HESI DEEZ

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

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

Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.) 1. Place stethoscope in suprasternal area to auscultate from bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds

1. Place stethoscope in suprasternal area to auscultate from bronchial sounds 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds Rationale: Begin auscultation of anterior breath sounds over the trachea and larynx to identify bronchial breath sounds. Assessment should proceed down the anterior chest from side to hear bronchovesicular sounds, which are located over major bronchi around the upper sternum in first and second intercostal spaces. To hear vesicular sounds over peripheral lung fields where air flows through smaller airway, the breast tissue should be displaced so the stethoscope lies directly on chest wall. Documentation should include normal breath sounds and any adventitious findings.

When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top last action on bottom.) 1. Rub hands palm to palm .2. Interlace the fingers, 3. Dry hands with paper towel. 4. Turn off the water faucet.

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

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

1.5

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? A) Recommend weight-bearing physical activity. B) Encourage bed rest and limited mobility. C) Suggest avoiding calcium-rich foods. D) Promote a sedentary lifestyle.

A) Recommend weight-bearing physical activity.

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

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

In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement? A) Document the extent of the bruising in the medical record. B) Apply ice to the fracture site. C) Notify the healthcare provider. D) Elevate the affected limb.

A) Document the extent of the bruising in the medical record.

While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A) Discontinue the painful IV after a new IV is inserted. B) Proceed with medication administration as scheduled. C) Assess the IV site without flushing. D) Administer pain medication and reevaluate the IV site later.

A) Discontinue the painful IV after a new IV is inserted.

A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.) A. Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptors. B. T3 and T4 hormone levels are increased C. Large protruding eyeballs are a sign of hyperthyroid function D. Weight gain is a common complaint in hyperthyroidism E. Early treatment includes levothyroxine (Synthroid).

A B C

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) a. Ease the client to the floor b. Loosen restrictive clothing c. Note the duration of the seizure d. nothing f. get coffee

A B C

The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply) A. Close car windows and use air conditioner B. Avoid sudden changes in temperature C. Decrease the raw sugars in the diet D. Stay indoors when grass is being cut. E. Keep away from pets with long hair

A B D E

To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). A. Practice relaxation exercises B. Limit fluids to avoid bladder distention C. Space activities to allow for rest periods D. Avoid persons with infections E. Take warm baths before starting exercise

A C D

During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (Select all that apply) a. Natural whole almonds b. Cheddar cheese cubes c. slightly salted potato chips d. plain, air popped popcorn e. canned fruit in heavy syrup

A D

When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply). A. Fresh turkey slices and berries B. Fresh vegetables with mayonnaise dip C. Soda crackers and peanut butter D. Chicken bouillon soup and toast E. raw unsalted almonds and apples

A E

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

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

A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours? A) Agitation and threatens to harm the staff. B) Elevated body temperature. C) Elevated blood pressure. D) Increased urine output.

A) Agitation and threatens to harm the staff.

An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? A) Clarify end-of-life desires. B) Administer a blood transfusion. C) Initiate enteral tube feeding. D) Request a psychiatric consultation.

A) Clarify end-of-life desires.

An elderly female client with osteoarthritis reports increasing pain and stiffness in her right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of her symptoms? A) Destruction of joint cartilage. B) Muscle strain. C) Ligament injury. D) Bursitis.

A) Destruction of joint cartilage.

While completing an admission assessment for a client with unstable angina, which closed questions should the nurse ask about the client's pain? A) Does your pain occur when walking short distances? B) How would you describe the location of your pain? C) Can you tell me about your family history of heart disease? D) What do you typically eat for breakfast?

A) Does your pain occur when walking short distances?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first? A) Ensure the client takes a diuretic every morning. B) Monitor the client's urine output and serum sodium levels. C) Administer hypertonic saline solution IV as ordered. D) Encourage the client to increase fluid intake.

A) Ensure the client takes a diuretic every morning.

A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first? A) Explore the client's reasons for wanting to be discharged. B) Administer a sedative medication. C) Call the client's family to discuss discharge plans. D) Inform the client that she needs to remain in the unit.

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

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

A) Hydrocortisone.

Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? A) IV thyroid hormones B) Oral administration of hypnotic agents C) IV bolus of hydrocortisone D) SQ Vitamin K

A) IV thyroid hormones Rationale: Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs.

An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first? A) Insertion of a left-sided chest tube. B) Chest X-ray. C) Administration of activated charcoal. D) Esophagogastroduodenoscopy (EGD)

A) Insertion of a left-sided chest tube.

A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse? A) Leakage around catheter insertion site. B) Clear, yellow urine in the drainage bag. C) Client reporting a sensation of bladder fullness. D) Hematuria noted in the catheter tubing

A) Leakage around catheter insertion site.

