HESI

A client with a fib receives a new prescription for dabigatran. What instruction should the nurse include in this clients teaching plan

Avoid use of non-steroidal anti-inflammatory drugs (NSAIDS)

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 Joint and muscle aches Urine output 300 ml/hr Dark, rust-colored urine

Blood pressure 170/98

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? Decreased white blood cell count Pruritus and muscle aches Elevated liver function tests Vomiting and diarrhea

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.

After administering an antipyretic medication. Which intervention should the nurse implement?

Encouraging liberal fluid intake

A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem?

Establish trust with community leaders and respect cultural and family values

A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? Hypernatremia Excessive thirst Elevated heart rate Poor skin turgor

Hypernatremia

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? Early treatment is very effective I will clean my hot tub better These warts are caused by a fungus I need to have regular pap smears

I need to have regular pap smears

The daughter of an older female client tells the clinic nurse that she is no longer able to care for her mother since her mother has lost the ability to perform activities of daily living (ADLs) due to aging. Which options should the nurse discuss with the daughter? Select all that apply Home hospice agency Long-term care facility Rehabilitation facility Independent senior apartment Home health agency

Long-term care facility Home health agency

A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson- Pratt bulb surgical drainage device is in place. Which interventions is most important for the nurse to include in this clients plan of care? Monitor urine output hourly. Assess for back muscle aches Record drainage from drain Obtain body weight daily

Monitor urine output hourly.

While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)

Move obstacle away from client Monitor physical movements Observe for a patent airway Record the duration of the seizure

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

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Abnormal responses for cranial nerves I and II Persistent coughing while drinking Unilateral facial drooping Inappropriate or exaggerated mood swings

Persistent coughing while drinking

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

A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome? Lorazepam (Ativan) Famotidine (Pepcid) Thiamine (Vitamin B1) Atenolol (Tenormin)

Thiamine (Vitamin B1) Rationale: Thiamine replacement is critical in preventing the onset of Wernickes encephalopathy, an acute triad of confusion, ataxia, and abnormal extraocular movements, such as nystagmus related to excessive alcohol abuse. Other medications are not indicated.

A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?

Transfer the client to the surgical floor.

A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client's discharge teaching plan?

Weigh daily

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 calcium 9 mg/dl hemoglobin 12 grams/dl partial thromboplastin time (PTT) 30 seconds

creatinine clearance 25 mL/ minute

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

serum creatinine

The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention?

• Postmenopausal women need an intake of at least 1,500 mg of calcium daily.

The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication? -Antibiotics -Anticoagulants -Antihypertensive -Anticholinergics

-Antibiotics

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

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

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

-Body mass index

Which statement is accurate regarding the pathological changes in the pulmonary system associated with acute (adult) respiratory distress syndrome (ARDS)? -Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema -A high ventilation-to-perfusion ratio is characteristic of affected lung fields in ARDS -Functional residual capacity and lung compliance increase as the disease progresses -Interstitial edema that occurs due to capillary fluid shifts is usually more serious than alveolar edema

-Capillary hydrostatic pressure exceeds colloid osmotic pressure, producing interstitial edema

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? -Low-grade fever, headache, and malaise for the past 72 hours -Unable to bear weight on the left foot, with the swelling and bruising -Chest discomfort one hour after consuming a large, spicy meal -One-inch bleeding laceration on the chain of the crying five-year-old

-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.

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 -Nitroglycerin (nitro-dur), an antianginal, to be given transdermally -Methylprednisolone (solu-medrol), a corticosteroid, to be given IV -Furosemide (lasix), a loop diuretic, to be given intravenously -Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous

-Clopidogrel (Plavix), an antiplatelet agent, given orally -Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous -Methylprednisolone (solu-medrol), a corticosteroid, to be given IV

A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? -Explain that it may take several weeks for the medication to be effective -Confirm the desired effect of the medication has been achieved. -Notify the health care provider than a change may be needed. -Evaluate when and how the medication is being administered to the client.

-Confirm the desired effect of the medication has been achieved. Rationale: Trazodone o Desyrel, an atypical antidepressant, is prescribed for client with AD to improve mood and sleep.

