HESI Module 9
A nurse administers scopolamine as prescribed to a client. For which side effect of this medication does the nurse monitor the client? Pupil constriction Increased urine output Complaints of dry mouth Complaints of feeling sweaty
Complaints of dry mouth
A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? "I didn't shampoo my hair." "I ate breakfast this morning." "I didn't take my anticonvulsant today." "It was hard not to drink coffee this morning, but I knew that I couldn't, so I didn't."
"I didn't shampoo my hair."
A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose of phenytoin is therapeutic? 3 mcg/mL (12 µmol/L) 8 mcg/mL (32 µmol/L) 16 mcg/mL (63 µmol/L) 28 mcg/mL (111 µmol/L)
16
A client tells the nurse that he has been experiencing frequent heartburn and has been "living on antacids." For which acid-base disturbance does the nurse recognize a risk? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis
A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than which value? 140 mg/dL (<3.64 mmol/L) 200 mg/dL (<5.2 mmol/L) 250 mg/dL (<6.5 mmol/L) 300 mg/dL (<7.8 mmol/L)
200
A client's baseline vital signs are temperature 98°F (36.7°C) oral, pulse 74 beats/min, respiratory rate 18 breaths/min, and blood pressure 124/76 mm Hg. The client suddenly spikes a fever of 103°F (39.4°C). Which respiratory rate would the nurse anticipate as part of the body's response to the change in client status? 12 breaths/min 16 breaths/min 18 breaths/min 22 breaths/min
22
A client with cardiovascular disease is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the primary health care provider before administering the dose? 3.0 mEq/L (3.0 mmol/L) 3.8 mEq/L (3.8 mmol/L) 4.2 mEq/L (4.2 mmol/L) 5.2 mEq/L (5.2 mmol/L)
3
Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the primary health care provider's prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)? 1 L/min 3 L/min 4 L/min 6 L/min
3
A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than which value? 7% 9% 10% 15%
7
A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above which value? 85% 89% 95% 100%
95
A nurse is monitoring a client who has undergone pleural biopsy. Which finding causes the nurse to suspect that the client is experiencing a complication? Warm, dry skin Mild pain at the biopsy site Complaints of shortness of breath Capillary refill time of less than 3 seconds
Complaints of shortness of breath
A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic alkalosis
A client who has just undergone a skin biopsy is listening to discharge instructions from the nurse. The nurse determines that the client needs further teaching if the client indicates planning to do what as part of aftercare? Use the antibiotic ointment as prescribed Return in 7 days to have the sutures removed Apply cool compresses to the site twice a day for 20 minutes Call the primary health care provider if excessive drainage from the wound occurs
Apply cool compresses to the site twice a day for 20 minutes
A client who has just undergone bronchoscopy was returned to the nursing unit 1 hour ago. With which assessment finding is the nurse most concerned? Oxygen saturation of 97% Equal breath sounds in both lungs Absence of cough and gag reflexes Respiratory rate of 20 breaths/min
Absence of cough and gag reflexes
A client who has just undergone surgery suddenly experiences chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism and immediately sets about to take which action? Preparing the client for a perfusion scan Attaching the client to a cardiac monitor Administering oxygen by way of nasal cannula Ensuring that the intravenous (IV) line is patent
Administering oxygen by way of nasal cannula
A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily? Placing the tube in warm water Hyperextending the head while inserting the tube Removing the tube if any resistance to insertion is met Asking the client to swallow as the tube is being advanced
Asking the client to swallow as the tube is being advanced
A nurse has a prescription to collect a 24-hour urine specimen from a client. Which measure should the nurse take during this procedure? Keeping the specimen at room temperature Saving the first urine specimen collected at the start time Discarding the last voided specimen at the end of the collection time Asking the client to void, discarding the specimen, and noting the start time
Asking the client to void, discarding the specimen, and noting the start time
A nurse receives a telephone call from a nurse on the post-anesthesia care unit, who reports that a client is being transferred to the surgical unit. What should the nurse plan to do first on arrival of the client? Assess the patency of the airway Check tubes and drains for patency Check the dressing for bleeding Assess the vital signs to compare them with preoperative measurements
Assess the patency of the airway
A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? Select all that apply. Clamp the chest tube Change the drainage system Assess the system for an external air leak Reduce the degree of suction being applied Document assessment findings, actions taken, and client response
Assess the system for an external air leak Document assessment findings, actions taken, and client response
A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action? Tape the tube in place Send the client for a chest x-ray Note how far the tube has been inserted Auscultate both lungs for the presence of breath sounds
