Hesi Practice Questions

The healthcare provider plans to do a paracentesis on a client with cirrhosis in 1 hour. In what order should the nurse perform the following activities? A. Ensure that the informed consent has been obtained. B. Measure the client's abdominal girth. C. Have the client empty his or her bladder. D. Assemble needed equipment. E. Administer oral pain medication.

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A client has an order for hydromorphone intravenous (IV) push 1 mg every 3 hours. The drug is available as 4 mg/mL. The nurse administers ______ Fill-in blank 1 mL of hydromorphone for one dose. (Fill in the blank.)

ANS: 0.25 mL

A client who was admitted to the hospital with cancer of the larynx is scheduled for a laryngectomy tomorrow. What is the client's priority learning need tonight? A. Anticipated body image changes. B. Pain management expectations. C. Communication techniques. D. Postoperative nutritional needs.

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Which change in the status of a client being treated for increased intracranial pressure warrants immediate action by the nurse? A. Urinary output changes from 20 to 50 mL/h B. Arterial PCO2 changes from 40 to 30 mm Hg C. Glasgow Coma Scale score changes from 5 to 7 D. Pulse drops from 88 to 68 beats/min

ANS: D Cushing triad and increasing ICP

Which situation warrants a variance (incident) report by the nurse? A. A client refuses to take prescribed medication. B. A client's status improves before completion of the course of medication. C. A client has an allergic reaction to a prescribed medication. D. A client received medication prescribed for another client.

ANS: D Deviation from a prescribed plan of care

A client who is immediately postoperative for aortic aneurysm repair has been receiving normal saline intravenously at 125 mL/h. The nurse observes dark yellow urine. The hourly output for the past 3 hours was 30 mL, 18 mL, and 10 mL. What action should the nurse take? A. Administer a bolus D5 ½ normal saline at 200 mL/h. B. Contact the healthcare provider. C. Monitor output for another 2 hours. D. Draw blood samples for blood urea nitrogen (BUN) and creatinine levels.

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A 4-year-old admitted with pneumonia weighs 18 kg. The healthcare provider has prescribed vancomycin 40 mg/kg/day IV. The order states to divide the dose and give it three times daily. How many milligrams of vancomycin should the child receive in each dose? (Round the answer to the nearest whole number.) _____________________ mg/dose

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Which activity should the nurse delegate to an unlicensed assistive personnel (UAP)? A. Assist a client to ambulate who was just admitted with stroke symptoms. B. Encourage additional oral fluids for an elderly client with pneumonia who has developed a fever. C. Report the ability of a client with myasthenia gravis to manage the supper tray independently. D. Record the number of liquid stools of a client who received lactulose for an elevated NH3 level.

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Which client is at the highest risk for respiratory complications? A. A 21-year-old client with dehydration and cerebral palsy who is dependent in daily activities. B. A 60-year-old client who has had type 2 diabetes for 20 years and was admitted with cellulitis. C. An obese 30-year-old client with hypertension who is noncompliant with the medication regimen. D. A 40-year-old client who takes a loop diuretic, has a serum K+ of 3.4 mmol/L (mEq/L), and complains of fatigue.

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While the nurse is caring for a client who has had a myocardial infarction, the monitor alarm sounds, and the nurse notes ventricular fibrillation. What should be the nurse's first course of action? A. Notify the healthcare provider. B. Increase the oxygen concentration. C. Assess the client. D. Prepare to defibrillate the client.

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A pediatric client is prescribed digoxin for a congenital heart defect. The maintenance dosage ordered is 50 mcg/kg/day. The child weighs 10 kg. The prescription requires the digoxin to be administered twice daily. The nurse prepares _________ mcg of digoxin at each dose. Fill-in blank

ANS: 250 mcg

A 68-year-old client who is diagnosed with Alzheimer's disease is admitted to the nursing home by the nurse. The client does not recognize spouse or children and forgets how to eat and dress. What is the nurse's priority intervention for the newly admitted client? A. Establish a daily routine and schedule B. Encourage involvement in structured activities C. Discuss strategies to coordinate care D. Stress the importance of self-nurturing

ANS: A Change is difficult for clients with Alzheimer's

A child with hydrocephalus is 1 day postoperative for revision of a ventriculoatrial shunt. Which finding is most important for the nurse to assess first? A. Increased blood pressure B. Increased temperature C. Increased serum glucose D. Increased hematocrit

ANS: A Increased BP is a sign of increased ICP which is a priority.

During the initial phase, a group member, who has a master's degree, states, "My educational background makes it easier for me to help the other group members." Which action should the nurse take to assure effective group functioning? A. Reiterating the purpose of the support group sessions B. Asking the group to identify various stressful problems C. Obtaining ideas from the members about strategies for stressful situations D. Terminating the meeting and evaluate the situation

ANS: A Initial phase

A client who is at 36 weeks' gestation is placed in the lithotomy position when she suddenly complains of feeling breathless and light-headed and shows marked pallor. Which action should the nurse take first? A. Turn the client to a lateral position B. Place the client in Trendelenburg position C. Obtain vital signs and pulse oximetry reading D. Initiate distraction techniques

ANS: A Lateral position will allow blood return

A child admitted with sickle cell crisis is anemic and has painful joints and a fever of 101° F. Which priority intervention should the nurse include in the plan of care for this child? A. Maintain oral fluids for hydration B. Apply cold packs to painful joints C. Administer aspirin daily for pain and fever D. Perform range-of-motion exercises to decrease joint pain

ANS: A Remain well hydrated to promote hemodilution which will reduce symptoms of pain.

The nurse reviews the medication record of a 2-month- old and notes that the infant was given a scheduled dose of digoxin with a documented apical pulse of 76 beats/min. Which action should the nurse take first? A. Assess the current apical pulse rate B. Observe for the onset of diarrhea C. Complete an adverse occurrence report D. Determine the serum potassium level

ANS: A Verify the infant's current cardiac function

A 3-week-old infant with pyloric stenosis has severe vomiting. Which signs of dehydration should the nurse anticipate in the infant? (Select all that apply.) A. Sunken fontanel B. Increased urine output C. High serum hematocrit level D. Cracked lips E. Thirst

ANS: A, C, D, E Signs & symptoms of dehydration. High hematocrit means dehydration. Infant is thirsty by rooting or the way they take their formula or breast milk.

A client with gestational diabetes asks the nurse to explain the reason her baby is at risk for macrosomia. Which explanation should the nurse offer? A. The placenta receives decreased maternal blood flow during pregnancy because of vascular constriction. B. The fetus secretes insulin in response to maternal hyperglycemia, causing weight gain and growth. C. Infants of diabetic mothers are postmature, which allows the fetus extra time to grow. D. Rapid fetal growth contributes to congenital anomalies, which are more common in infants of diabetic mothers.

ANS: B Baby gains weight and grows

A client who is 72 hours post cesarean section is preparing to go home. She complains to the nurse that she can't get the baby's diaper on right. Which action should the nurse take? A. Demonstrate how to diaper the baby correctly B. Observe the client diapering the baby while offering praise and hints C. Call the social worker for long-term follow-up D. Reassure the client that she knows how to take care of her baby

ANS: B Client is in the taking-hold phase. Nurse should observe and reinforce.

The healthcare provider prescribes the anticonvulsant phenytoin for an adolescent with a seizure disorder. The nurse should instruct the client to notify the healthcare provider if which condition develops? A. Dry mouth B. Dizziness C. Sore throat D. Gingival hyperplasia

ANS: B Phenytoin can cause dizziness. The nurse should monitor the patient taking phenytoin for safety.

The nurse is planning to teach client strategies for coping with anxiety. The nurse finds the client engaged in compulsive handwashing. What action should the nurse take next? A. While the client is handwashing, introduce alternatives to handwashing. B. Ask the client to immediately stop handwashing; then begin teaching. C. Allow client to complete handwashing; then begin teaching. D. Ask client to describe events that precipitated the handwashing

ANS: C The best time for learning is at the end of the compulsive behavior, when the client's anxiety is lower.

An adult client is admitted to the inpatient mental health unit with a diagnosis of severe depression. As the client begins to recover, the client develops rapport with the nurse. After being discharged from the hospital, the client and the nurse happen to meet in the coffee shop. The client asks the nurse if they can schedule future meetings at the coffee shop. Which response by the nurse is most therapeutic? A. "I'll contact the nurse supervisor about this plan." B. "Let's not plan to meet; however, we may inadvertently see each other here." C. "It's not appropriate for me to discuss therapy with you when I'm off duty." D. "A social relationship with a former client is not appropriate."

ANS: D A, B, C open the door to a social relationship when that is not appropriate.

Which nursing action has the highest priority for an infant immediately after birth? A. Place the infant's head in the "sniff" position and give oxygen via face mask. B. Perform a bedside glucose test and feed the infant glucose water as needed. C. Assess the heart rate and perform chest compressions if rate is <60 beats/min. D. Dry the infant and place him or her under a radiant warmer or skin to skin with the mother.

ANS: D Cold stress is a major cause of metabolic problems in the newborn, including hypoglycemia. The neonatal resuscitation protocol is T-A-B-C (Temp, airway, breathing, circulation).

A 2-year-old child's blood work is evaluated by the nurse. Considering that the child is prescribed furosemide, captopril, and digoxin for congestive heart failure, which value should the nurse verify with the laboratory? A. Hypocalcemia B. Hypernatremia C. Low hemoglobin D. Hypokalemia

ANS: D Furosemide and digoxin in combination can deplete potassium stores and place the client at risk for digoxin toxicity.

The nurse observes an adolescent client experiencing a tonic-clonic seizure. Which intervention should the nurse provide first? A. Restrain the client to protect against injury B. Flex the neck to ensure stabilization C. Use a tongue blade to open the airway D. Turn client on side to aid ventilation

ANS: D Helps aid ventilation and provide protection

A pregnant client tells the nurse that she drinks only one glass of wine a day. Which information should the nurse provide the client about the effects of drinking alcohol during pregnancy? A. Alcohol causes vasoconstriction and decreases placental perfusion. B. Alcohol decreases the lecithin:sphingomyelin (L:S) ratio, contributing to lung immaturity. C. Alcohol causes vasodilation and increased fluid overload for the fetus. D. Alcohol during pregnancy places the fetus at risk for fetal alcohol spectrum disorders.