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? A) Leave the room and close the door quietly. B) Politely ask the client and visitor to stop. C) Immediately administer the IV antibiotic. D) Report the situation to the charge nurse

A) Leave the room and close the door quietly.

A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture? A) Lower the left arm below the level of the heart. B) Administer a local anesthetic to the site. C) Apply a warm compress to the affected area. D) Assess the client's blood glucose level.

A) Lower the left arm below the level of the heart.

A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention? A) Maintain contact transmission precautions. B) Isolate the client in a negative pressure room. C) Administer broad-spectrum antibiotics. D) Allow the client to interact freely with other patients.

A) Maintain contact transmission precautions

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A) Monitor for secondary infections. B) Administer IV chemotherapy. C) Initiate strict isolation precautions. D) Provide pain management with opioids

A) Monitor for secondary infections. Rationale: Kaposi's sarcoma is a type of cancer that forms in the lining of blood and lymph vessels. The tumors (lesions) of Kaposi's sarcoma typically appear as painless purplish spots on the legs, feet or face.

A young adult female client with recurrent pelvic pain for 3 year returns to the clinic for relief of severe dysmenorrhea. The nurse reviews her medical record which indicates that the client has endometriosis. Based on this finding, what information should the nurse provide this client? A) Oral contraceptives increase the symptoms of endometriosis. B) The symptoms of endometriosis can increase with menopause. C) An option to diagnose disease extent and provide therapeutic treatment is laparoscopy. D) Infertile is successfully treated with removal of intra-abdominal endometrial lesions.

A) Oral contraceptives increase the symptoms of endometriosis.

A nurse who works in the nursery is attending the vaginal delivery of a term infant. What action should the nurse complete prior to leaving the delivery room? A) Place the ID bands on the infant and mother. B) Record the delivery time in the chart. C) Check the vital signs of the mother. D) Prepare the infant for breastfeeding.

A) Place the ID bands on the infant and mother.

The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? A) Plastic tubing located at the chest insertion site. B) Drainage collection chamber. C) Water-seal chamber. D) Suction control chamber.

A) Plastic tubing located at the chest insertion site.

An infant is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant's heart rate drops to 80 beats / minute. What action should the nurse take A) Slow the feeding and monitor the infant's response. B) Continue the feeding at the same rate. C) Increase the rate of the feeding. D) Stop the feeding and notify the healthcare provider

A) Slow the feeding and monitor the infant's response.

During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 F. which intervention should the nurse implement? A) Stop the transfusion and start a saline flush. B) Administer an antipyretic medication. C) Monitor the client's vital signs closely. D) Notify the healthcare provider immediately.

A) Stop the transfusion and start a saline flush.

A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse? A) Total calcium 5.0 mg/dl. B) Serum potassium 3.8 mEq/L. C) Sodium level 140 mEq/L. D) Hemoglobin level 12.5 g/dL

A) Total calcium 5.0 mg/dl. Thyroidectomy can cause hypoparathyroidism in which body produces abnormally low levels of parathyroid hormone (PTH). PTH is key to regulating and maintaining a balance of two minerals in your body — calcium and phosphorus. Low calcium levels in the blood, a complication from thyroid surgery that is usually shortterm and relatively easily treated with calcium pills. If left untreated, low calcium may be associated with muscle twitching or cramping and, if severe, can cause seizures and/or heart problems.

A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? A) Vomiting. B) Increased appetite. C) Decreased heart rate. D) Improved urine output

A) Vomiting.

A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? A. Avoid exposure to large crowds B. Do not take any over the counter medications C. Call the crisis hot line if feeling lonely D. Eat a high carbohydrate, low fat, low protein diet

A. Avoid exposure to large crowds

A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? A. Bone marrow transplantation B. Blood transfusion C. Chemotherapy D. Immunosuppressive therapy

A. Bone marrow transplantation

A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement? A. Elevate the head of the bed 60 to 90 degrees B. Measure from corner of mouth to angle of jaw C. Administer a PRN analgesic D. Assess for a gag reflex

A. Elevate the head of the bed 60 to 90 degrees

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take? A. Explain that memory loss and confusion are common with vitamin B12 deficiency. B. Ask if the client is experiencing any changes in bowel habits C. Determine if the client is taking iron and folic acid supplements D. Encourage the husband to bring the client to the clinic for a complete blood count.

A. Explain that memory loss and confusion are common with vitamin B12 deficiency. Rationale: Pernicious anemia is related to the absence of intricic factor in gastric secretions, leading to malabsorption of vit B12, and commonly causes memory loss, confusion and cognitive problems, and GI manifestations. The nurse should reassure the husband that the client's signs are consistent with the primary disease. Although B, C and D provide additional information about the client's compliance and response to therapy, a quick and dramatic response can occur after 72 hrs. of B12 injections.