Auscultate both lungs for the presence of breath sounds
A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the mostspecific indicator of this disease? Hemoglobin Serum bilirubin Blood urea nitrogen (BUN) Erythrocyte sedimentation rate (ESR)
Bili
A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client? Bleeding Renal colic Infection at the site Increased temperature
Bleeding
A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which signs/symptoms does the nurse anticipate that this client will exhibit? Increased heart rate and increased blood pressure Increased heart rate and decreased blood pressure Decreased heart rate and increased blood pressure Decreased heart rate and decreased blood pressure
Both decreased
A nurse reviews a client's urinalysis report. Which findings does the nurse recognize as abnormal? Select all that apply. pH of 6.0 Glucose noted Casts apparent An absence of protein The presence of ketones Specific gravity of 1.018
Casts apparent Glucose noted The presence of ketones
A nurse assesses the closed chest tube drainage system of a client who underwent lobectomy 24 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. Which action should the nurse take first? Contact the primary health care provider Check for kinks in the drainage system Check the client's blood pressure and heart rate Connect a new drainage system to the client's chest tube
Check for kinks in the drainage system
A nurse is assessing a postoperative client on an hourly basis. The nurse notes that the client's urine output for the past hour was 25 mL. On the basis of this finding, the nurse should take which action first? Call the primary health care provider Increase the rate of the IV infusion Check the client's overall intake and output record Administer a 250-mL bolus of normal saline solution (0.9%)
Check the client's overall intake and output record
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first? Continue suctioning to remove the blood Check the degree of suction being applied Encourage the client to cough out the bloody secretions Remove the suction catheter from the client's nose and begin vigorous suctioning through the mouth
Check the degree of suction being applied
A client has just returned to the nursing unit after bronchoscopy. To which intervention should the nurse give priority? Ambulating the client Administering pain medication Encouraging copious fluid intake Checking for the return of the gag reflex
Checking for the return of the gag reflex
Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing reveals a pH of 7.45, PaCO2 of 30 mm Hg (3.99 kPa), and HCO3 of 19 mEq/L (19 mmol/L). The nurse interprets these results as indicative of which disorder? Compensated metabolic acidosis Compensated respiratory alkalosis Uncompensated metabolic alkalosis Uncompensated respiratory acidosis
Compensated respiratory alkalosis
A client who has undergone abdominal surgery calls the nurse and reports that she just felt "something give way" in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse should take which immediate action? Document the findings Contact the primary health care provider Place the client in a supine position with the legs flat Cover the abdominal wound with a sterile dressing moistened with sterile saline solution
Cover the abdominal wound with a sterile dressing moistened with sterile saline solution
A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? Reinsert the chest tube Contact the primary health care provider Transfer the client back to bed Cover the insertion site with a sterile occlusive dressing
Cover the insertion site with a sterile occlusive dressing
A nurse is preparing a client for intravenous pyelography (IVP). Which action by the nurse is most important? Administering a sedative Encouraging fluid intake Administering an oral preparation of radiopaque dye Questioning the client about allergies to iodine or shellfish
Questioning the client about allergies to iodine or shellfish
A nurse is preparing to examine a client's skin using a Wood light. What should the nurse do to facilitate this procedure? Darken the examining room Administer a local anesthetic Obtain a signed informed consent Shave the skin and scrub it with povidone-iodine (Betadine)
Darken the examining room
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which effect? Be drying to nasal passages Decrease the client's oxygen-based respiratory drive Increase the risk of pneumonia as a result of drier air passages Decrease the client's carbon dioxide-based respiratory drive
Decrease the client's oxygen-based respiratory drive
A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) level is 88 seconds (88 seconds). The client's baseline before the initiation of therapy was 30 seconds (30 seconds). Which action does the nurse anticipate is needed? Shutting off the heparin infusion Increasing the rate of the heparin infusion Decreasing the rate of the heparin infusion Leaving the rate of the heparin infusion as is
Decreasing the rate of the heparin infusion
The nurse is admitting a client with a diagnosis of renal calculi. What does the nurse know can contribute to the client's diagnosis? Dehydration Foods low in protein Decreased intake of dairy products Low level of parathyroid hormone (PTH)
Dehydration