ANS: D It is not advisable that women drink alcohol during pregnancy.

A client diagnosed with borderline personality disorder returns after a weekend pass with lacerations to both wrists. The client complains about how the nurse is performing the dressing change. The nurse's response should be presented in which manner? A. Disinterested B. Concerned C. Matter-of-fact D. Empathetic

ANS: D Less likely the client will use splitting

A client with a history of alcohol abuse is admitted to the medical unit for gastrointestinal bleeding and pancreatitis. The admission data include BP 156/96 mm Hg, pulse 92 beats/min, and temperature 37.3° C (99.2° F). Which intervention is most important for the nurse to implement? A. Provide a quiet, low-stimulus environment B. Initiate seizure precautions C. Administer as-needed (PRN) lorazepam (Ativan) as prescribed D. Determine the time and quantity of the client's last alcohol intake

ANS: D Most important to determine the client's risk for withdrawal or delirium tremens

A school-age child with nephrotic syndrome is seen at the clinic 2 days after discharge from the hospital. Which assessment is most important for the nurse to perform after discharge? A. Pain B. Capillary refill C. Urine ketones D. Daily weight

ANS: D Obtaining weight would inform the nurse about fluid balance.

The charge nurse confronts a staff nurse whose behavior has been resentful and negative since a change in unit policy was announced. The staff nurse states, "Don't blame me; nobody likes this idea." Which is the charge nurse's priority action?​ A. Confront the other staff members involved in the change of unit policy. B. Call a unit meeting to review the reasons the change was made. C. Develop a written unit policy for the expression of complaints. D. Encourage the nurse to be accountable for her own behavior.

ANS: D The nurse is disruptive and inappropriate, and she needs to be responsible for her behaviors.

A female client who is a 5-year breast cancer survivor received confirmation that she has a recurrence of breast cancer. She informs her family that the biopsy was negative. What action should the nurse take? A. Tell the client's family to consult the healthcare provider. B. Ask the client to restate what the healthcare provider told her. C. Encourage the client to inform her family about the results. D. Suggest the client talk to the nurse about her fears.

ANS: D The nurse provides the client with a safe place to share her concerns until she is ready to abandon denial.

An RN working on a hospice unit finds a client crying. The client states that he is afraid to die. Which actions should the RN implement? (Select all that apply.) A. Sit quietly with the client and listen to his concerns. B. Provide the client with privacy. C. Give the client an anti anxiety medication. D. Contact the client's spiritual counselor or pastor. E. Assess the patient for signs of impending death.

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At change of shift, the charge nurse assigns the UAP four clients. The RN should direct the UAP to take vital signs on which client first? A. The 89-year-old with chronic obstructive pulmonary disease who is resting quietly on 2 L of oxygen and who needs assistance with a bath. B. The client who returned from surgery and needs their second set of every-15-minute vitals signs taken. C. The client newly diagnosed with type 2 diabetes who had a fingerstick glucose level of 5.0 mmol/L (90 mg/dL) and needs help with breakfast. D. The newly admitted client with rheumatoid arthritis who needs hand splints reapplied to both hands.

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The nurse is part of the triage team at a disaster. Which client should be seen first? A. A 90-year-old woman with a crushed pelvis and head injuries. B. A 21-year-old man screaming in pain from a broken leg. C. A 30-year-old woman with a flail chest secondary to a puncture wound to the chest. D. A 12-year-old crying with multiple lacerations to both legs.

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The nurse is teaching a young adult female who has a history of Raynaud disease how to control her pain. What information should the nurse offer? A. Take oral analgesics at regularly spaced intervals. B. Avoid extremes of heat and cold. C. Limit foods and fluids that contain caffeine. D. Keep the affected extremities in a dependent position.

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The nurse is updating the plan of care for a client who has a borderline personality disorder. Which intervention is most important to implement? A. Assign the same nurse to care for the client. B. Avoid challenging inappropriate behavior. C. Limit the client's contact with other clients. D. Remove consequences for acting-out behaviors.

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When entering a client's room, the nurse finds the client threatening to cut herself. What is the priority intervention? A. Call in an extra nurse or UAP for the next shift. B. Assign one of the current UAPs to sit with the client. C. Move the client to another room with a roommate. D. Administer an as-needed (PRN) dose of lorazepam.

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The nurse admits a client with suspected early DIC. Which symptoms may indicate early organ ischemia? (Select all that apply.) A. Slight gingival bleeding B. Alterations in mental status C. Petechial hemorrhage to chest D. Slight decrease in urine output E. Bluish discoloration of fingertips

ANS: B, D, E Early

Today's lab report of the lithium level is 1.3 mEq/mL for a client diagnosed with bipolar disorder. Which is the first action the nurse should take? A. Withhold the dose until after breakfast B. Give the client the prescribed dose C. Obtain a prescription to increase the dose D. Withhold the dose and notify the healthcare provider

ANS: D Above 1.2 indicates toxicity.

The triage nurse in the emergency room is assessing four clients. Which client requires the most immediate intervention? A. The adult client who arrived via ambulance with numbness and tingling of his left arm and face. B. The adult client who had a seizure at home who is sleeping on his left side. C. The 60-year-old client who complains of frequent urination and has a blood sugar of 16.7 mmol/L (300 mg/dL). D. The middle-aged client who presents with severe unilateral back pain and previous history of kidney stones.

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When accessing the medication dispensing system (Pyxis), the nurse finds chlorpropamide in the drawer instead of the expected chlorpromazine. Which actions should the nurse take? (Select all that apply.) A. Remove the tablets of chlorpropamide. B. Notify the pharmacy about the mistake. C. Place an incident occurrence report. D. Be extra vigilant because pharmacy is making mistakes. E. Place a warning note on the Pyxis machine.

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A client with a known cardiac history is admitted to the acute care unit with stable angina. At 7:00 a.m., the client had stable vital signs and was on 2 L of oxygen via nasal cannula. At 10:00 a.m., the client reports chest pain of 6 on a scale of 1 to 10, is slightly diaphoretic and pale, has a blood pressure (BP) of 100/52 mm Hg, and has a respiratory rate of 24 breaths/min. Which action should the nurse implement first? A. Apply 4 L of oxygen as ordered. B. ​​Administer a fluid bolus of 0.9 normal saline. C. Administer the prescribed opioid for pain control. D. Obtain a full set of vital signs, including temperature.

ANS: A Maximize perfusion to the myocardium

The nurse is caring for a child who had a tonsillectomy 2 hours ago. Which sign or symptom most likely relates to a complication? A. Apical rate 90 beats/min B. Blood pressure 96/50 C. Frequent swallowing D. Nasal congestion

ANS: C

pH = 7.43​ pCO2 = 40​ HCO3 =24​ Fill-in blank ​This client has _____________

ANS: Normal, document and continue to monitor

pH = 7.33​ pCO2 = 50​ HCO3 = 29 Fill-in blank ​This client has _______

ANS: Partially compensated respiratory acidosis

pH = 7.32​ pCO2 = 50​ HCO3 =25 ​ Fill-in blank ​This client has _________________

ANS: Respiratory acidosis

A UAP is assisting with the care of several clients on a postpartum unit. Which assignment should the nurse delegate to the UAP? A. Check fundal firmness and lochia for the clients who delivered vaginally. B. Take vital signs every 15 minutes for a client with preeclampsia. C. Provide breastfeeding instructions for a primigravida. D. Assist with daily care activities for all clients as needed.

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A client at 39 weeks' gestation plans to have an epidural block when labor is established. What intervention(s) should the nurse implement to prevent side effects? (Select all that apply.) A. Teach about the procedure and effects of the epidural. B. Place the client in a chair next to the bed. C. Administer a bolus of 500 mL of normal saline solution. D. Monitor the fetal heart rate and contractions continuously. E. Assist the client to empty her bladder every 2 hours.

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A client at 41 weeks' gestation who is in active labor calls the nurse to report that her membranes have ruptured. The nurse performs a vaginal examination and discovers that the umbilical cord has prolapsed. Which intervention should the nurse implement first? A. Move the presenting fetal part off the cord. B. Cover the cord with sterile moist saline gauze. C. Prepare for an emergency caesarean delivery. D. Administer O2 by face mask at 10 L/min.

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A client who has posttraumatic stress disorder is found one night trying to strangle his roommate. Which intervention is the nurse's highest priority? A. Give the client a sedative or hypnotic. B. Administer an antipsychotic. C. Assign a UAP to sit with the client. D. Process with both clients about event.

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A client with chronic back pain is not receiving adequate pain relief from oral analgesics. Which alternative action should the nurse explore to promote the client's independence? A. Ask the healthcare provider to increase the analgesic dosage. B. Obtain a prescription for a second analgesic to be given by the IV route. C. Consider the client's receptivity to complementary therapy. D. Encourage counselling to prevent future addiction.

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A client with type II diabetes is scheduled for an intravenous pyelogram (IVP). Which assessment is most important for the nurse to complete before the test is performed? A. Baseline vital signs. B. Current medication list. C. Coagulation status. D. Electrolyte levels.

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A client's arterial blood gas results are as follows: pH 7.29, Pco2 55 mm Hg, and Hco3 26 mEq/L. Which compensatory response should the nurse expect to see? A. Respiratory rate of 30 breaths/min. B. Apical rate of 120 beats per minute. C. Potassium level of 5.8 mmol/L (mEq/L). D. Complaints of pounding headache.

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A female adolescent is admitted to the mental health unit for anorexia nervosa. In planning care, what is the nurse's highest priority? A. Teach the client the importance of self-expression. B. Supervise the client's activities closely. C. Include the client in daily group therapy. D. Facilitate social interactions with others.