During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen in the video. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem? A. Infection B. Ineffective airway clearance C. Altered comfort D. Impaired gas exchange

A. Infection

A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first?pH 7.50; PaCo2 42; HCO3 33; pO2 92 A. Infuse 0.9 % sodium chloride 500 ml bolus B. Insert nasogastric tube to intermittent suction. C. Maintain head of bed at 45 degrees D. Document strict intake and output

A. Infuse 0.9 % sodium chloride 500 ml bolus

A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first? A. Initiate a prescribed IV for parenteral fluid. B. Feed the infant 3 ounces of Isomil. C. Give the infant 5% dextrose in water orally. D. Insert a nasogastric tube for feeding.

A. Initiate a prescribed IV for parenteral fluid.

A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A. Mean arterial pressure (MAP) B. White blood cell count C. Blood culture D. Oxygen saturation

A. Mean arterial pressure (MAP)

An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. Which action should the nurse take? A. Notify the healthcare provider of the client's refusal B. Administer an oral PRN medication for agitation C. Ask for staff assistance with administering the injection D. explain that oral medications will no longer be required

A. Notify the healthcare provider of the client's refusal

The nurse is assessing and elderly bedridden client. Which finding indicates that the turning and positioning schedule is effective in protecting the client's skin? A. Reddened skin areas disappear within 15 minutes of being turned and positioned. B. No complaints of pressure or pain are verbalized by the client after being turned C. Only small areas of redness remain longer than 30 min after the client is turned. D. The client verbalizes feeling better after being turned and positioned

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

A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority? A. Signs a no-self-harm contract. B. Sleep at least 6 hours nightly. C. Attends group therapy every day D. Verbalizes a positive self-image.

A. Signs a no-self-harm contract.

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A. Watery diarrhea B. Yellow-tinged sputum C. Increased fatigue D. Nausea and headache

A. Watery diarrhea Linezolid, antibiotic, used to treat infections, including pneumonia, and infections of the skin.

The nurse is caring for four clients...postoperative hemoglobin of 8.7 mg/dl; client C, newly admitted with potassium...an appendectomy who has a white blood cell count of 15,000mm3. What intervention? A.)Determine the availability of two units of packed cells in the blood bank for client B B.)Increase the oxygen flow rate to 4 liters/minute per face mask for clientA C.)Remove any foods, such as banana or orange juice, for the breakfast tray for client C D.)Inform client D that surgery is likely to be delayed until the infection responds to antibiotics

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

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

Administer PRN dose of albuterol

The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider? A) Reports intermittent low back pain. B) Fetal heart rate of 200 beats/minutes C) Complains of early morning heartburn D) Maternal hemoglobin of 11.0 g/ dl or 110 g/l (SI)

B) Fetal heart rate of 200 beats/minutes Normal 110-160

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

B. Furosemide

An elderly male client is admitted to the urology unit with acute renal failure due to a postrenal obstruction. Which questions best assists the nurse in obtaining relevant historical data? A. "Have you had a heart attack in the last 6 months" B. "Have you had any difficulty in starting your urinary stream" C. "Have you taken any antibiotics recently" D. "Have you received any blood products in the last year"

B. "Have you had any difficulty in starting your urinary stream"

A 17-year -old male is brought to the emergency department by his parents because he has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? A. Obtain a chest X-ray per protocol. B. Place a mask on the client's face. C. Assess the client's temperature. D. Determine the client's blood pressure

B. Place a mask on the client's face.

A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide? A. "You have become dehydrated from the nausea. You will need to rest and increase fluid intake" B. "you need to seek immediate medical assistance to evaluate the cause of these symptoms" C. A urine specimen will be needed to determine what kind of infection you have developed" D. use insulin per sliding scale until the nausea resolves, and then resume your oral medication"

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

The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain? A. Degree of skin elasticity B. Appearance of wound C. Bilateral pedal pulse force D. Onset of any bleeding

B. Appearance of wound

A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, an exhibiting signs of restlessness. Which action should the nurse take fist? A. Administer PRN dose of lorazepam B. Auscultate bilateral breath sounds C. Check urinary catheter for obstruction D. Review the heart rhythms on cardiac monitor.

B. Auscultate bilateral breath sounds

Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? A. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen? B. Avoid administration of oxygen at high levels for extended periods. C. Increase oxygen rate during sleep to compensate for slower respiratory rate. D. Oxygen is less toxic when it is humidified with a hydration source.