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

-Contractions of the sternocleidomastoid muscle

A 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? -Encourage the family to plan daily activities to keep the client busy -Have friends and family visit the client at a welcome home party -Discuss the importance of continuing the usual at-home activities -Instruct family to monitor the client's choice of television programs

-Discuss the importance of continuing the usual at-home activities

A neonate with a congenital heart defect (CHD) is demonstrating symptoms of failure (HF). Which interventions should the nurse include in the infant's plan of care? Select all that apply -Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90% -Administer diuretics via secondary infusion in the morning only -Evaluate heart rate for effectiveness of cardio tonic medications -Ensure Interrupted and frequent rest periods between procedures. -Use high energy formula 30 calories/ounce at Q3 hours feeding via soft

-Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90% -Evaluate heart rate for effectiveness of cardio tonic medications -Ensure Interrupted and frequent rest periods between procedures. -Use high energy formula 30 calories/ounce at Q3 hours feeding via soft Rationale: Pulse oximetry screening supports prescribed level of O2. HR provides an evaluative criterion for cardiac medications, which reduce heart rate, increase strength contractions (inotropic effects) and consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings with high energy formula. D minimize fatigue is necessary.

The nurse plans to administer a schedule dose of metoprolol (Toprol SR) at 0900 to a client with hypertension. At 0800, the nurse notes that client's telemetry pattern shows a second degree heart block with a ventricular rate of 50. What action should the nurse take? -Administer the Tropol immediately and monitor the client until the heart rate increases. -Provide the dose of Tropol as scheduled and assign a UAP to monitor the client's BP q30 minutes. -Give the Tropol as scheduled if the client's systolic blood pressure reading is greater than 180. -Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern.

-Hold the scheduled dose of Tropol and notify the healthcare provider of the telemetry pattern. Rationale: Beta blockers such as metoprolol (Tropol SR) are contraindicated in clients with second or third degree heart block because they decrease the heart rate. Therefore, the nurse should hold the medication.

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

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) -Monitor abdominal girth. -Increase oral fluid intake to 1500 ml daily. -Report serum albumin and globulin levels. -Provide diet low in phosphorous. -Note signs of swelling and edema.

-Monitor abdominal girth. -Report serum albumin and globulin levels. -Note signs of swelling and edema. Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.

Which problem reported by a client taking lovastatin requires the most immediate follow up by the nurse? Diarrhea and flatulence Abdominal cramps Muscle pain Altered taste

-Muscle Pain Rationale: statins can cause rhabdomyolysis, a potentially fatal disease of skeletal muscle characterized by myoglobinuria and manifested with muscle pain, so this symptom should immediately be reported to the HCP.

A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider? -Headache -Joint stiffness -Persistent fever -Increase hunger and thirst

-Persistent fever Rationale: Enbrel decrease immune and inflammatory responses, increasing the client's risk of serious infection, so the client should be instructed to report a persistent fever, or other signs of infection to the healthcare provider.

When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? -Prepare to administer atropine 0.4 mg IVP -Gather emergency tracheostomy equipment -Prepare to administer lidocaine at 100 mg IVP -Place cardiac monitor leads on the client's chest.

-Place cardiac monitor leads on the client's chest. Rationale: Before further interventions can be done, the client's heart rhythm must be determined. This can be done by connecting the client to the monitor. A or C are not a first line drug given for any of the life threatening, pulses dysrhythmias

a primigravida client is 36 weeks gestation is admitted to the labor and delivery unit because her membranes ruptured 30minutes ago. Initial assessment indicates 2cm dilation, 50% effaced, -2 station, vertex presentation greenish colored amniotic fluid, and contractions occurring 3-5 minutes with a low FHR after the last contraction peaks: Administer Oxygen via face mask Apply an internal fetal heart monitor Notify the healthcare provider Use a vibroacoustic stimulator

Administer Oxygen via face mask

After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

Administer PRN nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation.

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

Affective

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

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

An older male comes to the clinic with a family member. When the nurse attempts to take the clients health history, he does not respond to the questions in a clear manner. What actions should the nurse implement first?

Assess the surroundings for noise and distractions

Which instruction is most important for the nurse to provide a client who is being discharge following treatment for Guillain-Barre syndrome? Avoid exposure to respiratory infections Use relaxation exercises when anxious Plan short, frequent rest periods Continue physical therapy at home

Avoid exposure to respiratory infections

An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?

Be alert for possible cross-sensitivity to cephalosporin agents.

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?

Bowel Patterns Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation.

The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

Brain damage with CP is not progressive but does have a variable course

A postpartal client complains that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information? Catheterize for residual urine after next voiding Initiate a perineal pad countAssess for a perineal hematoma Determine the client's usual voiding pattern

Catheterize for residual urine after next voiding

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 Attach the IV tubing to the central line Set the infusion pump at the prescribed rate Prime the IV tubing with TPN solution

Check the TPN solution for cloudiness

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

Compulsion

A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? discontinue the magnesium sulfate immediately Decrease the client's iv rate to 50 ml per hour Continue with the plan of care for this client Change the client's to NPO status

Continue with the plan of care for this client Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs, kidney perfusion increases. With improvement perfusion, fluid is drawn into the intravascular bed from the interstitial tissue and then cleared by the kidneys

A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse? Total calcium 9 mg/dl (2.25 mmol/L SI) Creatinine 4 mg/dl (354 micromol/L SI) Phosphate 4 mg/dl (1.293 mmol/L SI) Fasting glucose 95 mg/dl (5.3 mmol/L SI)

Creatinine 4 mg/dl (354 micromol/L SI)

A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client?