The nurse is caring for a client with a diagnosis of suspected uric acid calculi. The nurse is carefully checking the history of the client. What areas should the nurse focus on? Select all that apply. History of anemia Dietary supplements Previous problems with fluid overload 8.9 mg/dL (529.9 μmol/L) Family history of urinary calculi Prescribed and OTC medications Previous episodes of stone formation
Dietary supplements Family history of urinary calculi Prescribed and OTC medications Previous episodes of stone formation
A nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse hears a wheeze. The nurse tries to remove the suction catheter from the client's trachea but is unable to do so. Which action should the nurse take first? Call a code Contact the primary health care provider Administer a bronchodilator Disconnect the suction source from the catheter
Disconnect the suction source from the catheter
A client with a history of lung disease is at risk for respiratory acidosis. For which signs/symptoms does the nurse assess this client? Disorientation and dyspnea Drowsiness, headache, and tachypnea Tachypnea, dizziness, and paresthesias Dysrhythmias and decreased respiratory rate and depth
Disorientation and dyspnea
A client has undergone pericardiocentesis to treat cardiac tamponade. For which signs/symptoms should the nurse assess the client to determine whether the tamponade is recurring? Decreasing pulse Rising blood pressure Distant muffled heart sounds Falling central venous pressure (CVP)
Distant muffled heart sounds
Polyethylene glycol-electrolyte solution is prescribed for a hospitalized client scheduled for colonoscopy. The client begins to experience diarrhea after drinking the solution. Which action by the nurse is appropriate? Administering a cleansing enema. Calling the primary health care provider Documenting the diarrhea in the medical record Giving intravenous replacement fluids in large amounts
Documenting the diarrhea in the medical record
A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving pre-procedure instructions tell the client that is important to do before the procedure? Eat only a light breakfast Wear comfortable clothing and shoes Drink 6 to 8 glasses of water without voiding Stop eating or drinking at midnight before the test
Drink 6 to 8 glasses of water without voiding
A client is scheduled to undergo computerized tomography (CT) with contrast for evaluation of an abdominal mass. The nurse should provide the client with which information about the test? The test may be painful The test takes 2 to 3 hours Food and fluids are not allowed for 4 hours after the test Dye is injected and may cause a warm flushing sensation
Dye is injected and may cause a warm flushing sensation
A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which signs/symptoms does the nurse assess this client? Disorientation and dyspnea Drowsiness, headache, and tachypnea Tachypnea, dizziness, and paresthesias Dysrhythmias and decreased respiratory rate and depth
Dysrhythmias and decreased respiratory rate and depth
A client has just returned to the nursing unit after a computerized tomography (CT) with contrast medium. Which action should the nurse plan to take as part of routine after-care for this client? Administering a laxative Encouraging fluid intake Maintaining the client on strict bed rest Holding all medications for at least 2 hours
Encouraging fluid intake
A nurse is watching as an assistive personnel (AP) measure the blood pressure (BP) of a hypertensive client. Which actions on the part of the AP would interfere with accurate measurement and prompt the nurse to intervene? Select all that apply. Measuring the BP after the client has sat quietly for 5 minutes Having the client sit with the arm bared and supported at heart level Using a cuff with a rubber bladder that encircles at least 60% of the limb Measuring the BP after the client reports having just drank a cup (236 ml) of coffee Allowing the client to talk as the blood pressure is being measured
Measuring the BP after the client has sat quietly for 5 minutes Having the client sit with the arm bared and supported at heart level Using a cuff with a rubber bladder that encircles at least 60% of the limb
A nurse is preparing a client for transfer to the operating room. Which action should the nurse take in the care of this client at this time? Ensuring that the client has voided Administering all daily medications Practicing postoperative breathing exercises Verifying that the client has not eaten for the last 24 hours
Ensuring that the client has voided
A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure? Flat Semi-Fowler Side-lying, with the head of the bed elevated Sitting up in a recliner with the feet elevated
Flat
A nurse has a prescription to apply a Holter monitor to a client for continuous cardiac monitoring for a 24-hour period. What steps should the nurse take to initiate this prescription? Select all that apply. Giving the client a device holder to wear around the waist Giving the client a diary in which to record activity and signs/symptoms Telling the client to rest as much as possible during the next 24 hours Instructing the client to enclose the monitor in plastic wrap before taking a bath Telling the client that occasional slight shocks from the monitor will be felt but that they are harmless
Giving the client a device holder to wear around the waist Giving the client a diary in which to record activity and signs/symptoms
A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply. Hematocrit 30% (0.30) Sodium 141 mEq/L (141 mmol/L) Hemoglobin 8.9 g/dL (89 g/L) Platelets 210× 103/μL (210 × 109/L) Serum creatinine 0.8 mg/dL (70 μmol/L)