B. Avoid administration of oxygen at high levels for extended periods.

The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take? A. Complete and file an incident (variance) report B. Call the healthcare provider who wrote the prescription C. Contact the healthcare provider review board for instructions D. Report the situation to the house supervisor

B. Call the healthcare provider who wrote the prescription

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client? A. Remain on clear liquids until the vomiting subsides B. Come to the clinic to be seen by a healthcare provider C. Make an appointment at the clinic if a fever occurs D. Take nothing by mouth until there is no more nausea

B. Come to the clinic to be seen by a healthcare provider

Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity? A. Range of motion. B. Distal pulse intensity. C. Extremity sensation. D. Presence of exudate

B. Distal pulse intensity.

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate? A. Blood pressure fluctuations means that the condition has become chronic B. Elevated blood pressure must be anticipated and identified quickly C. Hypotension leading to sudden shock can develop at any time D. Sodium intake with meals and snacks affects the blood pressure

B. Elevated blood pressure must be anticipated and identified quickly

During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond? A. I would prefer to discuss this with you privately B. Give me specific examples to support your statements C. Does anyone else on the staff fell the same way D. Your remarks are not true and are very unkind

B. Give me specific examples to support your statements

A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effect he stopped taking the medication 6 days ago. Which finding warrants immediate intervention by the nurse? A. Fluid retention. B. Hypotension and fever .C. Anxiety and restlessness. D. Increased blood glucose.

B. Hypotension and fever Rationale: Sudden withdrawal from a corticosteroid can cause sudden decreased adrenal function resulting in low serum sodium, high serum potassium, and low blood pressure, which can lead to shock and possible death. Hypotension and fever (B) are the first signs of precipitous withdrawal. Fluid retention (A), anxiety and restlessness (C), and glucose intolerance (D) are common side effects of taking a corticosteroid.

The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement? A. Inquire about food allergies and food likes and dislikes B. Talk directly to the adolescent while providing care C. Initiate open communication with the teen's parents D. Monitor vital signs and neuro status every 2 hours

B. Talk directly to the adolescent while providing care Rationale: Talking directly to the adolescent (A) who is in a sustained vegetative state provides environmental stimulation and includes him in an interpersonal relationship because he may still be able to hear and process verbal communication. (B) is not warranted for a non-acute comatose client. (C) is not warranted for a comatose client or a client who is in a vegetative state. Open communication that is compassionate and honest (D) provides support to the family, but verbal stimulation is an important aspect of caring for comatose clients and offers hope for the possibility of a response.

A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother A. Give another dose. B. Withhold this dose. C. Administer a half dose now. D. Mix the next dose with food.

B. Withhold this dose . Rationale This dose should be withheld (B) because the amount absorbed by the infant is unknown. (A and C) pose safety concerns due to the unknown absorption. (D) is not recommended because all of the mixture (food and medicine) may not be eaten.

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply). A. A bedside commode is positioned near the bed B. A saline lock is present in the right forearm C. A full pitcher of water is on the bedside table D. The client is lying in a supine position in bed E. A low sodium diet tray was brought to the room

C D

The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, what actions should the nurse take before inserting the catheter? (Select all that apply) A. Nothing B. Go outside C. Gently palpate the client's bladder for distention D. Hold the catheter 3 - 4 inches (7.5 - 10 cm) from its tip E. Secure the urinary drainage bag to the bed frame

C D E

A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse? A.Instruct the client that these mild symptoms can generally be controlled with changes in his diet B. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms C. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer D. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with food

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

A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next? A. Record "no known drug allergies" on preoperative checklist B. Assess client's allergies to non-drug substances C. Assess client's knowledge of an allergy response D. Flag "no known drug allergies" on the front of the chart

C. Assess client's knowledge of an allergy response

A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer? A. Pickle relish. B. Steak sauce. C. Fresh horseradish. D. Tomato ketchup.

C. Fresh horseradish Rationale A cardiac diet restrict sodium intake. Horseradish (C) should be recommended because it is low in sodium. (A, B, and D) are high in salt content and should not be offered.

An adolescent, whose mother recently died, comes to the school nurse complain headache. Which statement made by the students should warrant further explanation nurse? A. I've had dreams about Mon since she died. B. I've been very sad and cry a lot at night. C. I miss Mom and would like to go see her'. D. it's hard to concentrate on my homework

C. I miss Mom and would like to go see her'.

An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? A. Record pain evaluation B. Assess blood glucose C. Identify pills in the bag D. Obtain a medical history

C. Identify pills in the bag

A client with a new diagnosis of Raynaud's disease lives alone. Which instruction should the nurse include in the client's discharged teaching plan? A. Hire a caregiver for eight hours daily. B. Develop a walking exercise routine. C. Keep room temperature 80. D. Wear TED stockings at night.

