HESI E
499. When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat?
Yogurt. Processed cheese.
456. The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement?
Observe the wound for dehiscence.
471. One day following a total knee replacement, a male client tells the nurse that he is unable to transfer because it is too painful. What action should the nurse implement?
Encourage use of analgesics before position change.
411. The nurse ask the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement?
Examine the genitalia as the last part of the total exam.
409. The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse?
Picking up the second glove.
453. The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective?
I need to have regular pap smears.
410. A male client reports to the clinic nurse that he has been feeling well and is often "dizzy" his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition?
Stroke.
465. When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first?
Ask the family to identify a specific spokesperson.
462. On a busy day, one hour after the shift report is completed, the charge nurse learns that a female staff nurse who lives one hour away from the hospital forgot her prescription eye glasses at home. What action should the charge nurse take?
Ask the nurse to return home and get her prescription eyeglasses for work.
417. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm?
Assess IV site frequently for signs of extravasation.
483. The nurse delegates to an unlicensed assistive personnel (UAP) denture care for a client with...daily leaving. When making this assignment, which instruction is most important for the nurse to do?
Place a washcloth in the sink while cleaning the dentures.
497. The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three day. The clients plan to live with a family member. Which action should the nurse implement? Select all that apply
Assess the client for self-care ability. Provide pain medication instructions. Teach care of ostomy to care provider.
437. A school-age child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine (Phenergan) 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/ml ampules. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).
0.4. Rationale: Convert pounds to kg 42lbs = 19.09 kg. Next calculate to prescribed dose, 0.5 mg x 1909 kg = 9.545. Then use the desired dose/ dose on hand x volume on hand (9.545/25x1ml =0.3818=0.4 ml). Or use ratio proportion (9.545 mg: x ml = 25 mg: 1ml. 25x = 9.545. X= 0.3818 = 0.4).
418. A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution?
0.9% sodium chloride solution (normal saline).
440. The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opioid-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
1.9. Rationale: D/H x Q 38/20x1=1.9 mL.
428. A client is receiving an IV solution labeled Heparin Sodium 20,000 Units in 5% dextrose injection 500 ml at 25 ml/hour. How many units of heparin is the client receiving each hour?
1000 units/hour. Rationale:20000/500=40x25=1000.
443. The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse?
Assist cardiac nurses with their assignments. Rationale: When receiving staff from another specialty unit, the charge nurse should allow the nurse to assist where possible (D) without taking a client assignment so that the nurse is not asked to perform unfamiliar skills (A, B, C) are likely to involve skills the nurse is not accustomed to performing.
455. A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider?
Creatinine clearance 25 mL/ minute.
430. The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman's risk for developing osteoporosis?
20 pack-year history of cigarette smoking. Rationale: Cigarette smoking (2 packs/day x 310 years = 20 packs-year) increases the risk of osteoporosis.
449. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image).
The second paddle is placed to the left of the apex of the heart.
402. A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only
7. Rationale: Convert the client's weight to kg, 2.2 pound: 1 kg:: 154 pounds: x kg = 154/2.2 = 70kg. Calculate the client infusion rate, 0.1 x 70 kg = 7 units/hour. Using the formula, D/H x Q = 7 units/hour / 100 units x 100 ml = 7ml / hour.
457. The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention?
A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. Rationale: an infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalances.
464. After teaching a male client with chronic kidney disease (CKD) about therapeutic diet...which menu of foods indicates that the teaching was effective? Select all that apply
A slice of whole grain toast. A bowl of cream of wheat.
484. The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs?
Cries frequently during the interview.
496. A client is admitted with a wound on the right hand and associated cellulitis. In assessing the client's hand, which finding required most immediate follow-up by the nurse?
Cyanotic nailbeds.
434. The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation?
Affirm that the UAP is using and effective strategy to reduce the client's anxiety. Rationale: Reduction is an effective technique is managing the anxiety of client with Alzheimer's disease, so the nurse should affirm the UAP is using an effective strategy (A). Nurse assertive communication and offering more choices (B) may increase... an agitation (C) is not indicated since the UAP is using redirection, an effective strategy.
414. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?
Altered consciousness within the first 24 hours after injury.
