device in their wheelchair at all times. Recommend that they replace the gel pad with a donut-shaped foam cushion. Advise them to avoid the use of any form of pressure cushion on their wheelchair. Teach them that regular use of skin moisturizer is more important than cushion use. Submit

Encourage them to continue to use this device in their wheelchair at all times. These cushions help redistribute weight so that it is not all on the ischium. The client should also be instructed to shift weight frequently.

Which laboratory finding is of most concern to the nurse? Potassium 3.9 mEq/L (3.9 mmol/L). Sodium 140 mEq/L (140 mmol/L). Phosphorous 4.1 mg/dL (1.32 mmol/L). Hemoglobin 11.2 g/dL (112 g/L).

Hemoglobin 11.2 g/dL (112 g/L). Normal hemoglobin for an adult male is 13.2 to 17.3 g/dL (132 to 173 g/L). Although lower levels are often found in older adults, 11.2 g/dL (112 g/L) indicates anemia.

Nursing DiagnosisThe PN and RN team leader identify a priority problem for the client's plan of care as "impaired skin integrity." Which etiology identified by the nurse is accurate? Noncompliance with turning schedule. Poor nutritional intake. Impaired physical mobility. Impaired adjustment.

Impaired physical mobility. Since the client is paraplegic, they have impaired physical mobility, a major factor that contributes to PI development.

The nurse making rounds finds the client unresponsive. The client's vital signs are: temperature 100.4° F (38.0° C) heart rate (apical) 135 beats/minute blood pressure 92/60 mmHg The client's blood sugar level is high. What condition, other than hyperglycemia, might the Hypernatremia. Hypervolemia. Ketonuria. Osmotic diuresis. Glycosuria.

Ketonuria. Osmotic diuresis. Glycosuria.

When the medication bottle is properly relabeled, the nurse mixes the suspension prior to pouring it. Which technique should the nurse use to mix the linezolid? Shake gently for 60 seconds. Mix according to directions. Shake vigorously until mixed. Stir medicine after pouring it into the medication measuring cups.

Mix according to directions. Instructions should be to turn 2-3 times, avoid shaking, according to manufacturer's specifications. Linezolid should never be shaken.

No evidence of drug toxicity is found. The client's next BP is within normal limits, and experiences no further episodes of diarrhea. The wound eschar has been removed (debrided), and there is no further drainage. A hydrocolloid dressing is placed over the wound, and the client is discharged. The client will complete the 2-week antibiotic treatment at home. The home care nurse visits the client a week after discharge to assess the wound. The nurse reviews symptoms of pressure injuries as well as preventative measures, with the client, and when to call the HCP. The client yells at the nurse and says that they do not need a nurse to tell them that they will spend the rest of their life in and out of hospitals. What initial action should the nurse take? Confront the client about their rude and unacceptable behavior and attitude. Offer the client the opportunity to discuss their feelings of anger. Ask the client's parents to calm the client so the nursing assessment can be completed. Reassure the client that they will not need to spend the rest of their life in and out of hospitals. Submit

Offer the client the opportunity to discuss their feelings of anger. Using therapeutic communication techniques, the nurse can provide the opportunity for the client to deal with his concerns.

The client has been receiving antibiotic therapy for several days. The client has a mild elevation in blood pressure and a 2 × 2 cm bruise in the antecubital space, where blood was obtained earlier that day and has had two diarrheal stools in 4 hours. The nurse is concerned that he is exhibiting signs of hepatoxicity related to antibiotic use.The client has been receiving antibiotic therapy for several days. The client has a mild elevation in blood pressure and a 2 × 2 cm bruise in the antecubital space, where blood was obtained earlier that day and has had two diarrheal stools in 4 hours. The nurse is concerned that he is exhibiting signs of hepatoxicity related to antibiotic use. Which diagnostic test should the nurse request an order for to determine if the client is developing drug toxicity? Culture and sensitivity. Therapeutic index. Half life. Peak and trough.

Peak and trough. Serum drug levels are obtained at the highest (peak) and lowest (trough) levels, which provides useful information regarding the amount of drug the individual client has in the bloodstream. If the trough is greater than the acceptable limit for the drug, the next dose should be withheld and the blood level rechecked 6 hours later.

The nurse knows that before drawing arterial blood gases, which interventions are the most important to be performed? (Select all that apply. One, some, or all options may be correct.) Perform Allen's Test. Use sterile technique. Utilize clean technique. Check two client identifiers. Draw blood gas after applying oxygen.

Perform Allen's Test. Use sterile technique. Check two client identifiers. *The Allen's test is performed prior to drawing an arterial blood test. It involves the nurse compressing both radial and ulnar arteries at the same time. The client's hand should become white as a result of the occlusion. The client's hand color should return as soon as the nurse releases both arteries.

Before pouring the suspension, the nurse determines that the medication and dose on the bottle's label are correct as prescribed, but the client name listed on the bottle is incorrect. Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy? HCP. Pharmacist. Client. Charge nurse. Submit

Pharmacist. Incorrectly labeled medications are the responsibility of the pharmacist.

Immediate Postoperative Care The surgery is successfully completed without complications.Following surgery, the client is admitted to the Post Anesthesia Care Unit. The operative report indicates that the client had a left hip replacement under general anesthesia. The initial nursing assessment reveals that the client is not responding to verbal stimuli. Their vital signs are T 97.6° F (36.4° C), P 88, R 14, and BP 130/70. What action should the nurse implement first? Position the client on her side. Observe the surgical dressing. Place the call bell within reach. Remove the oral airway.