C. Keep room temperature 80.

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

C. Malignancy Rapid enlargement of a lymph node, particularly the subclavian node with no tenderness or inflammation is suggestive of malignancy (B). Lymphangitis (A) is characterized by pain and inflammation. In infectious processes (C and D) the involved nodes become warm and tender to the touch.

A male client with an antisocial personality disorder is admitted to an in-patient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior this client's history is most likely to include which finding? A. Phobias and panic attacks when confronted by authority figures. B. Suicidal ideations and multiple attempts C. Multiple convictions for misdemeanors and class B felonies. D. Delusions of grandiosity and persecution

C. Multiple convictions for misdemeanors and class B felonies.

When checking a third grader's height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement? A. Report findings to the parents. B. Document findings in the child's school file. C. Refer child to the family healthcare provider. D. Encourage child to get more sleep.

C. Refer child to the family healthcare provider. Rationale ADHD is most commonly managed with methylphenidate, which causes insomnia due to CNS stimulation and growth suppression secondary to appetite suppression. The child should be referred to the healthcare provider (C) because a change in the administration schedule of methylphenidate or discontinuing the drug is indicated until the child's growth increases. (A and B) may not ensure referral for a valuation of the medication's impact on the child's growth pattern. (D) is ineffective.

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum sodium of 145 mEq/L (145 mmol/L SI) C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) D. White blood cell count of of 12,000 mm3 (12 x 109/L SI)

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

After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life- threatening condition? A. CIWA-Ar for alcohol withdrawal score of 30 B. Acute onset of unrelenting chest pain C. Widening QRS complexes and flat waves D. Intense tremor and involuntary muscle activity

C. Widening QRS complexes and flat waves

A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide? A. soft pretzels B. fruit-flavored yogurt C. oatmeal cookies D. low fat cheese sticks

C. oatmeal cookies

To reduce the risk of being named in malpractice lawsuit, which action is most important for the nurse to take? A. Establish a trusting nurse-client relationship. B. Complete an incident report following a client injury. C. Maintain current professional malpractice insurance, D. Adhere consistently to standards of care.

D. Adhere consistently to standards of care.

While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? A. "I think I am qualified to teach this group." B. "How old do you think I am?" C. "Do you think you can teach it any better?" D. "We need to stay focused on the topic."

D. "We need to stay focused on the topic." "Rationale(D) is the best response since the nurse should keep the students focused and avoid entering into an argument with them. (A) is defensive; there is no need for the nurse to defend her/his position. (B) is irrelevant; it does not matter how old the student thinks the nurse is. (C) is sarcastic; the nurse should avoid this kind of exchange and remain professional.

The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy the client's serum blood potassium is elevated, which finding requires immediate action by the nurse? A. Tall peak T waves on the cardiac monitor B. Peripheral pitting edema at 2 + indentation C. Serum creatinine above 0.5 mg/dl or 44.2 micro-mmol/dl D. Anuria for the last 12 hours.

D. Anuria for the last 12 hours.

A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement? A. Instruct the client to use the call button when a bedpan is needed B. Apply adult diapers after each attempt to void C. Check residual urine volume using an indwelling urinary catheter D. Assist the client's to a bedside commode every two hours

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

A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication? A. Hypertension. B. Apical heart rate 72 beats/minute. C. Muscle weakness. D. Blood pressure 90/76 mm Hg.

D. Blood pressure 90/76 mm Hg.. Sedative and Antihypertensive drug

A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication? A. Pupillary response B. Oxygen saturation C. Peripheral pulses D. Bowel patterns

D. Bowel patterns Mesalamine is a medication commonly used to treat inflammatory bowel disease and works by reducing inflammation in the intestines. Monitoring the patient's bowel movements can help determine if the medication effectively manages the symptoms.

A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? A. Knows that insulin must be given 30 min before eating B. Frequently eats fruits and vegetables at meals and between meals C. Has someone available who can prepare and oversee the diet D. Demonstrates willingness to adhere to the diet consistently

D. Demonstrates willingness to adhere to the diet consistently

The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation? A. Determine the presence of hematemesis as the UAP irrigates the NGT B. Instruct the UAP to bring an antiemetic to the nurse at the bedside C. Assess the appearance of the emesis while the UAP checks bowel sounds D. Direct the UAP to measure the emesis while the nurse irrigates the NGT

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

The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take? A. Plan to observe the secured IV site after the insertion procedure B. Confirm that the nurse has gathered the necessary supplies C. Remind the nurse to tape the gauze dressing securely in place D. Instruct the nurse to use a transparent dressing over the site

D. Instruct the nurse to use a transparent dressing over the site

A client who has a suspected brain tumor is schedules for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement? A. Determine if the client has had a knee or hip replacement B. Immobilize the client's neck before moving onto stretcher C. Give an antiemetic to control nausea D. Obtain the client's food allergy history