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A female client presents in the emergency department with right lower quadrant abdominal pain and pain in her right shoulder. She has no vaginal bleeding, and her last menses was 6 weeks ago. Which actions should the nurse take first? A. Assess for abdominal rebound pain, distention, and fever. B. Obtain a complete set of vital signs and establish IV access. C. Observe for recent musculoskeletal injury, bruising, or abuse. D. Collect specimens for pregnancy test, hemoglobin, and white blood cell count

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A hospitalized client has been newly diagnosed with type 2 diabetes. Which task(s) can the RN delegate to the UAP? (Select all that apply.) A. Contacting the dietitian for a prescribed consult. B. Reviewing the client's insulin injection technique. C. Obtaining the fingerstick blood glucose level before each meal and at bedtime. D. Reminding the client to dry the toes carefully after a shower. E. Talking to the client about foods that raise the blood glucose level.

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A male client with a peritoneal dialysis (PD) catheter calls the clinic to report that he feels poorly and has a fever. What is the best response by the nurse? A. Encourage him to come to the clinic today for assessment. B. Instruct him to increase his fluid intake to 3 L/ day. C. Review his peritoneal dialysis regimen. D. Inquire about his recent dietary intake of protein and iron.

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A nurse has been assigned a pregnant client who has heart disease. The client's condition has been diagnosed as New York Heart Association (NYHA) class II cardiac disease. What important fact(s) about activities of daily living while pregnant should the nurse teach this client? (Select all that apply.) A. Increase fiber in the diet. B. Anticipate the need for rest breaks after activity. C. Notify the healthcare provider if her rings do not fit. D. Maintain bed rest with bathroom privileges. E. Start a low-impact aerobic exercise program.

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A nurse is planning the client assignments for the night shift. The nursing team includes a registered nurse, a licensed practical nurse, and two unlicensed assistive personnel (UAP). Which duty (or duties) could be delegated to the UAPs? (Select all that apply.) A. Transport a client to the radiology department for a computed tomography (CT) scan. B. Bathe a client with sickle cell disease who has multiple IV lines and a patient-controlled analgesia pump. C. Turn a 92-year-old client who has end-stage heart failure and a do-not-resuscitate order. D. Report to the healthcare provider the fingerstick blood glucose level of 2.72 mmol/L (49 mg/dL) E. Feed a female client her first meal after she experienced a stroke.

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A nurse working at a clinic finds a client in one of the examination rooms slumped over and apneic. The nurse notes an empty syringe and needle still in the client's arm. Which action has the highest priority? A. Call 911. B. Remove the syringe and needle. C. Assess for a pulse. D. Obtain the automated external defibrillator (AED).

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A victim of a motor vehicle collision is dead on arrival at the emergency department. The significant other arrives and is noticeably upset. What action should the nurse take to assist the significant other with this crisis? A. Ask whether there are family, friends, or clergy to call. B. Talk about the former relationship with the significant other. C. Provide education about the stages of grief and loss. D. Assess the significant other's level of anxiety.

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After a change-of-shift report on an orthopedic floor, which client should the nurse assess first? A. A client who had surgery yesterday and has a temperature of 37.6°C (99.7°F). B. A client who is complaining of numbness and tingling distal to the fracture site. C. A client who had a left leg amputation and states he is experiencing pain in the left foot. D. A client who is extremely upset with their care and is requesting to speak to the manager.

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An 18-year-old woman is being discharged after delivering a healthy baby. She has a cousin whose baby died from sudden infant death syndrome (SIDS). The client seems to know many of the precautions to take. Which information does the nurse need to correct? A. Always place infants on their backs to sleep. B. Room sharing has been shown to decrease SIDS. C. Keep the crib free of stuffed animals and crib pads. D. Sleeping with the baby can alert the mother to changes.

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The RN is evaluating the effects of the administration of fresh frozen plasma (FFP) on a client diagnosed with cirrhosis. Which finding(s) would indicate a positive outcome? (Select all that apply.) A. Blood urea nitrogen (BUN) 3.9 mmol/L (11 mg/ dL); creatinine 62 mcmol/L (0.7 mg/dL). B. Hemoglobin level of 100 mmol/L (10 gm/dL). C. Return of temperature to normal. D. Decreased bleeding from the gums. E. Negative guaiac for occult bleeding.

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The arrythmia alarm sounds on a client on the telemetry unit, indicating that the client is in ventricular tachycardia. Place the nurse's actions for this client in order of priority from first to last. A. Call the rapid responses team. B. Assess for blood pressure. C. Give oxygen via nasal cannula. D. Bring defibrillator/crash car to the bedside. E. Document the incident.

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The charge nurse is planning the daily schedule for clients on the mental health unit. A male client who is manic should be assigned to which activity? A. A basketball game in the gym. B. Jogging at least 1 mile daily. C. A table tennis game with a peer. D. Group activity with the art therapist.

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The charge nurse reminds clients on the mental health unit that breakfast is at 8 AM, medications are given at 9 AM, and group therapy sessions begin at 10 AM. Which treatment modality has been implemented? A. Milieu therapy. B. Behavior modification. C. Peer therapy. D. Problem-solving.

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The clinic nurse is caring for a client taking argatroban for atrial fibrillation. What information is essential for the nurse to include in the client's teaching plan? (Select all that apply.) A. Have protamine sulfate available. B. Notify the healthcare provider of any unusual bleeding. C. Eat a diet high in green leafy vegetables. D. Keep the medication in a dark, dry container. E. Avoid aspirin or aspirin-containing medications.

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The clinic nurse suspects that a 2-year-old child is being abused. Which assessment finding(s) would support this? (Select all that apply.) A. Petechiae in a straight line on the chest. B. Gray-blue pigmented areas on the sacral region. C. Bald patches on the scalp. D. Ear tugging and crying. E. Symmetrical burns on the hands.

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The emergency department staff nurse is assigned four clients. Which client should the nurse assess first? A. A preschooler with a barking cough, an O2 saturation of 93% on room air, and occasional inspiratory stridor. B. A 10-month-old infant with a tympanic temperature of 38.9°C (102°F) and green nasal drainage who is pulling at her ears. C. A crying 8-month-old with a harsh, paroxysmal cough; an audible expiratory wheeze; and mild retractions. D. A clingy 3-year-old who has a sore throat and drooling and whose tongue is slightly protruding from his mouth.

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The healthcare provider has prescribed the removal of a client's internal jugular central line catheter. To remove the catheter safely, the nurse should give which intervention(s) the highest priority? (Select all that apply.) A. Carefully remove the bio-occlusive dressing. B. Place the client in the Trendelenburg position. C. Send the catheter tip to the laboratory for a culture and sensitivity. D. Have the client hold a deep breath during removal. E. Apply pressure for 20 minutes after removal of the catheter.

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The home health nurse evaluates the insulin preparation and administration technique of a 36-year-old male client newly diagnosed with diabetes. The client has been prescribed lispro insulin before meals and glargine insulin once daily in the morning. Which finding indicates that the client needs further education? A. He mixes glargine and lispro in the same syringe for the morning dose. B. He leaves the insulin syringe in place for 10 seconds after injection. C. He stores the opened insulin vials at room temperature in the cabinet. D. He recaps and disposes of the single-use insulin syringe.

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The nurse is administering medications to a client admitted for an overdose and a history of substance abuse. Which intervention(s) is (are) a priority to include in this client's plan of care? (Select all that apply.) A. Allow the client to take medications independently. B. Ensure that all medications have been swallowed before leaving the client's room. C. Request that oral pain medications be changed from tablet to oral suspension. D. Administer flumazenil as prescribed every 6 hours around the clock. E. Administer all medications to the client via the intravenous route.

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The nurse is admitting a client who is a paraplegic and has a non healing pressure injury with a possible methicillin-resistant Staphylococcus aureus infection. A PN and UAP are assigned to the nurse's team. Which tasks should be delegated to the PN? (Select all that apply.) A. Place the client in isolation. B. Complete a dressing change. C. Assess and document the wound. D. Insert a urinary catheter. E. Administer oral pain medications.

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The nurse is assigning tasks to the UAP. Which client situation requires the registered nurse (RN) to intervene? A client with: A. active tuberculosis who is leaving the room without a mask. B. end-stage renal disease requesting orange juice to drink. C. anemia who is complaining of fatigue and asking for help getting dressed to go home. D. chronic obstructive pulmonary disorder who removes his oxygen and is leaving the unit to smoke.

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The nurse is calling the healthcare provider (HCP) about a client's current needs. What is the best way to communicate? A. Call the HCP with the request and a recommendation. B. Use the SBAR (situation, background, assessment, recommendation) tool for communication. C. Send a text message or page with the needed order. D. Ask the HCP to come back to the unit to discuss the client's needs.

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The nurse is caring for a client who had a thoracotomy 48 hours earlier and has left lower lobe chest tubes. The nurse notes that a chest tube is not tidaling. Which action should the nurse take first? A. Check for kinks in the chest drainage system. B. Assess the heart rate and blood pressure. C. Notify the rapid response team immediately. D. Reconnect the chest tube to wall suction.

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The nurse is planning to lead a seminar for community health nurses on violence against women during pregnancy. Which statement describes an appropriate technique for assessing for violence? A. Women should be assessed only if they are part of a high-risk group. B. Women may be assessed in the presence of young children but not intimate partners. C. The assessment only needs to be completed at the beginning of the pregnancy. D. Women should be reassessed face-to-face by a nurse as the pregnancy progresses.

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The nurse is providing discharge instructions to a client who has been diagnosed with angina pectoris. Which instruction is most important? A. Avoid activity that involves the Valsalva maneuver. B. Seek emergency treatment if chest pain persists after the third nitroglycerin dose. C. Rest for 30 minutes after having chest pain before resuming activity. D. Keep extra nitroglycerin in an airtight, light-resistant bottle.

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The nurse is providing discharge teaching for a client who has been prescribed diltiazem. Which dietary instruction has the highest priority? A. Maintain a low-sodium diet. B. Eat a banana each morning. C. Ingest high-fiber foods daily. D. Avoid grapefruit products.