Position the client on her side. During the immediate postanesthesia period, the unconscious client should be positioned on the side to maintain an open airway and promote drainage of secretions.

The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document? Excessive pallor. Unusual skin mottling. Dependent sacral rubor. Reactive hyperemia.

Reactive hyperemia. Reactive hyperemia occurs when tissue is relieved of pressure. It is considered abnormal when the redness lasts longer than 1 hour and the surrounding tissue does not blanch.

Once the OR team has assembled in the room, the circulating nurse calls for a time out. What action should the nurse take during the time out? Ensure that sufficient surgical supplies are available. Check that all surgical personnel are properly attired. Review the scheduled procedure, site, and client. Confirm that informed consent has been obtained.

Review the scheduled procedure, site, and client. A time out, the designated method for final verification before surgery begins, is a component of The Joint Commission's universal protocol to prevent wrong site, wrong procedure, wrong person surgery.

It is most important to include this group in which aspect of the client's overall care? Reviewing class notes and studying for exams. Helping the client plan meals to promote wound healing. Purchasing wound care supplies for the client. Reminiscing about life when they were all younger. Submit

Reviewing class notes and studying for exams. The young adult is developmentally involved in establishing intimacy and working toward future goals. In addition, studying with his peers will help maintain a sense of normalcy for the client. Other tasks can easily be performed by other groups, such as family members. This task can best be performed by his peers.

Intraoperative Care The client is transferred to a stretcher and taken to the operating room (OR). The nurse assists the client off the stretcher and onto the OR table. After general anesthesia is induced, the nurse positions the client for surgery. Which nursing diagnosis has the highest priority at this time? Ineffective protection. Ineffective tissue perfusion. Risk for perioperative-positioning injury. Risk for imbalanced body temperature.

Risk for perioperative-positioning injury. During surgery the client may remain in one position for a prolonged period. The nurse must ensure that the client is protected from injury secondary to inappropriate positioning.

Pharmacologic Calculations When the client arrives on the unit, the nurse notes that their IV is wide open. Review of the client's postoperative prescriptions indicates that sodium chloride 0.9% is to infuse at 75 mL/hour, alternating with Lactated Ringer's solution at 75 mL/hour. An infusion pump is not immediately available, so the nurse notes that the infusion tubing has a drop factor of 15 drops/mL and resets the IV. At what rate in drops/min, should the IV infuse? (Enter numeric value only. If rounding is required, round to the whole number.)

19

When the nurse begins teaching about the benefits of early mobilization following surgery, the client states, "Oh, I know if I stay in bed very long I will get bedsores." How should the nurse respond? "Getting a bedsore is very serious. Sometimes people die from infected bedsores." "The nurses will make sure you do not stay in bed long enough to get bedsores." "Bedsores are one of many problems that can occur from prolonged bedrest." "Those are now called pressure ulcers because they are caused by pressure."

"Bedsores are one of many problems that can occur from prolonged bedrest." This response acknowledges the client's previous learning and promotes further learning related to other complications of immobility such as thrombus formation, constipation, and atelectasis.

Surgical Preparation The next week, the client arrives at the surgery center 3 hours before their scheduled surgery. Which question is most important for the nurse to ask the client during the admission interview? "Have you had anything to eat or drink since midnight?" "Are any of your family members or friends here with you?" "Do you understand you will be admitted to the hospital following surgery?" "Did you bring any valuables with you that need to be stored during surgery?"

"Have you had anything to eat or drink since midnight?" Ensuring that the client has remained NPO for the prescribed length of time before surgery is critical to prevent vomiting and aspiration during surgery.

After the client stops crying, she states, "My father was in so much pain before he died. Talking about pain brings back so many memories." How should the nurse respond? "We do not need to talk about pain control today if it makes you sad." "Perhaps you need to see a counselor to help you resolve your grief." "It sounds as if you went through a difficult time when your father died." "You need to focus on your own needs now and not on past memories."

"It sounds as if you went through a difficult time when your father died." This open-ended acknowledgment of the client's distress is therapeutic and allows the opportunity for further discussion by the client if desired.

Which response by the client is of most concern to the nurse? "I usually get up during the night at least once to urinate." "It takes me longer to urinate than it did when I was younger." "My urine had a foul smell this morning." "My urine is yellow and pale in color."

"My urine had a foul smell this morning." New onset of a foul smell in the urine could be a sign of a urinary tract infection (UTI) and should be investigated further. Bladder (cystitis) and kidney (pyelonephritis) infections are common problems in clients with diabetes.

While the nurse begins to assess the client, another nurse finds an infusion pump and prepares a prescribed "now" dose of an intravenous antibiotic. The prescription is for 2 grams of cefazolin, which arrives from the pharmacy diluted in 50 mL of sodium chloride 9% and is to be administered over 30 minutes. At what rate in mL/hr, should the infusion pump be set? (Enter numeric value only. If rounding is required, round to the whole number.)

100

Which result of the dipstick urinalysis does the nurse recognize as abnormal? (Select all that apply.) +1 Ketones. pH 5.0. Absence of glucose. Scant sediment. Trace leukocytes.

+1 Ketones. Scant sediment. Trace leukocytes.

After the client receives the first dose of linezolid, the nurse reports to the HCP that a rash and itching develop on his thorax, but he has no respiratory symptoms. Which class of medication should the nurse expect to administer? A 5HT3 receptor antagonist, such as palonosetron. An adrenergic medication, such as epinephrine. A tocolytic medication, such as terbutaline. An antihistamine, such as diphenhydramine. Submit

An antihistamine, such as diphenhydramine. An antihistamine should control the itching and rash of this reaction. Rash and itching are identified side effects of linezolid. The nurse should, however, continue to monitor for a more severe allergic response.