454. While the nurse is conducting a daily assessment of an older woman who resides in a long-term facility, the client begins to cry and tells the nurse that her family has stopped calling and visiting. What action should the nurse take first?
Ask the client when a family member last visited her.
498. A female client with chronic urinary retention explains double voiding technique to the nurse by stating she voids partially, hold the remaining urine in her bladder for three minutes, then voids again to empty her bladder fully. How should the nurse respond?
Advise the client to empty her bladder fully when she first voids.
495. The healthcare provider prescribes heparin protocol at18 units/kg/hr for a client with a possible pulmonary embolism. This client weighs 144 pounds. The available solution is labeled, heparin sodium 25,000 units in 5% dextrose 250 ml. the nurse should program the pump to deliver how many ml/hr? (Enter numeric value only. If rounding is require round to the nearest whole number.)
Answer 12. Rationale: 144/2.2= 65kg. 18units/kg/hr. 65 kg x 18units/kg/hr= 1170 units/hr. 25000 units heparin/250 ml of D5W = 100 units heparin per ml of solution . Formula D/H x A = X.
406. A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide?
Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
450. A client who had an open cholecystectomy two weeks ago comes to the emergency department with complaints of nausea, abdominal distention, and pain. Which assessment should the nurse implement?
Auscultate all quadrant of the abdomen.
433. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
Auscultated bilateral breath sounds. Rationale: Restlessness often results from decreased oxygenation so breath sounds should be assessed first. Giving an anxiolytic such as lorazepam, might be indicated but first the client should be assessed for the cause of the restlessness. An obstruction in the urinary drainage system can cause a distended bladder that may result in restlessness, but patent airway is the priority intervention. The client should be assessed before evaluating the cardiac rhythm on the monitor.
424. The home care nurse provide self-care instruction for a client chronic venous insufficiency cause by deep vein thrombosis. Which instructions should the nurse include in the client's discharge teaching plan? Select all that apply
Avoid prolonged standing or sitting. Use recliner for long period of sitting. Continue wearing elastic stocking.
475. During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply)
Background. Assessment. Recommendation. Rationale: BCD are correct. The current situation is reported regarding the client's nausea and pain (A). Based on SBAR communication, critical information about the client's clinical history (B), and assessment (C) such as pain scale or vital signs related to client's response to medication, are not included, nor are any recommendations for further follow-up (D). (E) Is not a component of SBAR communication
488. A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding... the client?
Blood pressure 149/101.
445. After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse?
Blood pressure 170/98.
474. Which information is more important for the nurse to obtain when determining a client's risk for (OSAS)?
Body mass index.
459. The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first?
Check the TPN solution for cloudiness
404. A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse?
Chest discomfort one hour after consuming a large, spicy meal. Rationale: Emergency triage involves quick assessment to prioritize the need for further evaluation and care. Those with trauma, chest pain, respiratory distress, or acute neurological changes are priority. In this example, while clients with other conditions require attention, the client with chest discomfort is at greatest risk and is a priority.
460. A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribes medications?
Clopidogrel (Plavix), an antiplatelet agent, given orally. Methylprednisolone (solu-medrol), a corticosteroid, to be given IV. Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous.
452. A 12-lead electrocardiogram (ECG) indicates a ST elevations in leads V1 to V4, for a client who reports having chest pain. The healthcare provider prescribe tissue plasminogen activator (t-PA). Prior to initiating the infusion, which interventions is most important for the nurse to implement?
Complete pre-infusion checklist.
412. The nurse is changing a client's IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is....which action should the nurse take to ensure adequate filling of the drip chamber?
Compress the drip chamber.
458. A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status?
Condition of hair, nails, and skin. Rationale: the assessment of hair, nails, and skin is most effective of long-term nutritional status, which is important in the healing process.
473. A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?
Contact the regional organ procurement agency.
489. A client with end-stage liver failure is declared brain dead. The family wants to discontinue feeding and donate any viable organs. Which action should the nurse take?
Contact the regional organ procurement agency.
476. The nurse is triaging victims of a tornado at an emergency shelter. An adult woman who has been wandering and crying comes to the nurse. What action should the nurse take?