Crutches with 4 point gate

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? Conversion of the client's PPD test from negative to positive. Length of time of the exposure to tuberculosis. Current diagnosis of hepatitis B. History of intravenous drug abuse.

Current diagnosis of hepatitis B. Rationale: prophylactic treatment of tuberculosis with isoniazid is contraindicated for persons with liver disease because it may cause liver damage. The nurse should withhold the prescribed dose and contact the healthcare provider. Other options do not provide data indicating the need to question or withhold the prescribed treatment.

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification?

Decreases the amount of HCL secretion by the parietal cells in the stomach

The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse? Diabetic ketoacidosis and titrated IV insulin infusion Emphysema extubated 3 hours ago receiving heated mist Subdural hematoma with an intracranial monitoring device Acute coronary syndrome treated with vasopressors

Diabetic ketoacidosis and titrated IV insulin infusion

An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

Digoxin

After receiving the first dose of penicillin, the client begins wheezing and having trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first?

Epinephrine Injection, USP IV

A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications? Review the surgical consent with the client Explain that vomiting can occur during surgery Remove the food from the client Withhold the preoperative medication

Explain that vomiting can occur during surgery Withhold the preoperative medication

A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger? Loud hallway noise. Fever Full bladder Frequent cough.

Full bladder Rational: a pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder. The other options are unlikely to produce the manifestation of autonomic hyperreflexia.

When finding a client sitting on the floor, the nurse calls for help from the unlicensed assistive personnel (UAP). Which task should the nurse ask the UAP to do? Check for any abrasions or bruises. Help the client to stand. Get a blood pressure cuff. Report the fall to the nurse-manager.

Get a blood pressure cuff.

A man comes in with severe sun burn and explains he didn't use sun screen because it was an overcast day. Large blisters are noted over his back and chest and his shirt is soaked with serosanguinous fluid. Which assessment finding warrants immediate intervention by the nurse? Hypotension. Fever and chills Dizziness Headache

Hypotension.

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

Infuse sodium chloride 0.9% (normal saline)

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

Instill beractant 100 mg/kg in endotracheal tube.

Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? Intravenous administration of thyroid hormones Oral administration of hypnotic agents Intravenous bolus of hydrocortisone Subcutaneous administration of vitamin k

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.

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? Urinary incontinence Left forearm hematoma Disorientation to surroundings Dislodge intravenous site

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

A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? Level of consciousness Percussion of abdomen Serum electrolytes Blood glucose.

Level of consciousness Rationale: Colonic bacteria digest lactulose to create a drug-induces acidic and hyperosmotic environment that draws water and blood ammonia into the colon and coverts ammonia to ammonium, which is trapped in the intestines and cannot be reabsorbed into the systemic circulation. This therapeutic action of lactulose is to reduce serum ammonia levels, which improves the client's level of consciousness and metal status.

A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug?

Maternal pulse rate of 162 beats per min

A client with acute pancreatitis is complaining of pain and nausea. Which interventions should the nurse implement (Select all that apply) Monitor heart, lung, and kidney function. Notify healthcare provider of serum amylase and lipase levels. Review client's abdominal ultrasound findings. Position client on abdomen to provide organ stability Encourage an increased intake of clear oral fluids

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

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

Monitor mental status

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. Encourage the use of the wheelchair Raise all bed rails when the client is resting

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.

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

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)

A client with urticaria due to an environmental allergies is taking diphenhydramine... Which complaint should the nurse identify to the client as a side effect of the OTC medication? Nausea and indigestion. Hypersalivation Eyelid and facial twitching Increased appetite

Nausea and indigestion.

An adult client with schizophrenia began treatment 3 days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take? Obtain a prescription for an anticholinergic medication Determine how many hours declined slept last night Administer the PRN prescription for severe anxiety Watch the thyroid cartilage move while the client swallows

Obtain a prescription for an anticholinergic medication Rationale: Antipsychotic medications have an extrapyramidal side effects one of which is difficult to swallowing the nurse should obtain a prescription for an anticholinergic medication which is used for the treatment of extrapyramidal symptoms. Other options are not warranted actions based on the symptoms presented.