The nurse observes that the reddish area is round and is directly over the client's sacrum. The skin is intact. In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? (Select all that apply. One, some, or all options may be correct.) Apply light pressure to the area with the fingertips. Measure the diameter of the redness. Obtain a wound culture. Gently lift a fold of skin. Observe for wound approximation.

Apply light pressure to the area with the fingertips. Measure the diameter of the redness.

The nurse notifies the HCP of sinus tracts discovered during the assessment and receives an order to irrigate the wound with sodium chloride (NS). Which irrigation technique is best? Pour the saline directly onto the wound from the bottle. Moisten a sterile gauze pad and pat the gauze over the wound. Irrigate as gently as possible using a 60-mL bulb syringe. Apply steady pressure using a 35 mL syringe and 19-gauge needle.

Apply steady pressure using a 35 mL syringe and 19-gauge needle. Using a 35 mL syringe and 19-gauge needle provides 8 pounds per square inch (PSI), which applies adequate pressure to ensure effective irrigation. Safe, effective pressure is between 4 and 15 PSI. More than 15 PSI will drive bacteria into the wound and destroy healthy tissue.

Which laboratory value needs to be reported immediately? Serum creatinine 1.2 mg/dL (91.5 mcmol/L). Arterial pH 7.05. Negative ketones. Serum osmolality 285 mOsm/kg (285 mmol/kg). Submit Previous Section

Arterial pH 7.05. An arterial pH below 7.35 indicates an abnormal blood gas and reflects a shift to an acidotic state. This is an emergency situation.

What action should the nurse take to assess for atelectasis? Auscultate the client's breath sounds. Observe the appearance of the sputum. Determine the client's temperature. Measure the client's blood pressure.

Auscultate the client's breath sounds. Atelectasis is a condition in which the alveoli collapse. Dull or absent breath sounds, along with changes in breathing patterns, are expected findings when atelectasis occurs.

The nurse correctly uses which technique when pouring the suspension? Hold the medication bottle up to eye level. Hold the medication cup up to eye level. Place the medication cup on a flat surface at eye level. Place the medication bottle on a flat surface at eye level. Submit Previous Section

Place the medication cup on a flat surface at eye level. To safely measure the prescribed dose, the medication cup must be on a flat surface at eye level.

During the course of antibiotic treatment with linezolid, which of the client's serum laboratory values requires intervention by the nurse? Platelet count (100 x 103/mcL (100 X 109 /L) Magnesium 1.82 mg/dL (0.75 mmol/L). Creatinine 1.2 mg/dL (91.5 mcmol/L). Potassium 3.5 mEq/L (3.5 mmol/L). Submit Previous Section

Platelet count (100 x 103/mcL (100 X 109 /L) This medication has been shown to decrease platelet count (thrombocytopenia). Normal platelet count is 130-400 x 103/mcL (130-400 X 109 /L).

What nursing action is most important? Observe the appearance of the client's oral mucosa. Assess the client for any signs of excessive bruising. Review common side effects of each of the medications. Explain the need to withhold the warfarin prior to surgery.

Explain the need to withhold the warfarin prior to surgery. Anticoagulants increase the risk for bleeding during surgery and the postoperative period, so the nurse must explain the need to withhold the warfarin prior to surgery and instruct the client to contact the surgeon to determine how long before surgery the medication should be stopped.

The HCP prescribes 1000 mL dextrose 5% with normal saline 0.9% and 20 mEq/L potassium chloride (KCl) to infuse at 100 mL/hr. The nurse is correct to question which additive to this infusion prescription? Normal saline (NS) and Potassium chloride (KCl). Normal saline (NS). Dextrose (D5). Potassium chloride (KCl).

Dextrose (D5). Solutions that contain dextrose are not recommended for client with diabetes because they can result in the rise of insulin, which will cause a decreased level of potassium in the blood. Dextrose may be prescribed for a client with diabetes to prevent low blood sugar during surgery. As a result of the many treatment and approaches to diabetes, it is important for the nurse to clarify the drug and intravenous fluid prescriptions with the HCP.

Which data is most important to report to the HCP? Dyspnea. Constipation. Heartburn. Pallor.

Dyspnea. Dyspnea can result from nutritional problems and may be indicative of anemia; therefore, it is the most important symptom to report.

The nurse encourages the client to select which breakfast items to provide a good source of protein? Whole wheat toast with butter. Bagels and cream cheese. Oatmeal and a banana. Eggs and orange juice. Submit

Eggs and orange juice. Eggs are a good source of protein, iron, and zinc, which are all important for wound healing. Citrus juices, such as orange juice, are a good source of vitamin C, which is also important for wound healing.

Along with clinical manifestations, which common laboratory finding indicates dehydration? (Select all that apply.) Elevated hemoglobin and hematocrit. Decreased BUN. Increased serum osmolarity. Increased urine specific gravity. Increased serum glucose.

Elevated hemoglobin and hematocrit. Increased serum osmolarity. Increased urine specific gravity. Increased serum glucose.

Based on the information gathered during the nurse's assessment, the HCP prescribes low doses of regular insulin by continuous IV infusion. In addition to the insulin, which immediate measure would be indicated in the treatment of the client? (Select all that apply.) Prednisone. Epinephrine. Potassium supplements. Sodium bicarbonate. Sodium chloride 0.9%.