D. Obtain the client's food allergy history

Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement? A. No action is required since postoperative bleeding can be expected B. Lower the client's head while assessing for symptoms of shock C. Call the health care provider and prepare to take the client back to the operating room D. Outline the area with ink and check it every 15 minutes to see if the area has increased

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

An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Ask the client to write feeling in a journal and then review it together C. Explain the purpose of each medication the client is currently taking D. Play a board game with the client and begin taking about stressors

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

The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats / minute. Which action should the nurse take? A. Continue the insertion since this is a typical response. B. Insert the feeding tube into the infant's nasal passage. C. Pause and monitor for a continued drop of the heart rate. D. Postpone the feeding until the infant's vital signs and stable.

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

An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first? A. Provide the client with a PRN antianxiety medication and allow privacy for her to grieve. B. Instruct the UAP to notify the client's spiritual advisor of her need for counseling. C. Ask another nurse to finish giving medications and attend to the client immediately. D. Tell the client that the nurse will be back to talk to her after medications are given.

D. Tell the client that the nurse will be back to talk to her after medications are given. Rationale The nurse should first acknowledge the client's grief and arrange with the client a time to provide support, then complete the administration of medications (D). During that time, the nurse should assess the client to determine what intervention is best to offer the grieving client (A). The nurse, not the UAP (B), should talk with the client to determine if the client needs her spiritual advisor's counsel and support. The client's grief is not an emergency situation, so after acknowledging it and informing her that the nurse will return to talk with her, the nurse should finish administering the medications (C) and then spend time supporting the grieving client.

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) a- Headache and tremors b- Irregular heart rate c- Skin hyperpigmentation d- Postural hypotension e- Pallor and diaphoresis

a b d e

During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy? A. Family history of adult onset diabetes. B. Treatment for chlamydia in the past year C. Client's age and previous sexual behavior D. Three year history of taking oral contraceptives

D. Three year history of taking oral contraceptives

An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? A. Pale, diaphoretic skin. B. Pain score 8 out of 10. C. Onset of mild confusion. D. Weak palpable distal pulses

D. Weak palpable distal pulses

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

Observe for unilateral swelling

The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.) "On left thigh with arrow pointing to inner thigh"

On left thigh with arrow pointing to inner thigh

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

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

The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? (Arrange from first on top to last on the bottom) Aspirate the desired volume from vial B Inject the volume of air to be aspirated from each vial Aspirate the desired volume from vial A Verify the drug and dose with the label on the vial

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

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? a- Ask the client about gastrointestinal pain b- Auscultate for bowel sounds in all quadrants c- Measure the client's fluid intake and output d- Monitor the client's serum electrolyte levels

a- Ask the client about gastrointestinal pain. Rationale: Proton pump inhibitor suppress gastric acid secretion, relieving the symptoms of peptic ulcer disease and GERD. To evaluate the effectiveness of PPIs, the client should be asked about the relief of symptoms such as gastrointestinal discomfort.

A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make? a- Contact the healthcare provider immediately to report the laboratory value regardless of the advice b- Call the lab to draw an additional blood sample for a repeat evaluation of the potassium level STAT. c- Flag the client's medical record to alert the healthcare provider immediately upon arrival to the unit. d- Ask the charge nurse to contact the healthcare provider with the laboratory results by mid-morning.

a- Contact the healthcare provider immediately to report the laboratory value regardless of the advice Rationale: A serum potassium level of 2 mEq/L or mm/L (SI) is dangerous low and requires immediate intervention A to prevent potentially fatal cardiac dysrhythmias, regardless of the charge nurse concern regarding disturbing the healthcare provider, B, C and D may result in a potentially fatal delay in responding to the hypokalemia.

A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate? a- Ineffective coping related to denial b- Anxiety related to treatment of choice c- Decisional conflict related to stress d- Deficient knowledge related to lifestyle changes

a- Ineffective coping related to denial

A 59-year-old male client comes to the clinic and reports his concern over a lump that, "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is not overlying tissue inflammation. What do these findings suggest? a- Malignancy b- Bacterial infection c- Viral infection d- Lymphangitis

a- Malignancy Benign tumors tend to grow slowly and do not spread. Malignant tumors can grow rapidly, invade and destroy nearby normal tissues, and spread throughout the body

When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about the client? a- Neurologically stable without indications of an increased ICP b- Insertion of ICP monitoring device is necessary c- Rehabilitative prognosis is an expected full recovery d- Risk for irreversible cerebral damage related to increased ICP

a- Neurologically stable without indications of an increased ICP

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

a- Request the mother to leave the room Rationale: The nurse should ask the family member to leave the room (A) because the behavior is disruptive to the nurse and to the client. After the assessment is completed, the nurse should the address the family member's concerns.