Delegate care of the crying client to an unlicensed assistant. Rationale: According to the simple triage and Rapid Treatment (START) protocol of triage, the nurse should determine which client fit the objective of providing the greatest good for the greatest number of people who are most likely to survive. Delegating the care of the crying person to an unlicensed assistant allow the nurse to care for the injured who require intervention based on their ability to breath, maintain circulation and follow simple commands. A and B are not indicated at this time. Although food and water may be indicative, the woman's distress should not be dismissed by sending her to the shelter alone.
431. A young couple who has been unsuccessful in conceiving a child for over a year is seen in the family planning clinic. During an initial visit, which intervention is most important for the nurse to implement?
Determine current sexual practice. Rationale: First a history should be obtained including practices that might be related to the infertility, such as douching, daily ejaculation or the male partner's exposure to heat, such as frequent sauna or work environment which can decrease sperm production (A B or C) may be indicated after a complete assessment is obtained.
426. A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first?
Determine the client's responsiveness and respirations. Rationale: Activities, such as brushing teeth, can mimic the waveform of VI, so first he client should be assessed (A) to determine if the alarm is accurate. The crash cart can be brought to the room by someone else and defibrillation (B) delivered as indicated by the client's rhythm. Based on as assessment of the client, CPR© as summoning the emergency response team (D) may be indicated.
487. The nurse is presenting information about fetal development to a group of parents with...when discussing cephalocaudal fetal development, which information should the nurse gives the parents?
Development progress from head to rump.
470. The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms?
Diaphoresis.
461. A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit?
Discuss the importance of continuing the usual at-home activities.
432. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider?
Elevated liver function tests. Rationale: Elevated liver function enzymes are a serious side effect of antivirals and should be reported. A decrease white blood count is a consistent finding with shingle B and (C and D) are side effects that affect that are of less priority than A.
422. After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement?
Initiate intravenous fluid as prescribed. Rationale: Venous blood return to the heart and drains from the subclavian vein into the superior vena cava. The X-ray findings indicate proper placement of the CVC, so prescribed intravenous fluid can be started. A and B are not indicated at this time. The catheter should be secure immediate following insertion (C).
420. The nurse is triaging clients in an urgent care clinic. The client with which symptoms should be referred to the health care provider immediately?
Headache, photophobia, and nuchal rigidity. Rationale: Headache, photophobia, and nuchal rigidity are classic signs of meningeal infection, so this client should immediately be referred to the health care provider. AC D do not have priority of B.
439. During a well-baby, 6-month visit, a mother tells the nurse that her infant has had fewer ear infections than her 10-year-old daughter. The nurse should explain that which vaccine is likely to have made the difference in the siblings' incidence of otitis media?
Hemophilic Influenza Type B (HiB) vaccine.
492. A male client is admitted with burns to his face and neck. Which position should the nurse place the client to prevent contract?
Hyperextended with neck supported by a rolled towel.
490. A male client who was hit by a car while dodging through traffic is admitted to the emergency department with intracranial pressure (ICP). A computerized tomography (CT) scan reveals an intracranial bleed. After evacuation of hematoma, postoperative prescription include: intubation with controlled mechanical ventilation to PaCO2...what is the pathophysiological basis for this ventilator settings?
Hypocapnea reduces ICP.
472. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion?
Increase the oxygen flow via nasal cannula if dyspnea is present.
415. In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis?
Infectious process.
480. The nurse is teaching a client about the antiulcer medications ranitidine which was... statement best describes the action of this drug?
It blocks the effects of histamine, causing decreased secretion of acid.
468. During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?
Instruct the client to keep the left leg straight. Observe the insertion site for a hematoma. Circle first noted drainage on the dressing.
442. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma?
Intravenous administration of thyroid hormones. Rationale: The high mortality of myxedema coma requires immediate administration of IV thyroid hormones (A). (B) Is contraindicated, because eves small doses can cause profound somnolence lasting longer than expected. (C) Is administered to clients diagnosed with adrenal insufficiency (Addisonian crisis) and (D) to clients who have had an overdose of warfarin.
401. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?
Last menstrual period was 7 weeks ago. Rationale: Acute lower abdominal pain in A young adult female can be indicative of an ectopic pregnancy, which can be life threatening. Since the clients last menstrual period was seven weeks ago a pregnancy test to be obtained to ruled out ectopic pregnancy, which can result in intra-abdominal hemorrhage caused by a ruptured Fallopian tube. Although the severity of pain requires treatment, the most significant finding is the clients last menstrual period. Other options are not the most important concerns.