Potassium supplements. Sodium bicarbonate. Sodium chloride 0.9%.

The nurse observes that the word, "Yes" has been marked on the client's left hip, and the word, "No" has been written on their right hip. What action should the nurse implement? Use an antimicrobial agent to cleanse the operative site. Take a photograph of the markings to place in the chart. Confirm that the left hip is the site of the scheduled surgery. Reassure the client that the surgeon will not make a mistake.

Confirm that the left hip is the site of the scheduled surgery. The nurse should ensure that the markings on the hips are correct to help reduce the potential for error during surgery. When the surgical site involves a distinction between left and right sides of the body, marking the site is a required component of The Joint Commission's universal protocol to prevent wrong site, wrong procedure, wrong person surgery.

The client is febrile with temperature of 101.5°F (38.6°C). Based on this information, which intervention should the nurse implement first? Contact the lab and request blood cultures be drawn. Administer acetaminophen per hospital protocol. Contact the HCP for a prescription for an antibiotic. Retake temperature with a tympanic thermometer.

Contact the lab and request blood cultures be drawn. Blood culture specimens are always drawn before giving acetaminophen or starting antibiotic therapy because the antibiotic usually interferes with the organism's growth in the laboratory.

The nurse considers which pharmacological age-related principle when administering medications or monitoring the effects of medications in the older client? (Select all that apply.) Gastric pH is often decreased in the older client. Decreased cardiac output increases the risk for adverse drug reactions. Mucosal edema can increase the absorption of drugs. Drugs administered intravenously have a faster absorption rate than oral drugs. Dehydration can prolong the half-life of drugs.

Decreased cardiac output increases the risk for adverse drug reactions. Drugs administered intravenously have a faster absorption rate than oral drugs. Dehydration can prolong the half-life of drugs.

During the client's hospital stay, the HCP prescribes insulin pens to replace the client's insulin syringes and vials. The nurse teaches the client to dial the pens to the prescribed amount and to use a magnifying glass to verify that the amount of insulin is correct with each injection. The nurse ensures that the two insulin pens are clearly marked as glargine or lispro so the client can identify them easily. The nurse understands that which information is correct regarding the prescribed insulin? Glargine is a rapid-acting insulin typically administered 15 minutes before meals. Lispro is an intermediate-acting insulin that peaks in 4 to 10 hours. Glargine does not have a peak interval. Lispro is typically given at bedtime on an empty stomach.

Glargine does not have a peak interval. Glargine, a long-acting insulin, has an onset of 1 to 2 hours, has no pronounced peak, and has a duration of 24+ hours.

Based on the lab data provided by the nurse, the HCP prescribes the transfusion of 2 units of packed red blood cells as soon as possible. Once the first unit of packed red blood cells is ready, the nurse obtains the blood from the blood bank. When the nurse enters the client's room to begin the transfusion, the UAP is giving the client a partial bath. What action should the nurse take? Place the unit of blood in the medication refrigerator until the client's personal care is completed. Hang the transfusion of packed cells while the UAP continues to complete the client's personal care. Lock the unit of blood in the computerized medication cart and assist the UAP in completing the personal care. Return the blood to the blood bank and send the UAP to obtain the blood when the personal care is completed.

Hang the transfusion of packed cells while the UAP continues to complete the client's personal care. Transfusion of the blood is a higher priority than personal care. If necessary, the remainder of the care can be delayed.

Which objective sign indicates dehydration? (Select all that apply.) Hematuria. Increased urine output. High creatinine levels. Postural hypotension. Heart rate greater than 100 bpm.

High creatinine levels. Postural hypotension. Heart rate greater than 100 bpm.

The home care nurse observes that the client's PI is red, with obvious granulation tissue filling in the wound crater. What teaching should the nurse provide? Another round of antibiotic therapy will probably be needed. Hydrocolloid dressings should be continued over the ulcer. Debridement of the pressure ulcer must be restarted. The pressure ulcer should now be kept open to the air. Submit Previous Section

Hydrocolloid dressings should be continued over the ulcer. The healing ulcer continues to need the protection and moist environment provided by a hydrocolloid dressing.

When monitoring the client's respiratory status, which symptom provides the nurse with the earliest indication of respiratory difficulty? Hypoxia. Dusky nail beds and lips. Decreased pulse rate. Cyanosis.

Hypoxia. Hypoxia is an early sign of respiratory distress. The nurse assesses respiratory depth, rate, and effort and listens for abnormal breath sounds that suggest breathing difficulty.

During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy. What action should the nurse implement? Apply heat to reduce the inflammation that has occurred at these sites. Notify the healthcare provider (HCP) that the client is retaining excess fluid. Reassure the client that no pressure damage is present at these sites. Identify these areas as sites where pressure damage has occurred.

Identify these areas as sites where pressure damage has occurred. Palpable changes in the consistency of the tissue underlying a bony prominence, often described as "spongy," is an indication that pressure damage has occurred. Additional manifestations may include a change in skin temperature and induration.

The nurse teaches the client safe transfer techniques and consults with the physical therapist to begin ambulation activities as soon as possible. What is the rationale for the inclusion of these actions in the client's plan of care? Frequent activity will distract the client from their concerns. Maintaining a safe environment reduces client depression. The client should depend on the therapist rather than the nurse. Increased mobility will promote an improved sense of control.

Increased mobility will promote an improved sense of control. Increasing mobility should result in increased independence and an improved sense of control, which will reduce the client's feelings of helplessness.