The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication? a. Medication port. b. Near the IV bag. c. At the Y-site connector. d. Distal to the IV pump.

a. Medication port.

A client presents to the labor and delivery unit, screaming "THE BABY IS COMING" which action should the nurse implement first. a. Observe the perineum b. Begin coaching the client to push c. Check the fetal heart rate d. Prepare for immediate delivery

a. Observe the perineum

Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? a. Blood tinged sputum b. Upper airway stridor c. Expiratory wheezing d. Oxygen saturations 90%

b. Upper airway stridor Stridor usually indicates an obstruction or narrowing in the upper airway, outside of the chest cavity.

Which class of drugs is the only source of a cure for septic shock? a- Antihypertensives b- Antiinfectives c- Antihistamines d- Anticholesteremics

b- Antiinfectives Rationale: Antiinfective agents, such as antibiotics, are the only drugs that eliminate bacteria. The only to halt destruction to organ system in septic shock is to eliminate the production of endotoxins by bacterial invaders. A is contraindicated due to the low cardias output which in low blood pressure and occurs in late septic shock. While C may reduce some of the destructive effects of massed cell release occurring with the inflammatory response that may occur, endotoxin release would not be stopped. D has no therapeutic effect relevant to septic shock

A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement? a- Obtain the results for STAT serum cardiac biomarkers b- Asses for contraindications for thrombolytic therapy c- Measure ST-segment height and waveform changes. d- Transfer for percutaneous coronary intervention (PCI)

b- Asses for contraindications for thrombolytic therapy

While removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, what action should the nurse implement? a- Encourage the client to continue verbalize his anxiety b- Attempt to distract the client with general conversation c- Explain the procedure in detail while removing the staples d- Reassure the client that this is a simple nursing procedure.

b- Attempt to distract the client with general conversation

A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care? a- Monitor deep vein blood flow using Doppler b- Evaluate daily blood clotting factors. c- Apply antiembolism stockings. d- Maintain strict bed rest.

b- Evaluate daily blood clotting factors. Rationale: Monitoring clotting factors is the most important intervention to include in this client's plan of care following oxygen administration, IV fluids and heparin administration to prevent clot enlargement. A C and D should be included in the client's plan of care, but these interventions do not have the priority of B

While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement? a- Administer a PRN dose of pain medication b- Place a portable toilet next to the bed c- Restrict activity to complete bed rest d- Evaluate the client's leg muscular strength.

b- Place a portable toilet next to the bed Rationale: Due to the contractures and muscle weakness that progress with MD, the client's awkward movements and clumsiness is an expected sequela. Using assistive devices, such as bedside toilet, should be implement to help limit the client's frustration and ensure client safety, Discomfort is constant and may not always require pain medication (A). Activity should be encouraged (C) as long as the client is capable. (D) should be implemented before mobilizing the client.

A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan? a- Consume a light snack with the medication b- Take on an empty stomach with a full glass of water c- Ingest an antacid 30 minutes of taking the medication. d- Eat within 30 minutes of taking the medication.

b- Take on an empty stomach with a full glass of water

The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, "She says it is OK." What action should the nurse take next? a- Have the interpreter co-sign the consent to validate client understanding b- Have the client sign the consent and the nurse witness the signature c- Ask for a full explanation from the interpreter of the witnessed discussion d- Clarify the client's consent through the use of gestures and simple terms.

c- Ask for a full explanation from the interpreter of the witnessed discussion Rationale: The interpreter's role is to literally translate exactly what the client indicates not to provide a summary. Further information is needed about what was said during the lengthy conversation before proceeding. The nurse concerns about informed consent are not answered by Ab or D

Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning? a- Slow weight loss b- Muscle weakness c- Cold sensitivity d- Leg numbness

c- Cold sensitivity Fluctuating hormones during menopause and perimenopause can cause a dysfunction in the hypothalamus. Hypothyroid is associated with cold intolerance. These hormones help regulate metabolism and temperature.

During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide? a- The immunosuppressant medication will be increased until the rejection subside b- Dialysis may be necessary until the chronic rejection can be reversed. c- Dialysis would need to be resumed if chronic rejection becomes a reality d- A different combination of immunosuppressant medications will be implemented

c- Dialysis would need to be resumed if chronic rejection becomes a reality Rationale: Chronic rejection is managed conservatively by treating the symptoms until dialysis is needed. Immunosuppressant medication dosage are not increased when chronic rejection occurs, but are during acute rejection.