H&H
A client is receiving intermittent bolus feedings by way of a nasogastric tube. In which position should the nurse place the client once the feeding is complete? Supine Head of bed flat Left lateral position Head of bed elevated 30 to 45 degrees
Head of bed elevated 30 to 45 degrees
A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath followed by what client action? Exhale during tube removal Bear down during tube removal Hold the breath during tube removal Breathe normally during tube removal
Hold the breath during tube removal
A client who is mouth breathing is receiving oxygen by face mask. The assistive personnel (AP) asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal? Prevent the client from getting a nosebleed Give the client added fluid by way of the respiratory tree Humidify the oxygen that is bypassing the client's nose Prevent fluid loss from the lungs during mouth breathing
Humidify the oxygen that is bypassing the client's nose
A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client's arterial blood gas (ABG) results are pH 7.25, PaCO234 mm Hg (4.52 kPa), PaO2 86 mm Hg (11.3 kPa), HCO3 14 mEq/L (14 mmol/L). Which acid-base disturbance does the nurse recognize in these results? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis
A client has been given a diagnosis of multiple myeloma. Which result does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis? Increased calcium level Decreased blood urea nitrogen (BUN) Increased white blood cell (WBC) count Decreased number of plasma cells in the bone marrow
Increased calcium level
A nurse is preparing a client for colonoscopy. Into which position does the nurse assist the client for the procedure? Left Sims' position Lithotomy position Knee-chest position Right Sims' position
Left Sims' position
A nurse is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which coexisting problem is cause for the nurse to suspect that the oxygen saturation readings are not entirely accurate? Infection Hypertension Low blood pressure Loss of cough reflex
Low blood pressure
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? Check the client's blood pressure Check the oxygen saturation level Have the client take some deep breaths Lower the head of the bed slowly until the dizziness is relieved
Lower the head of the bed slowly until the dizziness is relieved
A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL (34.4 mmol/L). After the nurse calls the primary health care provider to report the finding and monitors the client closely for which condition? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis
A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Metabolic acidosis
A client in the post-anesthesia care unit has an as-needed prescription for ondansetron. Which occurrence would prompt the nurse to administer this medication to the client? Paralytic ileus Incisional pain Urine retention Nausea and vomiting
N&V
A nurse is reading the radiology report of a client who has a chest tube attached to a closed drainage system and has undergone chest x-ray. The report states that the client's affected lung is fully re-expanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding? No fluctuation in the water seal chamber Continuous bubbling in the water seal chamber Increased drainage in the collection chamber Continuous gentle suction in the suction control chamber
No fluctuation in the water seal chamber
A client who just returned from the recovery room after a tonsillectomy and adenoidectomy is restless and the pulse rate is increased. As the nurse continues the assessment, the client begins to vomit a copious amount of bright-red blood. The nurse should take which immediate action? Notify the surgeon Continue the assessment Check the client's blood pressure Obtain a flashlight, gauze, and a curved hemostat
Notify the surgeon
A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs/symptoms of respiratory alkalosis does the nurse assess this client? Disorientation and dyspnea Drowsiness, headache, and tachypnea Tachypnea, dizziness, and paresthesias Dysrhythmias and decreased respiratory rate and depth
Tachypnea, dizziness, and paresthesias
A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing? Steak Veal Cheese Oranges
Oranges
A client has been scheduled for magnetic resonance imaging (MRI). For which condition, a contraindication to MRI, does the nurse check the client's medical history? Pancreatitis Pacemaker insertion Type 1 diabetes mellitus Chronic airway limitation
Pacemaker insertion
A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting which finding? Urine output of 40 mL/hr Blood pressure of 118/76 mm Hg Respiratory rate of 18 breaths/min Pallor and coolness of the right leg
Pallor and coolness of the right leg
A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily for which reason? It is unnecessary to use both hands Feeling dual pulsations may lead to an incorrect measurement Palpating both carotid pulses simultaneously could occlude the trachea Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop
Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop
A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care? Restricting fluid intake for the first 24 hours Periodically testing the urine for occult blood Avoiding the administration of opioid analgesics Having the client ambulate in the room and hall for short distances
Periodically testing the urine for occult blood