Before the client's bath, the nurse examines the client's right heel and documents a diabetic nonhealing ulcer. A dressing change is prescribed. Prior to changing the dressing on the client's right heel wound, the nurse should first take which action? Inspect the feet carefully for temperature, sensation, and drainage. Elevate the affected foot. Avoid weight-bearing activities. Administer broad-spectrum antibiotics. Submit Previous Section

Inspect the feet carefully for temperature, sensation, and drainage. An inspection must be done by the nurse to assess for drainage in case a culture and sensitivity test needs to be done to rule out infection. Peripheral neuropathy may begin with nerve irritation and pain that progresses to the loss of sensation to fine touch. Diabetic clients may ignore or be unaware of irritation or injury to the feet.

The nurse anticipates that the client will receive which treatment for pernicious anemia? Iron supplements by mouth daily. Increase in vitamin C in the diet. Intramuscular injection of vitamin B12. Prescription strength folic acid supplements. Submit Previous Section

Intramuscular injection of vitamin B12. Pernicious anemia is a deficiency of vitamin B12 that is often caused by a lack of intrinsic factor.

While assessing the client, the nurse observes that the surgical dressing is in place on the left hip, with no visible drainage. How should the nurse document this finding? No problems with dressing on left hip. Left hip dressing clean, dry, and intact. Dressing present over left hip incision. Incision well-approximated with no drainage.

Left hip dressing clean, dry, and intact. This documentation is concise but thorough, providing a clear picture of the assessed data.

Which result can affect drug distribution and influence drug-to-drug interactions? Elevated BUN. Low serum albumin levels. Reduced glomerular filtration rate. Elevated creatinine levels.

Low serum albumin levels. Serum albumin levels can affect the binding of drugs. Low levels of albumin can result in toxic effects, especially in the elderly.

Following wound irrigation, the nurse plans to apply a wet-to-dry dressing. What is the purpose of this type of dressing? Mechanically debride the tissue. Facilitate tissue healing. Decrease risk of infection. Preserve granulation tissue. Submit Previous Section

Mechanically debride the tissue. Moistened gauze is placed on the wound and allowed to dry. It then adheres to the wound tissue and debrides necrotic or infected tissue as it is removed.

The nurse creates a care plan for the client and records a nursing problem of knowledge deficit related to signs and symptoms of hypoglycemia. Which teaching point should be included in this plan of care? (Select all that apply.) Report a blood glucose reading of 70 mg/dL (3.89 mmol/L). Notify the HCP if there is headache or irritability. Report excessive hunger and/or weakness. Report cold and clammy skin. Notify the HCP of hot, dry skin.

Notify the HCP if there is headache or irritability. Report excessive hunger and/or weakness. Report cold and clammy skin.

A month later, the client arrives in the emergency department at the local hospital and reports having had the flu and has spent most of their time in bed for the last several days. The client has been experiencing vomiting and diarrhea. The nurse observes that the sacral PI is open, has a crater-like appearance, and is draining a large amount of thick yellow-tan fluid with an unpleasant odor. A small amount of eschar is present. The client is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis. How should the nurse describe the drainage in documenting the wound? Infectious. Purulent. Serous. Sanguineous. Submit

Purulent. Purulent refers to something that contains or produces pus. Pus is an indication that an infection is likely.

The nurse formulates the client's plan of care and notes that teaching should be initiated related to the client's diabetic peripheral neuropathy. The nurse understands that which symptom is associated with diabetic peripheral neuropathy? (Select all that apply.) Reduced ability to feel pain or temperature in the extremities. Frequent UTIs or incontinence. Muscle weakness and difficulty walking. Problems with erectile dysfunction. Extreme sensitivity to touch.

Reduced ability to feel pain or temperature in the extremities. Muscle weakness and difficulty walking. Extreme sensitivity to touch.

Which information about the client is of most concern to the nurse? Blood glucose rises from 120 mg/dL (6.66 mmol/L) to 125 mg/dL (6.94 mmol/L) in 8 hours. Washes the hands with soap and water and allows alcohol swab wipe to dry before performing chemstick. Reports a new onset of blurry vision. Depends on handwritten notes to recall his last blood glucose reading.

Reports a new onset of blurry vision. Blurry vision can indicate cataracts, glaucoma, optic nerve damage, or diabetic retinopathy.

The nurse reports the client's blurry vision to the healthcare provider (HCP), who then evaluates and treats the client for worsening diabetic retinopathy. Which other symptom should the nurse expect to find in a client with a diagnosis of diabetic retinopathy? (Select all that apply.) Reports of floaters. Loss of vision. Jaundice of the sclera. Difficulty with color perception. Pupil fixation.

Reports of floaters Loss of vision. Difficulty with color perception.

The client is placed on an electrocardiogram (EKG) monitor because of a concern about hypokalemia and potential dysrhythmias. Which pattern should the nurse report immediately to the HCP? ST depression and "U" waves. Sinus tachycardia. Sinus bradycardia. Sinus arrhythmia. Submit

ST depression and "U" waves. After insulin therapy, hypokalemia is expected because the potassium shifts back into the cell. Hypokalemia is a serum potassium level less than 3.5 mEq/L and can be life-threatening. Flat or inverted T waves or increased "U" waves can occur with hypokalemia.

Nursing Plan of CareThe nurse is assisting the client to the bedside commode on the second postoperative day. The client states, "I have never had to depend on anyone before. I like to take care of myself. I feel so helpless." In response to these remarks, the nurse plans care for the client based on the identification of which nursing diagnosis? Disturbed body image. Situational low self-esteem. Anticipatory grieving. Impaired physical mobility.