The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement? a- Obtain a second IV access. b- Decrease the room temperature. c- Give the prescribed antiemetic. d- Insert an indwelling catheter

c- Give the prescribed antiemetic. carboprost is used to treat severe bleeding after childbirth (postpartum).two-thirds experienced vomiting and diarrhea, approximately one third had nausea, one-eighth had a temperature increase greater than 2° F, and one-fourteenth experienced flushing

A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results a- Instruct the client to breath into a paper bag. b- Prepare to administer sodium chloride fluids c- Institute coughing and deep breathing protocols d- Initiate oxygen administration at 2 to 3 L per nasal cannula

c- Institute coughing and deep breathing protocols Rationale: Pulmonary hygiene measures will clear the respiratory tract of mucus and purulent drainage, thereby improving ventilation, since these ABG's reveal respiratory acidosis, and treatment should be directed to improving ventilation. A would be good for respiratory alkalosis, B for metabolic alkalosis A paO2 of 95 is within normal limits do D is not necessary44

The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN? a- Diabetic ketoacidosis whose Glasgow coma Scale score changed from 10 to 7 b- Myxedema coma whose blood pressure changed from 80/50 to 70/40 c- Viral meningitis whose temperature changed from 101 F to 102 F. d- Subdural hematoma whose blood pressure changed from 150/80 to 170/60.

c- Viral meningitis whose temperature changed from 101 F to 102 F. Rationale: The most stable patient should be assigned to the PN, changes in the Glasgow coma Scale indicated the client's neurological status is worsening. The client decreasing BP is physiologically unstable. An increasing systolic blood pressure and widening pulse pressure is indicative of increasing intracranial pressure

An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a- 0800, 1200, 1600, 2000 b- Administer with meals and a bedtime snack c- Five in equally divided doses during waking hours d- 1000, 1600, 2200, 0400

d- 1000, 1600, 2200, 0400 Rationale: D is the best schedule because the antibiotic should be administered around the clock to keep the blood level of the antibiotic constant.

When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? a- Massage the uterus to decrease atony b- Review the hemoglobin to determine hemorrhage c- Increase intravenous infusion d- Check for a distended bladder

d- Check for a distended bladder Rationale: The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow.

The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first? a- Administer schedule medications b- Offer the client PRN anxiolytic c- Assess the lungs for wheezing d- Evaluate the oxygen saturation.

d- Evaluate the oxygen saturation. Rationale: The client is exhibiting symptoms of an acute exacerbation of a chronic obstructive lung disease such as emphysema. The client... baseline oxygen level should be compared to the current level to determine if respiratory decompensation is occurring. Schedule medications can be administered after completing the oxygen saturation assessment. Respiratory distress often makes a client anxious, which may worsen the symptoms, so should be considered after implementing D. Assessing the lung for wheezing does not reveal further respiratory compromise

The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first? a- Provide the gloves for the UAP to apply b- Offer to help reposition the client c- Instruct the UAP to raise the bed level d- Place the side rails in an up position

d- Place the side rails in an up position Rationale: To maintain the client safety, it is most important for the nurse to place the side rails in a up position to reduce the risk of falls and injury. A, B and C can then be completed

While taking vital signs, a critically ill male client grabs the nurse's hand and ask the nurse not to leave. What action is best for the nurse to take? a- Allow the client to hold the nurse's hand until the vital signs can be completed b- Reassure the client that the nurse will return after all vital signs are taken c- Tell the client that he must release the nurse's hand. d- Pull up a chair and sit beside the client's bed

d- Pull up a chair and sit beside the client's bed Rationale: The critically ill client is most likely pleading for the presence of another person. D is the action that a compassionate nurse would implement. A, B, C do not demonstrate the compassion of D

A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement? a- Instruct the client to add ground beef and chicken in small amount to casseroles. b- Encourage the client to try to eat these foods in moderation despite the taste c- Advise the client to replace the bitter-tasting foods with fruits and vegetables. d- Suggest the use of alternative sources of protein such as dairy products and nuts.

d- Suggest the use of alternative sources of protein such as dairy products and nuts. Rationale: Beef, chicken, and eggs are good source of protein. To promote weight gain and adequate protein intake, the nurse should teach the client about another source of protein. Attempting to eat food that cause a bitter taste A and B is likely to increase the client's anorexia. C does not provide a sufficient source of protein.

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? a- Loss of appetite b- Serum K 4.0 mEq/or mmol/dl (SI) c- Loose, runny stool d- Tented skin turgor.

d- Tented skin turgor. D indicate dehydration, a serious complication following prolonged diarrhea that requires further interventions by the nurse.

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? a- Ask the mother what she usually uses on the child's lips and nose b- Apply a petroleum jelly (Vaseline) to the child's nose and lips c- Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips d- Use a water soluble lubricant on affected oral and nasal mucosa

d- Use a water soluble lubricant on affected oral and nasal mucosa

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

one with the clamp