A nurse is preparing for intershift report when an assistive personnel (AP) pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first? Call the primary health care provider Check the hourly urine output Check the IV site for infiltration Place the client in a modified Trendelenburg position
Place the client in a modified Trendelenburg position
A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client? Pour the residual volume into the nasogastric tube through a syringe with the plunger removed Discard the residual volume properly and record it as output on the client's fluid balance record Dilute the residual volume with water and inject it into the nasogastric tube, applying pressure on the plunger Mix the residual volume with the formula and pour it into the nasogastric tube, using a syringe without a plunger
Pour the residual volume into the nasogastric tube through a syringe with the plunger removed
A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? Pulse rate Blood pressure Pulmonary artery systolic pressure Pulmonary artery end-diastolic pressure
Pulse
A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing pre-procedure instructions, should tell the client to implement which measure? Eat a regular supper and breakfast Remove all metal and jewelry before the test Expect diarrhea for a few days after the procedure Take all oral medications as scheduled with milk on the day of the test
Remove all metal and jewelry before the test
A client has the following arterial blood gas (ABG) results: pH 7.51, PaCO231 mm Hg (4.12 kPa), PaO2 94 mm Hg (12.45 kPa), HCO3 24 mEq/L (24 mmol/L). Which acid-base disturbance does the nurse recognize in these results? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Resp Alk
A client with histoplasmosis has the following arterial blood gas (ABG) results: pH 7.30, PaCO2 58 mm Hg (7.72 kPa), PaO2 75 mm Hg (9.93 kPa), HCO3 26 mEq/L (26 mmol/L). Which acid-base disturbance does the nurse recognize in these results? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis
A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the PaCO2 is 50 mm Hg (6.65 kPa). Which acid-base imbalance does the nurse recognize in these findings? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory acidosis
A nurse is caring for a client who has undergone pulmonary angiography with catheter insertion through the right femoral vein. The nurse assesses for allergic reaction to the contrast medium by monitoring for the presence of which sign/symptom? Bradycardia Respiratory distress Hematoma in the right groin Discomfort in the right groin
Respiratory distress
A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which value, noted by the nurse reviewing the results, would be expected in this client at this time? Hemoglobin (Hb) 15 G/100 mL 14 to 18 g/100 mL, males; 12 to 16 g/100 mL, females Potassium (K+) 4 mEq/L Total calcium (Ca2+) 9 mg/dL Serum amylase 395 units/L
Serum amylase 395 units/L
A nurse is reviewing laboratory results for a newly admitted client. Which serum lab result does the nurse document as abnormal? Serum creatinine 0.2 mg/dL (17.6 μmol/L) Prothrombin time 11.0 to 12.5 seconds; 85% to 100% Sodium cholesterol Serum sodium (NA) 136 to 145 mEq/L or 136/145 mmol/L (SI units)
Serum creatinine 0.2 mg/dL (17.6 μmol/L)
A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. Setting the suction pressure to 60 mm Hg Applying suction throughout the procedure Assessing breath sounds before suctioning Placing the client in a supine position before the procedure Hyperoxygenating the client with 100% oxygen before suctioning
Setting the suction pressure to 60 mm Hg Applying suction throughout the procedure Placing the client in a supine position before the procedure
An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse that some of the client's lab data are abnormal? Select all that apply. Sodium (NA) 149 mEq/L Hematocrit (HCT) 30% (0.30) Calcium (CA) 9 mg/dL LDL Cholesterol 140 Magnesium (MG) 2.2 mEq/L Bicarbonate 21 mEqL
Sodium (NA) 149 mEq/L Hematocrit (HCT) 30% (0.30) LDL Cholesterol 140 Bicarbonate 21 mEqL
A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The primary health care provider has prescribed a clear liquid diet for the client. Which item does the nurse ensure is available in the client's room before allowing the client to drink? Straw Napkin Suction equipment Oxygen saturation monitor
Suction equipment
A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take? Taking the client's vital signs Giving the client a drink of water Monitoring the client for a sore throat Being alert to complaints of heartburn
Taking the client's vital signs
A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client? Assessing the client's chest for crepitus once every 24 hours Taping the connections between the chest tube and the drainage system Adding 20 mL of sterile water to the suction control chamber every shift Recording the volume of secretions in the drainage collection chamber every 24 hours
Taping the connections between the chest tube and the drainage system
A client who has sustained a myocardial infarction is scheduled to have an echocardiogram. Which measure should the nurse take before the procedure? Imposing nothing-by-mouth (NPO) status for 4 hours Asking the client to sign an informed consent form Asking the client about a history of allergy to iodine or shellfish Telling the client that the procedure is painless and takes 30 to 60 minutes to complete