Situational low self-esteem. The client's remarks regarding feelings of helplessness relate to her sense of how she perceives herself and her present ability to care for herself.

The nurse suspects that the client's wound has developed a sinus tract, or tunneling. Which equipment should the nurse utilize to assess the length of the tract? Sterile gloves and lubricant. Sterile tape measure. Sterile cotton-tipped applicator. Sterile irrigation tray with syringe.

Sterile cotton-tipped applicator. A sinus tract is an extension of the wound under the skin, and it is best assessed by gentle insertion of a sterile cotton-tipped applicator to determine the location and length of the tunneling. Once length is noted with applicator, then use tape measure to document exact length.

The nurse understands that which concept is important when addressing the client's physiological and psychosocial needs? Socialization is important, but community dining should be avoided because the timing is restrictive and could lead to adverse reactions of medications. The client's need for a special diabetic meal plan overrides the benefits of community dining; therefore, meals should be prepared in the apartment. The client's diabetes mellitus should not present a problem for community dining. The nurses in the community dining center should take any food containing sugar away from clients who have diabetes mellitus.

The client's diabetes mellitus should not present a problem for community dining. The client should be able to order or select dishes on a diabetic meal plan from the community dining center. A special dietary need will not typically prevent a client from enjoying the social benefits of a community dining experience.

The nurse discusses postoperative pain management with the client and explains the use of a patient-controlled analgesia (PCA) pump. The client expresses fear that they might accidentally overdose herself, since they will be sleepy after surgery. How should the nurse respond? "You will only use the PCA pump for the first 24 hours after surgery." "The surgeon will prescribe the dose of medication that is correct for you." "I will tell the surgeon that you prefer that the nurses administer your pain medicine." "The pump has a control device that prevents you from taking too much medicine."

The pump has a control device that prevents you from taking too much medicine." This response provides the client with the information needed to understand that she cannot overdose herself while she is sedated after surgery.

The nurse understands that which physiological age-related change is often responsible for dehydration in the older client? Taste buds are more sensitive, leading to a decreased desire for liquids. Thirst decreases, contributing to less fluid intake. Increased glomerular filtration rate. Constriction of the esophagus prevents fluid metabolism.

Thirst decreases, contributing to less fluid intake. Older adults have a higher baseline osmolality and, thus, a higher osmotic operating point for thirst sensation. As the thirst mechanism decreases, older adults are more likely to take in fewer fluids. Urine output rises from osmotic diuresis.

The nurse teaches the client to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 PI? Transparent film dressing. Aherent film dressing. Gauze dressing. Hydrogel covered with a foam dressing. Submit

Transparent film dressing. This type of dressing allows for visualization of the area and protects it from shear.

The client tells the nurse that taking warm baths helps his joints feel better. The nurse is concerned that peripheral neuropathy may cause the client to unintentionally burn the skin when taking a bath at the assisted living facility. Which instruction related to bath safety is best? Use the toes or an elbow to make sure that the water is not too hot. Let hot bath water sit for 10 minutes before entering the bath. Use equal amounts of hot and cold water when preparing the bath. Use a bath thermometer to ensure that the temperature is below 102° F (38.8° C).

Use a bath thermometer to ensure that the temperature is below 102° F (38.8° C). Use of an unbreakable thermometer to ensure a water temperature below 102° F (38.8° C) will help prevent burns for the client with peripheral neuropathy.

The nurse develops a plan of care to prevent the client's feet from further skin breakdown. Which action will help to maintain skin integrity? (Select all that apply.) Use heel protectors. Use a special mattress or foot cradles. Apply drying agents, such as alcohol, to the skin. Apply skin moisturizers to prevent cracking. Instruct the client to wear clean white socks.

Use heel protectors. Use a special mattress or foot cradles. Apply skin moisturizers to prevent cracking. Instruct the client to wear clean white socks.

The nurse asks the client additional questions related to the urinary symptoms. The client reports mild pain with urination. The client's temperature is 98° F (36.7° C). The nurse reports the foul smelling urine to the HCP who prescribes a random dipstick urinalysis test. The nurse should instruct the client to take which action first when collecting a urine sample? Collect 1 or 2 ounces of urine. Wipe the genital area clean. Dry any excess urine from the outer specimen cup. Hold the cup a few inches from the urethra.

Wipe the genital area clean.

The nurse plans to administer an ordered dose of linezolid, an antibiotic, which interferes with the production of proteins that bacteria need to multiply and divide. The order states, "linezolid suspension 400 mg by mouth (PO) every 12 hours for 14 days." The medication is labeled, "100 mg/5 mL." blankHow many mL of medication will the nurse administer?

20

The HCP orders intravenous (IV) antibiotic ampicillin 1 gram every 6 hours. The pharmacist delivers the client's dose of ampicillin in a 100 mL bag of sodium chloride 0.9%. In order to deliver the medication over 30 minutes, the nurse sets the pump to deliver how many mL/hr?

200

The nurse understands that the older client should drink at least 30 mL/kg of fluid each day with a minimum of 1,500 mL/day. The client weighs 226 lb (102.7 kg). How many mL of fluid should the client drink per day?

3081

The HCP prescribes clindamycin 900 mg in 100 mL over 30 minutes. The IV tubing drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many drops per minute?

50

The HCP prescribes 1000 mL normal saline 0.45% with 20 mEq/L potassium chloride (KCl) to infuse at 125 mL/hr. The nurse calculates that it will take how many hours for the infusion to be complete?