419. A client with Alzheimer's disease falls in the bathroom. The nurse notifies the charge nurse and completes a fall follow-up assessment. What assessment finding warrants immediate intervention by the nurse?
Left forearm hematoma. Rationale: The left forearm hematoma may be indicative an injury, such as broken bone, that requires immediate intervention. A may be likely be due to the inability to use the toilet due to the fall. Disorientation is a common symptom of Alzheimer's disease. IV Dislodged is not an urgent concern.
500. The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis?
Long distance runner since high school.
441. The nurses observes that a postoperative client with a continuous bladder irrigation has a large blood clot in the urinary drainage tubing. What actions should the nurse perform first?
Observe the amount of urine in the client's urinary drainage bag.
444. A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care?
Maintain effective breathing patterns. Rationale: Basic airway management (B) is the priority. Pain management (A), risk of infection (C), and prevention of injury (D) do not have the same priority as (C).
448. A nurse is planning discharge care for a male client with metastatic cancer. The client tells the nurse that he plans to return to work despite pain, fatigue, and impending death. Which goals is most important to include in this client's plan of care?
Marinating pain level below 4 when implementing outpatient pain clinic strategies. Rationale: An outpatient pain clinic provides the interdisciplinary services needed to manage chronic pain. Also the client has a terminal disease and is being discharge home, hospice and health care are not indicating at this time. Short term counseling is not an option.
429. The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan?
Monitor for an elevated temperature. Rationale: The client should be instructed to monitor or elevated temperature because immunosuppressant agents, which are prescribed to reduce rejection after transplantation, place the client at risk for infection. The client should recognize sign of liver rejection, such as sclera jaundice and increasing abdominal girths, but fever may be the only sign of infection. A is not as important and monitoring for signs of infection.
479. Which intervention should the nurse include in the plan of care for a client with leukocytosis?
Monitor temperature regularly.
435. An older female who ambulate with a quad-cane prefer to use a wheel chair because she has a halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply)
Move personal items within client's reach. Lower bed to the lower possible position. Give directions to call for assistance. Assist client to the bathroom in 2 hours. Rationale: A client who needs assistive devices, such as quad-cane is at risk for falls. Precautions that should implement include ensuring that personal items are within reach the bed is in the lowest position and directions are given to call assistance to minimize the risk for falls. Frequently assisting the client to the bathroom help ensure this client does not go the bathroom by herself, thereby decreasing the possibility of falling.
481. A client with superficial burns to the face, neck, and hands resulting from a house fire...which assessment finding indicates to the nurse that the client should be monitored for carbon monoxide...?
Mucous membranes cherry red color.
425. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention?
Muscle spasms of the back and neck. Rationale: An extra pyramidal symptom (EPS) characterized by abnormal muscle spasms of the neck (A) requires immediate intervention because it can cause difficulty swallowing and jeopardize the airway. Though (A, B and C) are also EPS caused by antipsychotic medication medications used to manage schizophrenia (D) has the highest priority to insure client safety is (A).
421. An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse?
Nausea and projectile vomit. Rationale: Projective vomiting is indicative of increasing intracranial pressure, which can lead to ischemic brain damage or death, so this finding warrants immediate intervention. Rebound abdominal tenderness may indicate internal bleeding. Diminished breath sound may be related to pain. Rib pain with inspiration may indicate rib fracture.
451. The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating
Normal sinus rhythm and complaining of chest pain.
485. When changing a diaper on a 2-day-old infant, the nurse observes that the baby's legs are... this finding, what action should the nurse take next?
Notify the healthcare provider.
436. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?
Observe both lower extremities for redness and swelling. Rationale: Intermittent compression devices (ICDs) are used to reduce venous stasis and prevent venous thrombosis in mobile and postoperative clients and its effectiveness is best assessed by observing the client's lower extremities for early signs of thrombophlebitis.
466. An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement?
Obtain a prescription for DNR.