The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider? White blood count of 19,000 mm3 Oral temperature of 100.6 F Fundus deviated to the right side Breasts are firm when palpated

Oral temperature of 100.6 F Rationale: A temperature greater than 100.4 F (38 C) (B), which is indicative of endometriosis (infection of the lining of the uterus), should be reported to the health care provider. (A and D) are findings that are within normal limits in the postpartum period. Fundal deviation to one side (C) is an expected finding related to a full bladder, so the nurse should encourage the client to void.

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. Distract client to interfere with the ritual. Ask why the client checks the pulse. Hold client's hand to stop the behavior.

Overlook the client's behavior.

The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? Rebound tenderness in the upper quadrants Hypoactive bowel sounds in the lower quadrants Tympany with percussion of the abdomen Light colored gastric aspirate via the nasogastric tube

Rebound tenderness in the upper quadrants

Following routine diagnostic test, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client? Maintain adequate cardiac output Promote adequate tissue perfusion Promote rest and sleep Reduce the risk for injury

Reduce the risk for injury

While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse take. Select all that apply Provide supplemental oxygen Auscultate bilateral lung fields Administer a nebulizer treatment Reinforce occlusive CT dressing Give PRN dose of pain medication

Reinforce occlusive CT dressing Provide supplemental oxygen Auscultate bilateral lung fields Rationale: the air bubbles indicate an air leak from the lungs, the chest tube site, or the chest tube collection system. Providing oxygen improves the oxygen saturation until the leak has been resolved. Auscultating the lung fields helps to identify absent or decrease lung sound due to collapsing lung.

An older adult male who had abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client's room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply). Report mental status change to the healthcare provider Assess the client's breath sounds and oxygen saturation Assign the UAP to re-assess the client's risk for falls Review the client's most recent serum electrolyte values Apply soft upper limb restrains and raise all four bed rails

Report mental status change to the healthcare provider Assess the client's breath sounds and oxygen saturation Review the client's most recent serum electrolyte values Rationale: The healthcare provider should be informed of changes in the client's condition (B) because this behavior may indicate a postoperative complication. Diminished oxygenation (C) and electrolyte imbalance (E) may cause increased confusion in the older adult. Raising all four bed rails (A) may lead to further injury if the client climbs over the rails and falls and restrains should not be applied until other measures such as re-orientation are implemented. The nurse should assess the client's increased risk for falls, rather than assigning this to the UAP (D).

The nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement? A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When

Reposition the client with the head of the bed elevated.

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

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

A client 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.

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 The clients complain of pain at the insertion site The client chest's x-ray indicates decreased pleural effusion The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26

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

A 2 year old is bleeding from a laceration on the right lower extremity as the result of a motor vehicle collision. The nurse is selecting supplies to start an IV access. Which assessment finding is most significant in the nurse's selection of catheter size? Thready brachial pulse. Respirations of 24/minute Right foot cool to touch Swelling at the site of injury

Thready brachial pulse.

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax? Continuous bubbling in the water seal chamber Decrease bright red blood drainage Tachypnea and difficulty breathing Tracheal deviation toward the left lung.

Tracheal deviation toward the left lung. Rationale: Tracheal deviation toward the unaffected left lung with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax.

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

Uncontrollable drooling

After removing a left femoral arterial sheath, which assessment finding warrant immediately interventions by the nurse? (Select all that applied.) Unrelieved back and flank pain. Quarter-size red drainage at site Cool and pale left leg and foot. Tenderness over insertion site Left groin egg-size hematoma.

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

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

Unresponsive to painful stimuli

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

Urine output 20 ml/hour

The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? What food does your baby usually eat in a normal day? What was the baby's weight at the last well-baby clinic visit? The baby is below the normal percentile for weight gain Your baby is gaining weight right on schedule

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

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? Withhold food and fluid intake. Initiate IV fluid replacement. Administer antiemetic as needed. Evaluate intake and output ratio.

Withhold food and fluid intake. Rational: The pathophysiologic processes in acute pancreatitis result from oral fluid and ingestion that causes secretion of pancreatic enzymes, which destroy ductal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas. The main focus of the nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO. Other choices are also important intervention but are secondary to pain management.

What interventions should the nurse include in the plan of care for a child with tetanus?

minimize the amount of stimuli in the room.

An adult male is brought to the emergency department by ambulance following a bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? Rebound abdominal tenderness nausea and projectile vomit rib pain with deep inspiration diminished bilateral breath sounds

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.

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

• Give the prescribed antiemetic.

A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer?

• Simethicone (Mylicon)

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

• Urinary output of 25mL per hour