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The nurse is returning phone calls to clients who are cared for at an outpatient mental health center. Which client should the nurse call first? A. The young mother diagnosed with schizophrenia who is hearing voices saying that they are pursuing her children. B. The elderly man at an assisted living facility who says he wants to end it all. C. The female client diagnosed with bipolar disorder who has not slept for 48 hours. D. The teenager diagnosed with bulimia whose mother called and reported that she found her daughter purging.

ANS:

The nurse is reviewing the cardiac markers for a client who was admitted with the diagnosis of chest pain. Which marker is the best to determine cardiac damage? A. Troponin levels. B. Myoglobin level. C. Creatine kinase myocardial band (CK-MB) level. D. Lactate dehydrogenase (LDH) level.

ANS:

The nurse is reviewing the laboratory values of her assigned clients. Which client has an abnormal laboratory report that the nurse should immediately call to the healthcare provider? A. The client who is post splenectomy after a motor vehicle accident and has a hemoglobin of 109 mmol/L (10.9 g/dL). B. The client receiving warfarin (Coumadin) who has an international normalized ratio (INR) of 2.3. C. The 38-year-old client who is 24 hours post thyroidectomy and has a total calcium level of 2.35 mmol/L (9.4 mg/dL). D. The newly admitted client with bipolar disorder with a lithium level of 2.5 mEq/L.

ANS:

The nurse is teaching a client who has chronic urinary tract infections about a prescription for ciprofloxacin 500 mg PO bid (twice daily). What side effect(s) could the client expect while taking this medication? (Select all that apply.) A. Photosensitivity. B. Dyspepsia. C. Diarrhea. D. Urinary frequency. E. Anemia.

ANS:

The nurse needs to initiate an IV on an 8-year-old child. Which intervention(s) is/are appropriate? A. Start the IV in the treatment room, not the child's room. B. Apply a lidocaine-based cream for a few minutes before starting the IV. C. Ask the parents to leave the room while performing the procedure. D. Encourage the child to use guided imagery to cope. E. Offer the child a reward if they cooperate during the procedure.

ANS:

The nurse receives change-of-shift report on her four acute care clients. Which action should the nurse take first? A. Administer an antiemetic to a postoperative client who has been nauseated and is now vomiting. B. Notify a family member of a client's impending transfer to the intensive care unit for angina and ST segment changes. C. Inform the healthcare provider of a potassium level of 5.2 mmol/L (mEq/L) in the client with end-stage renal disease. D. Begin assessment rounds, starting with the palliative care client having a diagnosis of congestive failure.

ANS:

The nurse receives report on a client from the emergency department with a diagnosis of pneumonia. Which intervention has the highest priority? A. Obtain blood cultures. B. Initiate prescribed antibiotics. C. Place the client in isolation. D. Obtain an accurate weight.

ANS:

The nurse who usually works on the orthopedic surgery unit is floating to a cardiovascular unit. Which client would be best to assign to the float nurse? A. Client scheduled for a heart catheterization this morning. B. Client admitted last night for chest pain. C. Client who is 1 day postoperative for popliteal bypass surgery. D. Client with heart failure and scheduled for a stress test today.

ANS:

The nursing supervisor calls the charge nurse on a step-down unit about the need for a bed for an unstable patient from the medical unit. Which client should the nurse transfer to the medical unit to receive this unstable client? A. A client admitted for an ST-elevation myocardial infarction (STEMI) who just returned from having a cardiac catheterization performed. B. A client diagnosed with congestive heart failure who is receiving an IV infusion of furosemide. C. A client with possible Guillain-Barré syndrome who may need an exchange transfusion. D. A client in hypertensive crisis who is prescribed a sodium nitroprusside drip.

ANS:

The outpatient clinic nurse is reviewing phone messages from the previous night. Which client should the nurse call back first? A. A woman at 30 weeks' gestation who has been diagnosed with mild preeclampsia and was unable to relieve her heartburn. B. A woman at 24 weeks' gestation who was crying about painful vulvar lesions and urinary frequency for the past 8 hours. C. A woman at 12 weeks' gestation who was recently discharged from the hospital with hyperemesis gravidarum and had had two episodes of vomiting in 6 hours. D. A woman with type 1 diabetes who tested positive with a home pregnancy kit and was worried about managing her diabetes.

ANS:

The emergency department nurse is assessing a client with a vesicular rash as a result of suspected smallpox exposure. Which transmission precautions should be most appropriate for this client? (Select all that apply.)​ A. Airborne B. Contact C. Aplastic D. Droplet E. Standard

ANS: A, B, D, E

The nurse is conducting an osteoporosis screening clinic at a health fair. Which information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.) A. Limit alcohol and stop smoking B. A.Suggest supplementing the diet with vitamin E C. Promote regular weight-bearing exercise D. Implement a home safety plan to prevent falls E. Propose a regular sleep pattern of 8 hours nightly

ANS: A, C, D Need protein and calcium for osteoporosis

The mental health RN is assigned to five clients. Which clients should have priority assessments? (Place in order of priority.) A. A newly admitted client diagnosed with major depression whose assessment is incomplete B. A client diagnosed with schizophrenia who is having auditory hallucinations of an infant crying C. A client who has a 5-year history of daily consumption of two six-packs of beer D. A client diagnosed with bulimia who is having difficulty attending group E. A client who has been taking benzodiazepines off and on daily for the last 2 years

ANS: A, C, E, B, D Unknown if A is suicidal. C needs to be assessed for delirium tremens (life threatening) and withdrawal. E May experience life-threatening withdrawal symptoms, (seizures) with abrupt withdrawal B auditory hallucinations are normal to schizophrenia D Psychosocial need that is not top priority

The nurse is reinforcing teaching for a school-age child and the child's parent regarding the administration of inhaled beclomethasone dipropionate and albuterol for the treatment of asthma. Which statement by the parent indicates that teaching has been effective? A. "I'll keep the inhalers in the refrigerator." ​B. "My child only needs to use inhalers when the peak flow numbers are in the red."​ C. "My child will take the bronchodilator first, then the corticosteroid." D. "My child will take the corticosteroid first, wait a few minutes, and then take the bronchodilator."

ANS: C Bronchodilator used to open and relax airways. Rinse mouth after corticosteroid

Which laboratory result for a preoperative client should prompt the nurse to contact the healthcare provider? A. Platelet count: 151 × 109/L (151,000/mm3) B. White blood cell (WBC) count: 85 × 109/L (8500/mm3) C. Serum potassium level: 2.8 mEq/L (mmol/L) D. Urine specific gravity: 1.031

ANS: C Can lead to perioperative arrhythmia

A woman who is in labor becomes nauseated, starts hiccupping, and tells her partner to leave her alone. The partner asks the nurse what he did to make this happen. Which response should the nurse provide? A. "In active labor, it is quite common for women to react this way. It's nothing you did." B. "I don't know what you did, but stop, because she is quite sensitive right now." C. "I'll come and examine her. This reaction is common during the transition phase of labor." D. "Early labor can be very frustrating. I'm sure she doesn't mean to take it out on you."

ANS: C Findings are normal but the nurse should still examine the woman to reassure the partner.

A client's suspected pregnancy is confirmed. The client tells the nurse that she had three previous pregnancies where she delivered one infant at 39 weeks, twins at 34 weeks, and another infant at 35 weeks. Using the GTPAL notation, how should the nurse record the client's gravidity and parity? A. 3-0-3-0-3 B. 3-1-1-1-3 C. 4-1-2-0-4 D. 4-2-1-0-3

ANS: C GTPAL - 4, 1, 2, 0, 4 Gravida pregnant for the 4th time Term (37 weeks) - 1 time Para (preterm pregnancies between 20-36 weeks) - 2 Abortion/spontaneous - 0 Living children - 4

The nurse is reinforcing discharge teaching for parents of a 4-year-old with cystic fibrosis. Which statement by the parents demonstrates understanding of the teaching presented? A. "We will discourage our child from playing outdoors." B. "We will use pancreatic enzymes only if needed." C. "We will thoroughly wash our child's hands after toileting." D. "We will schedule a physical therapist evaluation."

ANS: C Hand washing is #1 at stopping infection

A client who has chronic obstructive pulmonary disease (COPD) is resting in a semi-Fowler's position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. Which action should the nurse take first? A. Call the HCP. B. Obtain a bedside pulse oximeter. C. Raise the head of the bed higher. D. Assess the client's vital signs.

ANS: C Least invasive

A client diagnosed with a history of bulimia is admitted to the mental health unit. What intervention is most important for the nurse to include in the initial treatment plan? A. Observe the client after meals for purging. B. Assess daily weight and vital signs. C. Monitor serum potassium and calcium. D. Provide a structured environment at mealtime.

ANS: C Physiological assessment is most important; therefore the nurse should monitor for low K and calcium, which can result from vomiting and use of laxatives.

The nurse is caring for a 16-year-old client with Down syndrome who has a mental age of 5. Which priority nursing action should be included in this client's plan of care? A. Monitoring for hearing loss B. Monitoring I&O C. Providing a dependable routine D. Providing small puzzles

ANS: C Suitable, predictable schedule will reduce anxiety.

The nurse and the unlicensed assistive personnel (UAP) take a group of mental health clients to a baseball game. During the game, a client reports shortness of breath and dizziness. Which intervention should the nurse implement first? A. Have the UAP escort the client back to the unit. B. Request that the client describes current feelings. C. Accompany the client to a quiet area. D. Ask the client if anything untoward occurred.

ANS: C Take an anxious client to an area of reduced environmental stimuli

The nurse is teaching an 86-year-old client who has glaucoma and bilateral hearing loss. Which intervention should the nurse implement? A. Maintain constant eye contact B. Stand on the side unaffected by glaucoma C. Speak in a lower tone of voice D. Keep the environment dimly lit

ANS: C The elderly client hears lower pitched sounds more easily

A client at 15 weeks' gestation is admitted for an inevitable abortion. Thirty minutes after returning from surgery, her vital signs are stable. Which intervention has the highest priority? A. Ask the client if she would like to talk about losing her baby. B. Place cold cabbage leaves on the client's breasts to decrease breast engorgement. C. Send a referral to the grief counselor for at-home follow-up. D. Confirm the client's Rh and Coombs' status and administer RhoGAM if indicated.