463. A client with pneumonia has an IV of lactated ringer's solution infusing at 30ml/hr current labor....sodium level of 155 mEq/L, a serum potassium level of 4mEq/L.... what nursing intervention is most important?
Obtain a prescription to increase the IV rate.
494. The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. Which nurse takes next
Open the roller clamp on the tubing.
403. The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider?
Oral temperature of 100.6 F. Rationale: Convert the client's weight to kg, 2.2 pound: 1 kg:: 154 pounds: x kg = 154/2.2 = 70kg. Calculate the client infusion rate, 0.1 x 70 kg = 7 units/hour. Using the formula, D/H x Q = 7 units/hour / 100 units x 100 ml = 7ml / hour.
407. A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement?
Overlook the client's behavior.
423. The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program?
Participation of community leaders in planning the program. Rationale: When developing a culturally-competent health promotion project, the participation of stakeholders and community leaders is most important. A and B might be useful background information, but t=first the program should be developed. D may be useful fulfilling the plan developed by the health care team and the community leaders if funding for this assistance is included in the budget.
447. In assessing a pressure ulcer on a client's hip, which action should the nurse include?
Photograph the lesion with a ruler placed next to the lesion. Rationale: An ulcer extends into the dermis or subcutaneous tissue and is likely to increase in size and depth, so assessment should include photograph with measuring device to document the size of the lesion.
405. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take?
Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading. Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an accurate measurement of oxygen saturation. Other options will not provide the needed assessment.
491. During a cardiopulmonary resuscitation of an intubated client, the nurse detects a palpable pulse throughout the two minutes cycle chest compression and absent breath sounds over the left lung. What action should the nurse implement?
Prepare for the endotracheal tube to be repositioned.
482. A female client who was mechanically ventilated for 7 days is extubated. Two hours later...productive cough, and her respirations are rapids and shallow. Which intervention is most important?
Prepare the client for intubation.
438. A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first?
Stabilize the victim's neck and roll over to evaluate his status.
469. A client whose wrists are sutured from a recent suicide attempt is been transferred from a medical unit. Which nursing diagnosis is of the highest priority?
Risk for self-directed violence related to impulsive actions.
An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor?
Serum potassium.
478. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action I the treatment plan should the nurse implement?
Teach client to listen to music or audio books while driving. Rationale: Desensitization is component in the treatment plan for clients with panic attacks which is best approached with anxiety-reducing strategies, such as listening to audio book (B) during situation that precipitate symptoms (A) is a flooding technique that requires professional guidance.
467. A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?
The body cells develop resistance to the action of insulin.
486. A school-aged child was recently diagnosed with celiac disease. Which instruction should the nurse give the classroom teacher?
The child should avoid eating homemade cookies and cupcakes during parties.
427. A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse?
The client has asymmetrical chest wall expansion. Rationale: A potential complication of thoracentesis is a pneumothorax. The symptoms of a pneumothorax are uneven, unequal movement of the chest wall. A is an expected finding after the local anesthetic effects "wear off" B is a desired result of thoracentesis and C is within normal limits.
416. A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?
The family reports a great reduction in client's maniac behavior.
446. The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide?
Too much salt can cause the kidneys to retain fluid. Rationale: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension.
493. A male client is discharged from the intensive care unit following a myocardial infarction, and the healthcare provider low-sodium diet. Which lunch selection indicates to the nurse that this client understands the dietary restrictions?
Turkey salad sandwich.
477. A client in septic shock has a double lumen central venous catheter with one liter of 0.9% Normal Saline Solution infusing at 1 ml/hour through one lumen and TPN infusing at 50 ml/hr. through one port. The nurse prepared newly prescribed IV antibiotic that should take 45 mints to infuse. What intervention should the nurse implement?
Use a secondary port of the Normal Saline solution to administer the antibiotic. Rationale: A client in septic shock needs antibiotic administered in a timely manner to ensure maintenance of therapeutic serum level. The nurse should administer the antibiotic using a secondary port of the Normal Saline solution. No other medications should be administered using TPN tubing or solution. TPN not should be place on hold because sudden cessation will cause rapid change in serum glucose levels. Excessively delays in the administration of the antibiotics.
408. A client is discharged with automated peritoneal dialysis (PD) to be used nightly...which instructions should the nurse include?
Wash hands before cleaning exit site.