8

The order states, "linezolid suspension 400 mg by mouth (PO) every 12 hours for 14 days." The medication is labeled, "100 mg/5 mL." The nurse is scheduled to administer 20 mL per their calculation. The nurse reviews the drug reference guide, which indicates that the recommended daily dosage for the medication is 800 to 1200 mg. What is the total daily dosage (in mg) that the client will be receiving?

800

After the HCP is notified of the lab results, the nurse receives a prescription to start oxygen (O2) at 2 liters per nasal cannula at 24% concentration with a recheck of arterial blood gases (ABGs) in two hours. The nurse should interpret which finding as expected limits for the client with COPD? 87% O2 saturation. 96% O2 saturation. 100% O2 saturation. 75% O2 saturation.

87% O2 saturation. A client with COPD who retains CO2 has adapted to high blood CO2, and relies on low PaO2 to stimulate breathing. A high concentration of O2 may raise the PaO2 level so that the client's stimulus to breathe is lost and respiratory depression may result. Not all clients with COPD rely on hypoxic drive; retention of CO2 must be confirmed by blood gas analysis.

The nurse reviews the client's medications. The client indicates that she has been taking two medications; hydrochlorothiazide, a diuretic, and warfarin , an anticoagulant, every day for more than a year. Which vital sign requires follow-up by the nurse? BP of 160/88 mmHg. Pulse of 68 beats/min. Respirations of 14 breaths/min. Temperature of 97.2° F (36.2° C).

BP of 160/88 mmHg. This blood pressure is elevated and requires further action by the nurse.

The client mentions that he feels "blue" lately because his wife died one year ago, and his children live out of state and seldom visit. The nurse knows that the greatest risk for major depression includes which event? Being retired from the military. The realization of growing older. Inability to attend church regularly. Becoming widowed within the past year.

Becoming widowed within the past year. The combinations of sadness, loneliness from losing a loved one in widowhood, and hopelessness leads to social withdrawal. Those feelings place an older adult at greater risk of suffering from major depression because older adults are reluctant to adapt to changes.

The nurse observes that the Hemovac drain is full of sanguineous drainage. What action should the nurse implement first? Compress the drain and re-establish suction. Empty the drain and measure the amount of drainage. Page the surgeon to report the finding. Document the appearance of the drainage.

Empty the drain and measure the amount of drainage. The nurse should first empty the drain and measure the drainage, then compress the drain to re-establish suction. Documentation of the findings and notification of the surgeon can then be done.

At the end of the appointment, the nurse provides client teaching about measures to promote healing and to prevent further tissue destruction. To provide pressure relief at night, the nurse teaches the client to sleep in which position? Supine with the head of the bed elevated. Supine with a foam wedge between the knees. Thirty-degree lateral inclined position. Full side-lying position supported with pillows. Submit

Thirty-degree lateral inclined position. This position best reduces pressure on bony prominences where PI frequently develop. Pillows and foam wedges may be used for support and protection in this position.

After the first dose, the client develops a maculopapular rash on the torso. The nurse notifies the HCP and the ampicillin is discontinued. Which antimicrobial medication is a safe alternative for clients with penicillin allergies? (Select all that apply.) Vancomycin. Cephalexin. Clindamycin. Ticarcillin. Erythromycin.

Vancomycin. Clindamycin. Erythromycin.

Which serum lab value requires follow-up by the nurse? Sodium of 135 mEq/L (135 mmol/L). WBC of 14,000/μL (4.0 x 109/L). Creatinine of 0.7 mg/dl (61.9 mmol/L). Hemoglobin of 14 g/dL (140 g/L).

WBC of 14,000/μL (4.0 x 109/L). The normal WBC count is 4,000 to 10,000/μL (4.0-10 x 109/L). An increase may indicate the onset of an infection, which may be a contraindication to surgery. The nurse should notify the surgeon of this abnormal lab value.

The client apologizes to the nurse and expresses how discouraged they are about the bed sore and the infection. Which nursing response best promotes effective communication? Clarify the difference between an infected pressure injury and a bed sore to the client. Explain to the client that they should not allow themself to become discouraged. Help the client identify the concerns he is trying to cope with at this time. Tell the client that he does not to worry about an infection that is almost resolved. Submit Previous Section

Help the client identify the concerns he is trying to cope with at this time. This response acknowledges the client's experience and encourages further insight and verbalization by the client.

While cleansing the incision, the nurse observes that the staples are intact, but a 2-cm gap has opened at the bottom of the incision. How should the nurse document this finding? Inferior edges of incision approximated. Small area of dehiscence at inferior portion of incision. Evisceration of incision noted at inferior edge. Wound healing via secondary intention.

Small area of dehiscence at inferior portion of incision. An unintentional opening in a surgical wound prior to healing is referred to as dehiscenc

Postoperative Wound Management During the postoperative assessment, the nurse observes the client's surgical site. The left hip dressing has a moderate amount of sanguineous drainage. What action(s) should the nurse implement? (Select all that apply. One, some, or all options may be correct.) Apply pressure to the site. Elevate the leg on a pillow. Observe the linens under the hip. Use sterile technique to replace the dressing. Mark the amount of drainage on the dressing.

1) Observe the linens under the hip. Gravity pulls drainage down, so the nurse should inspect the area below the surgical site for additional drainage. 2) Mark the amount of drainage on the dressing. Marking the amount of drainage on the dressing will allow for later comparison.