Telling the client that the procedure is painless and takes 30 to 60 minutes to complete
A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test? That mammography takes about 1 hour Not to eat or drink on the morning of the test That there is no discomfort associated with the procedure That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test
That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test
A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply. That informed consent is required That the test takes about 4 hours to complete That no premedication for sedation will be necessary That food and fluids will be withheld before the procedure That multiple position changes may be necessary to pass the tube
That informed consent is required That food and fluids will be withheld before the procedure That multiple position changes may be necessary to pass the tube
A nurse is reading the chest x-ray report of a client who has just been intubated. The report states where the endotracheal tube is positioned. What finding is considered a normal position for the endotracheal tube? The first tracheal cartilaginous ring The point where the larynx connects to the trachea The bifurcation of the right and left main stem bronchi The area connecting the oropharynx to the laryngopharynx
The bifurcation of the right and left main stem bronchi
A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? The client's vital signs The amount of drainage The client's lung sounds The chest tube connections
The chest tube connections
A nurse is performing nasotracheal suctioning on a client. Which observations should be cause for concern to the nurse? Select all that apply. The client becomes cyanotic. Secretions are becoming bloody. The client gags during the procedure. Clear to opaque secretions are removed. The heart rate varies from 80 to 82 beats/min.
The client becomes cyanotic. Secretions are becoming bloody.
A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should provide which information to the client? The procedure is performed in the operating room It is necessary to lie quietly on a hard x-ray table for about 4 hours The room is bright and well lit, and it is best to keep the eyes closed The client may have feelings of warmth or flushing during the procedure
The client may have feelings of warmth or flushing during the procedure
A CD4+ lymphocyte count is performed on a client who is infected with HIV. The results of the test indicate a CD4+ count of 450 cells per cubic millimeter of blood. The nurse interprets this test result as indicating which? Improvement in the client The need for antiretroviral therapy The need to discontinue antiretroviral therapy An effective response to the treatment for HIV
The need for antiretroviral therapy
A client has made an appointment for her annual Papanicolaou test (a.k.a. Pap smear). The nurse who schedules the appointment should provide which information to the client? Vaginal douching is required an hour before the test Spicy foods should not be eaten on the day of the test The test has absolutely no discomfort associated with it The test cannot be performed while the client is menstruating
The test cannot be performed while the client is menstruating
A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? HIV infection has been confirmed The client probably has an opportunistic infection The test will need to be confirmed with the use of a Western blot A positive test is a normal result and does not mean that the client is infected with HIV
The test will need to be confirmed with the use of a Western blot
A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which? The tube is patent There is probably a kink in the tubing Suction should be added to the system The client is retaining airway secretions
The tube is patent
A nurse is providing post-procedure instructions to a client returning home after arthroscopy of the shoulder. The nurse should provide the client with which information? To resume full activity the next day Not to eat or drink anything until the next morning To keep the shoulder completely immobilized for the rest of the day To report to the primary health care provider the development of fever or redness and heat at the site
To report to the primary health care provider the development of fever or redness and heat at the site
A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the primary health care provider? Select all that apply. Unequal chest expansion Pulse rate of 82 beats/min Respiratory rate of 22 breaths/min Diminished breath sounds in the right lung Complaints of discomfort at the needle insertion site
Unequal chest expansion Diminished breath sounds in the right lung
A primary health care provider is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client? Supine Upright Left side-lying Right side-lying
Upright
A client with diabetes mellitus (DM) is scheduled to have blood drawn in the morning for a fasting blood glucose determination. What does the nurse tell the client that it is acceptable to consume on the morning of the test? Water Tea without any sugar Coffee without any milk Clear liquids such as apple juice
Water
A nurse in a primary health care provider's office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client? Wear sweatpants and a heavy sweatshirt Eat a small meal just before the procedure Wear comfortable rubber-soled shoes such as sneakers Avoid consuming caffeine for 30 minutes before the procedure
Wear comfortable rubber-soled shoes such as sneakers