ANS: D Priority. If the woman is Rh Negative and Coombs' negative, she should receive RhoGAM within the first 72 hrs after placental separation to prevent isoimmunization which could harm future fetuses.

A client at 33 weeks' gestation who has been diagnosed with pregnancy-induced hypertension (PIH) is admitted to the labor and delivery area. The client expresses concern for the health of her baby. Which response should the nurse make? A. "You have the best doctor on the staff, so don't worry about a thing." B. "Your anxiety is contributing to your condition and may be the reason for your admission." C. "This is a minor problem that is easily controlled, and everything will be all right." D. "As I assess you and your baby, I will explain the plan for your care and answer your questions."

ANS: D Provide teaching & reassurance

The nurse is reviewing the current medication list of a client, newly diagnosed with type 1 diabetes, who will be prescribed insulin. Which medications should the RN discuss with the healthcare provider? (Select all that apply.) A. Prednisone B. Atenolol C. Clarithromycin D. Acetaminophen E. Ibuprofen F. Pantoprazole sodium

ANS: A, B, C Prednisone can increase glucose levels. Atenolol which is a beta-blocker can lower blood sugar. Certain antibiotics potentiate the effects of hypoglycemic agents.

The nurse is assigned to receive a client in the emergency department with suspected anthrax exposure predecontamination. Which transmission precautions should be most appropriate for the client? (Select all that apply.) A. Airborne B. Contact C. Aplastic D. Droplet E. Standard

ANS: A, B, D, E

The newly licensed nurse overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed nurse should be implemented first? A. Monitor the nurses closely for further occurrences. B. Advise them to cease their communication. C. Inform the nurse manager of the conversation. D. Submit an occurrence or variance report.

ANS: B Calmly advise that this is not the place to share information.

While receiving IV antibiotics for sepsis, a 2-month-old infant is crying inconsolably, despite the parent's presence. The nurse recognizes that the infant is exhibiting symptoms related to which likely condition? A. Allergic reaction to antibiotics B. Pain related to IV infiltration C. Separation anxiety from parent D. Hunger and thirst

ANS: B The infant cries inconsolably from pain until the pain stops.

Which client should be assigned to a graduate nurse orienting to the neurological unit? A. A client with a head injury who has a Glasgow Coma Scale of 6 B. A client who developed autonomic dysreflexia after a T6 spinal cord injury C. A client with multiple sclerosis who needs the first dose of interferon D. A client diagnosed with Guillain-Barré syndrome

ANS: C New grad should be able to administer the medication, teach the client about the med, and assess for any adverse effects. Guillain-Barre client is at risk for resp. distress and should be monitored by an experienced nurse.

The nurse is preparing for change of shift. Which action by the nurse is characteristic of ineffective handoff communication? A. The nurse states to the nurse coming on duty: "The client is anxious about pain after surgery. Review the information I provided about how to use an incentive spirometer." B. The nurse refers to the electronic medical record (EMR) to review the client's medication administration record. C. During rounds, the nurse talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client. D. Before giving report, the nurse performs rounds on assigned clients so that there is less likelihood of interruption during handoff.

ANS: C Rounds are not the place for holding staff accountable

Picture: Rhythm strip The nurse is caring for a client in shock of unknown etiology and observes the rhythm on the right on the monitor. Which is the nurse's priority intervention? A. Check for a carotid pulse. B. Defibrillate the patient with 360 joules of energy. C. Administer an intravenous saline bolus. D. Give two breaths via Ambu® bag.

ANS: A First assess the client before performing an intervention.

A client with pneumonia has impending respiratory failure. Which set of ABG values demonstrate acute respiratory failure? ​ A. pH-7.30 PCO2-52 PO2-56 HCO3-26 B. pH-7.35 PCO2-44 PO2-86 HCO3-28 C. pH-7.35 PCO2-62 PO2-66 HCO3-31 D. pH-7.30 PCO2-39 PO2-88 HCO3-22

ANS: A Lungs are failing

The nurse is planning a class on stroke prevention for clients with hypertension. Which information reflects accurate prevention measures that the clients can undertake? (Select all that apply.) A. Limit salt intake to 1500 mg/day or less B. Eliminate tobacco products C. Initiate a program of walking 1 mile per day D. Achieve a body mass index (BMI) of 26.2 E. Schedule routine health assessments biannually

ANS: A, B, C Limiting salt can lower blood pressure. Cigarette smoking greatly increases risk for stroke. CDC recommends 2 hours and 30 min of moderate-intensity exercise.

An older client with a history of hypertension, heart failure, and sleep apnea is admitted to the acute care unit. Which finding(s) should relate most directly to a diagnosis of acute decompensated heart failure? (Select all that apply.) A. Respiratory rate of 25 breaths/min B. Orthopnea C. S3 heart sound D. Dry, nonproductive cough E. Heart rate of 69 and irregular

ANS: A, B, C Pulmonary edema or decompensated heart failure is caused by abnormal accumulation of fluid in the lung. Leading to dyspnea, tachypnea, orthopnea, tachycardia (S3, S4 gallop), severe coughing productive of frothy and blood-tinged sputum, with noisy, wet breath sounds that do not clear with coughing. Would be a productive cough

A practical nurse (PN) is assigned to care for an 82-year-old client who had a total right hip replacement with cement 2 days ago. Which observation(s) should the PN immediately report to the RN? (Select all that apply.) A. The client complains of incisional pain, rating it an 8 on a scale of 0 to 10. B. The client has had a change in orientation to person but not to time or place. C. Swelling and redness have developed in the client's lower left leg. D. The LPN emptied 15 mL of bloody drainage from the Jackson-Pratt drain. E. The client's last set of vital signs was temperature 37.9°C (100.2°F), pulse 87, respirations 12, blood pressure 108/74, and O2 saturation 93%.

ANS: A, B, C, E Severe pain Pending sepsis VTE Low grade fever pending sepsis/serious illness

While the nurse is obtaining the health history of a client and reviewing the medical records, which data should alert the nurse that the client has an increased risk of developing peptic ulcer disease? (Select all that apply.) A. Excess of gastric acid or a decrease in the natural ability of the GI mucosa to protect itself from acid and pepsin B. Invasion of the stomach and/or duodenum by H. pylori​ C. Viral infection, allergies to certain foods, immunological factors, and psychosomatic factors D. Taking certain drugs, including corticosteroids and anti inflammatory medications E. Having allergies to foods containing gluten in their ingredients

ANS: A, B, D Viral infections & gluten allergies can cause gastritis but not necessarily ulcers.

The charge nurse is planning client assignments for the unit. The collaborative care team consists of a registered nurse (RN), a practical nurse (PN), and an unlicensed assistive personnel (UAP). Which client(s) should be assigned to the RN? (Select all that apply.) A. A client awaiting a blood transfusion for gastrointestinal bleeding with an Hgb 7.0 mg/dL (70g/L) B. A client with pernicious anemia who is awaiting vitamin B12 injection C. A client with resolving sickle cell crisis awaiting IV fluid conversion to saline lock D. A client with a pressure ulcer who has been prescribed negative pressure wound (vacuum-assisted closure [VAC]) care E. A client who received two blood transfusions yesterday and is awaiting morning care

ANS: A, C RN needs to initiate blood transfusion Needs assessment before conversion to saline lock

The charge nurse is planning client assignments for the shift. The care team includes a registered nurse (RN), a licensed practical nurse (PN), and unlicensed assistive personnel (UAP) on the care team. Which client(s) are appropriate to be assigned to the PN? (Select all that apply.) A. A client scheduled for a STAT CAT x-ray after a fall from a stretcher B. A client receiving IV vancomycin through a peripherally inserted catheter (PICC) line C. A client with sickle cell crisis who was transferred from the ICU to the acute care area and who is receiving hydromorphone via a patient-controlled analgesia (PCA) pump D. A client with a pressure ulcer who was prescribed negative pressure (wound VAC) care E. A postoperative client who has been prescribed 2 units of packed red blood cells

ANS: A, D No central access/IV for LPN Dressing change Cannot assess client with sickle cell No blood transfusion

A charge nurse is making assignments for five clients. The nursing team has an RN, a PN, and two UAPs. Which client(s) are appropriate to assign to the RN? (Select all that apply.) A. A client from the previous shift with unstable angina B. A client with a stage 3 pressure ulcer who needs a bed bath C. A client with an enteral feeding absorbing at 30 mL/h D. A cardiotomy client who is day 2 postoperative and who has chest tubes E. A client with quadriplegia for whom urinary catheterization is prescribed

ANS: A, D Unstable or potentially unstable

A client is admitted with a 2-day history of cough, fever, and fatigue. The medical history is positive for type I diabetes and recent upper respiratory infection (URI). Vital signs are heart rate 109 beats per minute, blood pressure 102/58 mm Hg, respiratory rate 24 breaths/min, temperature 104°F (40°C), and SpO2 92% on 2 L oxygen via nasal cannula. Which prescription has the highest priority in this client's care? A. Initiate large-bore IV access. B. Draw two sets of blood cultures. C. Administer the ordered IV antibiotics. D. Draw serum lactate and glucose levels.

ANS: B Client has suspected sepsis. Identify pathogen

The nurse is administering 0900 medications to three clients on a telemetry unit when the UAP reports that another client is complaining of a sudden onset of substernal discomfort. What action should the nurse take? A. Ask the UAP to obtain the client's vital signs B. Assess the client's discomfort C. Advise the client to rest in bed D. Observe the client's ECG pattern

ANS: B Critical to assess the client immediately, can finish med pass later.