The nurse prepares to contact the HCP with lab results, knowing that all lab information must be collected prior to reporting. Which lab results does the nurse need to report first to the HCP? Arterial Blood Gases (ABGs), O2 saturation, White Blood Cell Count (WBC). Potassium (K+), Chloride (Cl), Creatinine (Cr). Glucose, HCO3, Blood Urea Nitrogen (BUN). Platelets, Sodium (Na+), Hemoglobin (HG)/Hematocrit (Hct).

Arterial Blood Gases (ABGs), O2 saturation, White Blood Cell Count (WBC). Normal values for adults are pH 7.35 to 7.45 , PaCO2 35 to 45 mmHg (4.6 - 5.9 kPa), PaO2 80 to100 mmHg (>10.6 kPa), HCO3 22 to 26 (22-26 mmol/L), O2 saturation 96% to 100%. The labs for the client are abnormal. As COPD worsens, oxygen in the blood decreases and carbon dioxide increases, resulting in chronic respiratory acidosis. Once baseline ABG values are obtained and communicated to the HCP, treatment and monitoring can begin. The WBC count is high and is indicative of possible infection which should be reported to the HCP.

After completing the admission interview, the nurse reviews the client's medical record and notes that the surgical consent form is filled out but is not signed by the client. What action should the nurse take? Ask the client if she has received sufficient information to sign the consent form. Call the operating room and notify the staff that the surgery needs to be cancelled. Notify the surgeon of the need to come to the client's room so the consent can be signed. Inform a family member of the need to serve as a witness to the client's signature.

Ask the client if she has received sufficient information to sign the consent form. The nurse may witness the client's signature if the nurse is able to determine that the client has been sufficiently informed of the necessary information.

The nurse identifies that the client has developed a Stage 1 pressure injury and is concerned that the client may have other pressure injuries. Which areas are most important for the nurse to observe for additional pressure injuries (PI)? Distal tips of the toes. Lower abdominal folds. Ischial tuberosities. Thighs and calves.

Ischial tuberosities. PI typically occur over bony prominences, such as the heels, ankles, ischial tuberosities, and sacral area. The client is in a wheelchair which makes the ischial tuberosities at greater risk for breakdown. While bony prominences are the most common sites for PI development, the nurse should perform a complete skin assessment.

Therapeutic Communication While discussing postoperative pain management strategies with the client, the nurse observes them begin to cry. What action should the nurse take? Quietly sit with the client. Offer reassurance about the surgery. Calmly continue the preoperative instructions. Leave the room until the client has composed herself.

Quietly sit with the client. Offering one's presence is a caring and therapeutic response.

The client is currently receiving Lactated Ringer's solution IV at a rate of 75 mL/hour. In transfusing the 250 mL unit of PRBCs, what action should the nurse implement? Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution. Infuse the Lactated Ringer's solution through the IV tubing concurrently with the blood at a combined rate of 75 mL/hour. Flush the IV tubing with a 5 mL bolus of normal saline before and after the transfusion, and transfuse the blood within 1 hour. Replace the Lactated Ringer's solution with the unit of packed red blood cells and administer through the tubing at 75 mL/hour.

Stop the IV solution and transfuse the packed cells at 125 mL/hour via tubing connected to a bag of saline solution. Packed red blood cells are only compatible with normal saline. The blood should be connected to a bag of saline solution using special Y-tubing and administered within 1½ to 2 hours, if possible, but no longer than 4 hours (250 mL transfused at 125 mL/hour = 2 hours).

Blood Transfusion The nurse notifies the surgeon of the wound drainage. What lab data is important for the nurse to report to the surgeon? White blood cell count. Hemoglobin and hematocrit. Culture and sensitivity. Type and cross match.

Hemoglobin and hematocrit. The nurse is reporting the amount of surgical drainage to the surgeon due to a concern for excessive blood loss. The surgeon needs to know information related to blood volume, provided by the hemoglobin and hematocrit levels.

After establishing the priority diagnosis, the nurse identifies goals and expected outcomes. Which goal should the nurses include in the client's plan of care? The client's skin will remain intact without deterioration. The client's motor function will be restored. Client teaching will be provided. Impaired skin integrity will not occur. Submit Previous Section

The client's skin will remain intact without deterioration. A goal should be a broad statement that includes, in positive terminology, the intended effect of the planned interventions.

Considering the client's developmental stage at the age of 20, the nurse's plan of care emphasizes interaction with which group? The clients parents, aunts, uncles, and cousins. A large group of the clients former high school classmates. A small group of the clients professors from the college. The clients girlfriend and his two best male friends from the college.

The clients girlfriend and his two best male friends from the college. As a young adult, the clients primary developmental task, according to the theorist Erikson, is to develop intimacy. The nurse should emphasize interaction with a small group of intimate friends to support this developmental task.

The client was diagnosed last year with type 2 diabetes mellitus. The client explains that he is experienced with self-administration of insulin injections, three times per day. The client also states that his eating habits are not great, but he never misses an insulin injection. The client lives alone and doesn't like to eat alone, so he rarely cooks. The client explains that other than an occasional walk, he does not exercise. With the understanding that the client's eating habits lack consistency, which physiological fact about the client's nutrition is most concerning to the nurse? (Select all that apply.) The nonhealing ulcer on the client's right heel could lead to amputation. The development of hypoglycemia could be life-threatening. Lack of exercise and activity require less nutritional nutrients. Dehydration exacerbated by lack of nutrition. Lack of appetite and not wanting to eat alone could lead to malnutrition.

The nonhealing ulcer on the client's right heel could lead to amputation. The development of hypoglycemia could be life-threatening. Dehydration exacerbated by lack of nutrition. Lack of appetite and not wanting to eat alone could lead to malnutrition.