A client with burn injuries has lost a significant amount of body fluid. An IV of lactated Ringer's solution is infusing at 200 mL/hour, and the client's urine output for the past 8 hours is 400 mL. Which sign or symptom is the top priority in early distributive shock? A. A change in BP from 118/60 to 102/68 B. A change in level of consciousness from awake to restless C. A decrease in O2 saturation from 98% to 93% D. A decrease in urine output over 8 hours from 400 to 240 mL

ANS: B Early

A client who had a vaginal hysterectomy the previous day is saturating perineal pads with blood that require frequent changes during the night. Which priority action should the nurse take? A. Provide iron-rich foods on each dietary tray B. Monitor the client's vital signs every 2 hours C. Administer IV fluids at the prescribed rate D. Encourage postoperative leg exercises

ANS: B Excessive bleeding and the nurse should monitor the client's VS more closely (every 2 hours).

A client who is 1 day postoperative after a left pneumonectomy is lying on his right side with the head of bed (HOB) elevated 10 degrees. The nurse assesses his respiratory rate at 32 breaths/min. What action should the nurse take first? A. Elevate the HOB. B. Assist the client into the supine position. C. Measure the client's O2 saturation. D. Administer intravenous (IV) PRN morphine.

ANS: B For repositioning and full lung expansion, and then elevate the HOB.

An awake, alert client with impending pulmonary edema is brought to the emergency department. The client provides the nurse with a copy of a living will that states that "no invasive" medical procedures should be used to "keep her alive." The healthcare team is questioning whether the client should be intubated. Which information should guide the team's decision? A. The living will removes the obligation to the client in any medical decision-making. B. The client is awake and alert, which makes the living will irrelevant and nonbinding. C. Lifesaving measures do not have to be explained to the client because of the signed living will. D. The family should be contacted to determine who has durable power of attorney for health care for the client.

ANS: B If the client is awake and alert, you can explain benefits and disadvantages, and the client may change their mind.

After the change of shift report, the nurse reviews assignments. Which client should the nurse assess first? A. The elderly client receiving palliative care for heart failure who complains of constipation and nervousness B. The adult client who is 48 hours postoperative for a colectomy and who is reported to be having nausea and vomiting C. The middle-aged client with chronic renal failure whose urinary catheter has been draining 95 mL for 8 hours D. The client who is 2 days postoperative for a thoracotomy and who has chest tubes, is on oxygen at 3 L/min, and has a respiratory rate of 12 breaths/min

ANS: B Nausea is a predictor of lack of bowel motility

The nurse is caring for a client with Guillain-Barré syndrome. Which information should the nurse report to the primary healthcare provider? A. Ascending numbness from the feet to the knees B. A decrease in cognitive status C. Blurred vision and sensation changes D. A persistent unilateral headache

ANS: B Not expected, HCP should be contacted.

The complete blood count (CBC) results for a client receiving chemotherapy are hemoglobin 85 mmol/L (8.5 g/dL); hematocrit, 32%; WBC count, 6.5 × 109/L (6500 cells/mm3). Which meal choice is best for this client? A. Grilled chicken, rice, fresh fruit salad, milk B. Broiled steak, whole wheat rolls, spinach salad, coffee C. Smoked ham, mashed potatoes, applesauce, iced tea D. Tuna noodle casserole, garden salad, lemonade

ANS: B Rich in nutrients needed by anemic client

A client with a history of uterine fibroids had a cesarean delivery 12 hours earlier and delivered healthy twins. At shift change, the nurse assesses the client and notes shortness of breath, cool extremities, and oozing of blood from the incision site. Based on the client's presentation, which nursing action has the highest priority? A. Assess the client's temperature. B. Notify the healthcare provider. C. Clean the blood from the incision site. D. Draw labs for PT, PTT, CBC, and fibrinogen

ANS: B The client is in shock and showing signs of DIC. Requires immediate attention from HCP.

A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2 mg IV 30 minutes ago for pain rating 8/10. The family member requests her father be checked immediately. On arrival to the room, the nurse finds the client difficult to arouse, with a respiration rate of 6. Which is the priority nursing action? A. Elevate the head of the bed. B. Administer naloxone 0.4 mg IV. C. Assess breath sounds. D. Check vital signs and pulse oximetry.

ANS: B Used to reverse the effects of narcotic medications

​​The nurse finds a client slumped in a chair. Place the nurse's actions in order of priority from first to last for this client. A. Activate the code team and obtain defibrillator. B. Determine unresponsiveness. C. Assess the cardiac rhythm using the "quick-look" paddles. D. Assess for a carotid pulse. E. Open airway and give two rescue breaths by bag-valve mask. F. Move the client to a flat position in bed or on the floor. G. Begin compressions.

ANS: B, A, D, F, G, E, C Determine response, Activate code team, Assess for pulse, Move client, Compressions, Rescue breaths, Assess cardiac rhythm

The nurse suspects a postoperative thyroidectomy client may have had an inadvertent removal of the parathyroid when the client begins to experience which symptoms? (Select all that apply.) A. Hematoma formation B. Harsh, vibratory sounds on inspiration C. Tingling of lips, hands, and toes D. Positive Chvostek's sign E. Sensation of fullness at the incision site

ANS: B, C, D Laryngeal stridor may be r/t tetany when the parathyroid gland are damaged or removed, leading to hypocalcemia. Tingling of toes, fingers, and lips, along with muscular twitching are signs of tetany. A positive Chvostek's sign is noted with hypocalcemia.

Four clients arrive in the emergency department after an explosion. In which order should they be assessed? All options must be used. A. A 70-year-old who is complaining of a pain level of 8/10 from a hand burn B. A 35-year-old with partial and full-thickness burns to the anterior and posterior chest C. A 25-year-old with a superficial burn to the right anterior arm and lateral chest D. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion

ANS: B, D, A, C

The nurse is precepting a nurse orientee who's caring for a client with a chest tube. The client is 12 hours postoperative from a left partial pneumonectomy. Which assessment will the nurse advise the orientee to immediately report to the healthcare provider? (Select all that apply.)​ A. Pain level of 6 out of 10 on the left side B. Tracheal deviation toward the right side C. Drainage from the chest tube of 50 mL in the last hour D. Oxygen saturation of 90% on 2 L/min E. Vigorous bubbling in the suction chamber

ANS: B, D, E Tracheal deviation is sign of pneumothorax O2 should be 95% Bubbling should be gentle

The registered nurse (RN) assigns the practical nurse (PN) a client diagnosed with diabetes. Which findings should the RN instruct the PN to report immediately? (Select all that apply.) A. Fingerstick blood sugar of 13.59 mmol/L (247 mg/dL) B. Cold, clammy skin C. Crackles at the end of inspiration D. Numbness in the fingertips and toes E. Unsteady gait, slurred speech

ANS: B, E Diaphoresis is a sign of hypoglycemia. Severe consequences of hypoglycemia to the brain require immediate medical intervention. Crackles that occur in small airways indicate atelectasis which is not a medical emergency. Numbness is a common complication. Unsteady gait & slurred speech may indicate lack of glucose available in the brain and is a medical emergency.

A client is in the oliguric phase of acute kidney injury. Which findings should the nurse expect to assess in the client? (Select all that apply.) A. 450 mL urine output in 24 hours B. Potassium of 6.2 mEq/L C. Sodium (serum) 155 mEq/L D. Metabolic alkalosis E. Weight gain

ANS: B, E Oliguria is urine output <400 mL. Hyperkalemia due to reduced potassium excretion. Acute kidney issue sodium drops and it becomes diluted. Metabolic acidosis occurs. Weight gain is common due to accumulation of fluid in body that cannot be effectively cleared by the kidneys.

The nurse is providing safety education to a client diagnosed with Parkinson disease who is prescribed carbidopa-levodopa. The nurse knows that safety education has been effective when the client verbalizes which statement? (Select all that apply.) A. "I will take the medication at bedtime." B. "I will apply sunscreen before I walk outdoors." C. "It's OK for me to eat tuna on whole wheat toast and a banana." D. "I will take the medication on an empty stomach early in the morning." E. "I will remember to keep hydrated and monitor urine output."

ANS: B, E Taken 3-4 times a day. Exercise is strongly encouraged. Drug-nutrient interaction decreases absorption and affects metabolism and excretion. Med should be taken with food that isn't high in protein or vitamin B6. May cause dark saliva, dark urine, nausea, urinary incontinence, and renal insufficiency.

In completing a client's perioperative routine, the nurse finds that the consent form has not been signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take? A. Witness the client's signature on the consent form. B. Answer the client's questions about the surgery. C. Inform the HCP that the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthetic is administered.

ANS: C

A client has not had a bowel movement in 2 days and reports this information to the nurse. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the HCP and request a prescription for a stool softener. C. Assess the client's medical record to determine his normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

ANS: C 2 days could be a normal for this client

What nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis?​ A. Reassure the client that this admission is only for a limited amount of time. B. Offer the client and family the opportunity to share their feelings about the admission. C. Determine the behaviors that resulted in the need for admission. D. Advise the client about the legal rights of all hospitalized clients.

ANS: C Assessment of harmful behaviors is the highest priority

Which client should the nurse assess first? A. The client receiving oxygen per nasal cannula who is dyspneic on mild exertion and has a hemoglobin of 7 g/dL (70 mmol/L)​ B. The client receiving IV aminoglycosides per CVC who complains of nausea and has a trough level below therapeutic levels​ C. The client with a chest tube that drained 150 mL in the last hour​ D. The client receiving chemotherapy whose temperature is 37.2° C(98.9° F) and who has a WBC count of 2.5 × 109/L (2,500/mm3)

ANS: C Drainage is > 70-100, HCP should be notified. A is expected finding. B is not priority. D is not priority.

A client who is receiving a transfusion of packed red blood cells has an inflamed IV site. Which action should the nurse take? A. Double-check the blood type of the transfusing unit of blood with another nurse B. Discontinue the transfusion and send the remaining blood and tubing to thelab C. Immediately start a new IV at another site and resume the transfusion at the new site D. Continue to monitor the site for signs of infection and notify the healthcare provider

ANS: C IV site shows symptoms of phlebitis not transfusion reaction. Transfusion reaction would be fever, chills, low back pain.

Which adaptation of the environment is most important for the nurse to include in the plan of care for a client diagnosed with myxedema? A. Reduce environmental stimuli B. Prevent direct sunlight from entering the room C. Maintain a warm room temperature D. Minimize exposure to visitors​​

ANS: C In Myxedema coma (hypothyroidism) the client experiences cold intolerance and hypothermia.

A client, who is HIV positive, asks why it is necessary to have a viral load study performed every 3 to 4 months. Which information should the nurse provide? A. To determine the progression of the disease B. To evaluate the enzyme-linked immunosorbent assay (ELISA) C. To monitor the effectiveness of the treatment D. To track the effectiveness of the vaccine

ANS: C Measuring the amount of HIV circulating in the blood. Determine how effectively the medications are working

The nurse is assessing a client who is scheduled for surgical fixation of a compound fracture of the right ulna. Which finding should the nurse report to the healthcare provider? A. Ecchymosis around the fracture site B. Crepitus at the fracture site C. Paresthesia distal to the fracture site D. Diminished range of motion of the right arm

ANS: C Paresthesia can indicate nerve damage

Which action by the unlicensed assistive personnel (UAP) requires immediate follow-up by the nurse? A. Positioning a client who is 12 hours post above-the-knee amputation (AKA) with the residual limb elevated B. Assisting a client with ambulation while the client uses a cane on the unaffected side C. Accompanying a client who has lupus erythematosus to sit outside in the sun during a break D. Helping a client with rheumatoid arthritis to the bathroom after the client takes celecoxib (Celebrex)

ANS: C Sunlight may trigger Lupus

A client recovering from ARDS is awake and alert but has residual fatigue and generalized weakness. The client's current vital signs are heart rate 83 beats per minute, blood pressure 104/64 mm Hg, respiratory rate 25 breaths/min, SpO2 is 92% on 2 L/min oxygen via nasal cannula. Which vital sign finding should the unlicensed assistive personnel (UAP) immediately report to the nurse? A. Heart rate of 83 beats per minute B. Blood pressure of 104/64 mm Hg C. Respiratory rate of 25 breaths/minute D. SpO2 92% of 2L/min O2 via nasal cannula

ANS: C The RR is high, especially for a client on O2

A client who is diagnosed with an obstruction of the common bile duct caused by cholelithiasis passes clay-colored stools containing streaks of fat. Which action should the nurse take? A. Auscultate for diminished bowel sounds B. Send a stool specimen to the lab C. Document the assessment in the chart D. Notify the healthcare provider

ANS: C This is an expected finding and should be documented as part of the nursing assessment.

​​A client who was recently prescribed metformin hydrochloride calls the clinic to discuss symptoms of bloating, nausea, cramping, and diarrhea. Which instructions should the nurse provide the client? (Select all that apply.) A. Discontinue the medication immediately B. Increase fiber and fluids in the diet C. Monitor the symptoms D. Continue to take the metformin as prescribed E. Seek immediate emergency medical care

ANS: C, D Symptoms usually subside. If not, the client should follow-up with HCP. Client should continue the drug. The initial dosage may have to be titrated over a few weeks.

A family member of a client who is in a Posey vest restraint (safety reminder device) asks why the restraint was applied. Which response should the nurse make?​ A. The restraint was prescribed by the healthcare provider. B. There is not enough staff to keep the client safe all the time. C. The other clients are upset when the client wanders at night. D. The client's actions place the client at high risk for self-harm.

ANS: D Client is at high risk of self-harm

The nurse palpates a crackling sensation around the insertion site of a chest tube in a client who has had thoracic surgery. Which action should the nurse take? A. Return the client to surgery. B. Prepare for insertion of a larger chest tube. C. Increase the water-seal suction pressure. D. Continue to monitor the insertion site.

ANS: D Some amounts of subcutaneous emphysema after thoracic surgery is expected, and will be absorbed, causing no problem. Nurse should continue to monitor.

The charge nurse is making assignments on the renal unit. Which client should the registered nurse assign to a practical nurse who is new to the unit? A. ​​An older client who has thick, dark red drainage in a urinary catheter 1 day after a transurethral prostatic resection B. A middle-aged client admitted with a diagnosis of acute renal failure secondary to a reaction to IV pyelogram dye C. An older client who has end-stage renal disease and complains of nausea after receiving digoxin D. A middle-aged client who receives hemodialysis and has been prescribed epoetin alfa subcutaneous daily

ANS: D This client is the most stable and should be assigned to the PN who is new to the unit.

A 4-year-old is brought to the clinic with a fever of 103 to the power of ring operator F, sore throat, and moderate respiratory distress caused by a suspected bacterial infection. Which medical diagnosis is a contraindication to obtaining a throat culture in the child? A. Tonsillitis B. Streptococcal infection C. Bronchiolitis D. Epiglottitis

ANS: D To avoid airway compromise in epiglottitis, do not swab

​A client in shock develops a mean arterial pressure (MAP) of 60 mm Hg and a heart rate of 110 beats per minute. Which prescribed intervention should the nurse implement first? A. Increase the rate of O2 flow. B. Obtain arterial blood gas results. C. Insert an indwelling urinary catheter. D. ​Increase the rate of intravenous (IV) fluids.

ANS: D To improve the cardiac output by correcting hypovolemia

The nurse is preparing to administer a purified protein derivative (PPD) test to a client who is entering nursing school. Which action is the nurse's highest priority? A. Prepare 0.1-mL solution for tuberculin syringe. B. Assess the skin condition on the forearm. C. Teach the client about positive findings. D. Inquire about bacillus Calmette-Guérin (BCG) vaccine history.

ANS: D Will be positive and will result in a large area.

The nurse directs the unlicensed assistive personnel (UAP) to play with a 4-year-old child on bed rest. Which activities should the nurse recommend? (Select all that apply.) A. Monopoly board game B. Checkers C. 50-piece puzzle D. Hand puppets E. Coloring book

ANS: D, E Preschoolers enjoy activities that involve "make-believe"

The nurse is orienting a graduate nurse (GN) caring for a client dependent on a ventilator. Which action by the GN demonstrates understanding of ventilator-associated pneumonia (VAP) care? (Select all that apply.) A. Administers a proton pump inhibitor as prescribed B. Rinses client's oral cavity with chlorhexidine every 2 hours C. Elevates the HOB 60 degrees D. Implements spontaneous breathing trial E. Performs hand hygiene before and after care

ANS: A, B, E Needs to be 30-45 degrees Increased gastric juices increases pneumonia risk, good to administer the PPI

The charge nurse is making assignments for each of four staff members, including a registered nurse (RN), a licensed practical nurse (PN), and two unlicensed assistive personnel (UAPs). Which task is best to assign to the PN? A. Maintain a 24-hour urine collection. B. Wean a client from a mechanical ventilator. C. Perform sterile wound irrigation. D. Obtain scheduled vital signs.

ANS: C More experience than UAP but less judgement than weaning the client.

Which client should the nurse assess first? A. The client diagnosed with hyperthyroidism who is exhibiting exophthalmos B. The client diagnosed with type 1 diabetes who has an inflamed foot ulcer C. The client with Cushing syndrome exhibiting moon face D. The client with Addison disease showing tremors and diaphoresis

ANS: D Hypoglycemia is seen with addison and can be life-threatening. The other options are not life-threatening.

The nurse observes an older client with glaucoma administer eye drops by tilting back the head, instilling each drop close to the inner canthus, and keeping the eye closed for 15 seconds. Which action should the nurse take first? A. Ask the client whether another family member is available to administer the drops B. Review the correct steps of the procedure with the client C. Administer the eye drops correctly in the other eye to demonstrate the technique D. Discuss the importance of correct eye drop administration for persons with glaucoma

ANS: B Immediate feedback and reteaching

A client with a 20-year history of type 1 diabetes mellitus is having renal function tests because of recent fatigue, weakness, BUN of 8.5 mmol/L (24 mg/dL), and a serum creatinine of 146 mmol/L (1.6 mg/dL). Which additional early symptom of renal insufficiency should the nurse expect? A. Dyspnea B. Nocturia C. Confusion D. Stomatitis

ANS: B In the early stage of renal insufficiency, polyuria results from the inability of the kidneys to concentrate urine, and this contributes to nocturia.

The nurse has just received report on four clients. Which client should the nurse assess first? A. A client with pericarditis with pain relieved by leaning forward B. A client with fractured ribs with pain reported at 6/10 on a 1 to 10 scale C. A client with stable angina who is awaiting discharge instructions D. A client with heart failure who needs transporting for an echocardiogram

ANS: A Pain is sometimes alleviated by leaning forward but it requires further assessment because this is also symptomatic of cardiac tamponade. Nurse needs to assess pain, difficulty breathing, confusion, and lightheadedness. B pain is expected. C the patient is stable. D the patient is stable

A client is receiving an infusion of dobutamine hydrochloride. The order reads: Infuse dobutamine IV at 5 mcg/kg/min. 500 mg in 250 mL D5W. The client weighs 65 kg. Calculate the flow rate in mL/hour. Fill-in blank ______________1​ mL/hour

ANS: 9.75 mL/hr

The nurse assigned to the women's health unit received the morning report. Which client should the nurse assess first? A. ​A 49-year-old client 1-day postvaginal hysterectomy who is saturating pads every 3 hours B. A 34-year-old client post uterine artery embolization who has not voided since her indwelling catheter was removed 4 hours ago C. A 52-year-old client who is 2 days post abdominal hysterectomy requesting oral analgesics instead of the PCA pump D. A 67-year-old client 1-day post anterior and posterior repair who is refusing to ambulate with the unlicensed assistive personnel (UAP)

ANS: A Client may be hemorrhaging and should be assessed now. There should be less than one saturated pad in 4 hours.

A postmenopausal client with a BMI of 19 has come to the clinic for an annual examination. Which information is most important for the nurse to prepare for this high-risk client? A. Osteoporosis B. Obesity C. Anorexia D. Breast cancer

ANS: A High risk for osteoporosis due to postmenopausal status and low BMI.

A parent is preparing a 5-year-old child for kindergarten. The child has not received any immunizations. Which vaccines should be given to this child? (Select all that apply.) A. DTaP B. Inactivated polio virus (IVP) C. Varicella D. Pneumococcal conjugate vaccine (PCV) E. Trivalent inactivated influenza vaccine (TIV)

ANS: A, B, C Per CDC

The charge nurse is assigning rooms for four new clients. Only one private room is available in the oncology unit. Which client should be placed in the private room? A. The client with ovarian cancer who is receiving chemotherapy B. The client with breast cancer who is receiving external beam radiation C. The client with prostate cancer who has just had a transurethral resection D. The client with cervical cancer who is receiving intracavity radiation

ANS: D Intracavity radiation needs a private room

A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral phosphate. The nurse notes that the client serum calcium is 12.5 mg/dL. What action should the nurse take? A. Hold the phosphate and notify the HCP. B. Review the client's serum parathyroid hormone level. C. Give a PRN dose of intravenous (IV) calcium per protocol. D. Administer the dose of oral phosphate.

ANS: D Oral phosphate reduces the blood calcium

The nurse is assessing clients at the site of a community disaster. Using the color-code system for triage, which client should the nurse tag with a red code? A. A client with a large head injury that is bleeding, an open chest wound, cyanotic skin, no capillary refill, and agonal respirations B. A client with bruising and swelling of the right forearm, assorted lacerations to the face and neck, dry skin, normal capillary refill, and a respiratory rate of 18 C. A client with scratches and scrapes to the head and face who is limping and helping other clients at the scene D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiratory rate 32, who is moaning

ANS: D Other clients are not the priority

Which vaccines should the nurse expect to be prescribed for a 2-month-old brought into the pediatrician's office for a well-baby checkup? (Select all that apply.) A. DTaP B. Hep B C. Hep C D. HIB E. IPV F. PCV

ANS: A, B, D, E, F

pH = 7.28​ pCO2 = 35​ HCO3 =18​ Fill-in blank ​This client has _________

ANS: Metabolic acidosis

The nurse is caring for a client who is 24 hours post-procedure for a hemicolectomy with a temporary colostomy placement. The nurses assesses the client's stoma, which is dry and dark blue. Which action should the nurse take based on this finding? A. Notify the healthcare provider of the finding. B. Document the finding in the client record. C. Replace the pouch system over the stoma. D. Place petrolatum gauze dressing on the stoma.

ANS: A Stoma should appear beefy red and moist

Picture: VT The nurse is caring for a client when the client suddenly becomes unconscious. The nurse identifies the following rhythm on the monitor. Which action is the highest priority? A. ​​Check for a carotid pulse B. Begin chest compressions C. Administer epinephrine 1:10,000 IV D. Initiate bag-valve mask ventilations

ANS: A The first step when a pt loses consciousness is to check the pulse, especially with VT

Which assignment should the nurse delegate to a UAP in an acute care setting? ​A. Checking blood glucose hourly for a client with a continuous insulin drip​ B. Giving PO medications left at the bedside for the client to take after eating C. Taking vital signs for an older client with left humeral and left tibial fractures D. Replacing a client's pressure ulcer dressing that has been soiled by incontinence

ANS: C Doesn't require expertise of the nurse

​​For which dysrhythmia should the nurse implement defibrillation? (Select all that apply.) A. ​​Asystole B. Pulseless electrical activity C. Ventricular fibrillation D. Pulseless ventricular tachycardia E. Ventricular tachycardia F. Atrial fibrillation

ANS: C, D Ventricular fib and pulseless ventricular tachy are Life threatening rhythms Asystole - CPR Pulseless electrical activity - mechanical issue Ventricular tachycardia - synchronized cardio

Which findings by the nurse indicate an early sign of increased ICP in a client newly diagnosed with a cerebral vascular accident? (Select all that apply.) A. Alteration in the ability to respond to questions B. Alteration in the ability to respond to verbal stimuli C. Consensual response of pupils D. Heart rate 50, blood pressure 192/60 E. Drooping of the mouth on one side

ANS: A, B Alteration in ability to respond to verbal stimuli is early sign. HR of 50 and BP of 192/60 are late signs.

The nurse is caring for several clients. Which client should the nurse assess first? A. A 20-year-old client whose Glasgow Coma Scale is 8 and unchanged from the last assessment B. A 45-year-old client with a left-sided cerebrovascular accident (CVA) who refuses his morning care C. A 38-year-old client who is increasingly stuporous after an aneurysm repair D. A 29-year-old client post motor vehicle accident (MVA) whose Glasgow Coma Scale was 9 one hour ago and is now 10

ANS: C Client's status is deteriorating

A client has advanced cirrhosis of the liver has an acute exacerbation of hepatic encephalopathy. Which type of food should the nurse teach the client to limit? A. Fruits B. Vegetables C. Meats D. Bread

ANS: C Consumption of red meat may exacerbate hepatic encephalopathy

The unlicensed assistive personnel (UAP) reports to the staff nurse that a client who had surgery 4 hours ago has had a decrease in blood pressure (BP), from 150/80 to 110/70, in the past hour. The nurse advises the UAP to check the client's dressing for excess drainage and report the findings to the nurse. Which factor is most important to consider when assessing the legal ramifications of this situation? A. The parameters of the state's or province's nurse practice B. The need to complete an adverse occurrence report C. Hospital protocol regarding the frequency of vital sign assessment every hour postoperatively D. The healthcare provider's prescription for changing the postoperative dressing

ANS: A Not within the UAP's scope of practice

A client who had an abdominal hysterectomy for cervical adenocarcinoma in situ is preparing for discharge. Which recommendation about women's health screening examinations should the nurse offer? A. Continue the annual Pap smear and mammogram, biannual clinical breast examinations, and monthly breast self-examinations (BSE). B. A Pap smear is no longer necessary, but continue the annual mammogram and biannual clinical breast examinations, plus monthly BSE. C. If the ovaries have been removed, only an annual mammogram and clinical breast examinations are necessary. D. Annual mammograms are not needed if biannual breast examinations and weekly BSE are performed.

ANS: A Regular pap screens, etc. are still important.

The nurse is teaching a client about Crohn disease. The nurse is correct in identifying which complication as being the result of cobblestone lesions of the small intestine? A. Malabsorption of nutrients B. Severe diarrhea of 15 to 20 stools per day C. A high probability of developing intestinal cancer D. An inability of the body to absorb water

ANS: A Cobblestone lesions are inflamed, edematous ulcerations of the bowel wall that can interrupt absorption of nutrients.

A client is receiving pancreatic enzyme replacement therapy for chronic pancreatitis. Which statement by the client indicates a need for more effective teaching? A. ​"I will need to mix the enzyme with a protein food." B. "I will take the enzymes with each meal." C. "My stools will decrease in number and frequency." D. "My abdominal pain may lessen."

ANS: A Do not mix enzyme preparations in protein-containing foods because it deactivates them. Enzymes should be taken with meals/snacks, stools will decrease is expected, less abdominal pain is expected.

After hemodialysis, the nurse is evaluating the blood results for a client who has end-stage renal disease. Which value should the nurse verify with the laboratory? A. Elevated serum potassium B. Increase in serum calcium C. ​Low hemoglobin D. Reduction in serum sodium

ANS: A Hyperkalemia should have been corrected by hemodialysis and the nurse should verify the results with the lab. Calcium levels should increase. Anemia is common. Serum sodium levels should fall as fluid and electrolytes are removed by hemodialysis.

A client with menopause reports that since stopping hormone replacement therapy (HRT), she has had increased vaginal discomfort during intercourse. Which action should the nurse take? A. Suggest the use of vaginal cream or lubricant B. Recommend that the client abstain from sexual intercourse C. Teach the client to perform Kegel exercises daily D. Instruct the client to resume HRT

ANS: A Lack of estrogen results in vaginal dryness.

The nurse is caring for a 2-year-old child suspected of having croup. Which early sign of respiratory distress requires the nurse's immediate attention? A. Cyanosis B. Restlessness C. Crying D. Barking cough

ANS: B Cyanosis, crying, barking cough are late signs.

A client is admitted with a diagnosis of Addison's crisis. The nurse places a peripheral saline lock. Which prescription(s) provided by the HCP should be questioned? (Select all that apply.) A. ​​​IV D5NS at 300 mL/h for 3 hours B. Hydrocortisone sodium succinate 100 mg IV push C. Potassium 20 mEq in 100 mL saline IV over 60 minutes D. 50% dextrose intravenous push E. 10% calcium chloride 5 mL intravenously over 10 minutes

ANS: C, E Addison's results in hyperkalemia and requires immediate medical care; K+ is contraindicated. Low blood pressure, low blood sugar, and high blood levels of potassium. Calcium is not an issue.

A client who with a history of coronary heart disease was admitted to the acute care unit 2 days ago for management of angina. During the assessment, the client states, "I feel like I have indigestion." In which order should the nurse implement care? (Arrange from first action to last.) A. ​​Notify the rapid response team. B. Administer PRN nitroglycerin prescription. C. Check the pulse, respirations, blood pressure, and oxygen saturation. D. Document assessment in the electronic medical record. E. Provide 2 L of oxygen via nasal cannula.

ANS: C, E, B, A, D Quickly gather VS, provide O2, administer NTG, notify rapid response, document

The nurse enters the room of a preoperative client to obtain the client's signature on the surgical consent form. Which question is most important for the nurse to ask the client?​ A. "When did the surgeon explain the procedure to you?" B. "Is any member of your family going to be here during your surgery?" C. "Have you been instructed in postoperative activities and restrictions?" D. "Have you received any preoperative pain medication?"

ANS: D Administration of an analgesic may prelude the client from being able to sign the surgical consent.

pH = 7.56 pCO2 = 44​ HCO3 =38 Fill-in blank ​This client has _____________

ANS: Metabolic alkalosis