HESI Practice Test
48. A client with draining skin lesions of the lower extremity is admitted with possible methicillin resistant Staphylococcus aureus (MRSA).What nursing intervention(s) should the nurse include in the plan of care? Select all that apply. -- A Monitor the client's white blood cell count. B Send wound drainage for culture and sensitivity. C Use standard precautions and wear a mask. D Institute contact precautions for staff and visitors. E Explain the purpose of a low bacteria diet.
- Institute contact precautions for staff and visitors. Institute contact precautions for staff and visitors:This is a correct intervention. Contact precautions involve using gowns and gloves when providing care to prevent the transmission of MRSA. It is important for both healthcare staff and visitors to adhere to contact precautions to reduce the risk of spreading the infection. - Monitor the client's white blood cell count. Monitoring the white blood cell count is a relevant intervention. An elevated white blood cell count may indicate an ongoing infection or an inflammatory response. Regular monitoring helps assess the client's immune response and the potential severity of the infection.
57. The healthcare provider prescribes diazepam 8 mg IM every 4 hours PRN muscle spasms for a client with a fractured femur. The available vial is labeled, "Diazepam Injection, USP 10 mg/2 mL." How many mL should the nurse administer to the client? (Enter numerical value only. If rounding is required round to the nearest tenth).
1.6 ml To determine how many milliliters (mL) of diazepam the nurse should administer to the client, first, we need to calculate the amount of medication needed for each dose. The prescribed dose is 8 mg of diazepam. Volume= Desired dose/available concentration per ml Available concentration per ml= 10mg/2ml Available concentration per ml= 5mg/ml Volume= 8mg/5mg per ml Volume= 1.6ml So, the nurse should administer 1.6 mL of diazepam to the client.
24. The healthcare provider prescribes regular insulin 10 units/hr IV. The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)
10 ml/hr To determine the mL/hr rate for the regular insulin infusion, we can set up a proportion: 10 units/hr (prescribed rate) = x mL/hr (unknown rate) Since the IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline, we know that each mL of the solution contains 1 unit of regular insulin. So, if 1 mL contains 1 unit, then x mL contains 10 units. x = 10 mL/hr
A family suspects that AIDS dementia is occurring in their adult child who is HIV positive. Which symptom confirms the suspicion? A. Refuses to see friends or to return their phone calls. B. Increased intervals of sleep 18 out of 24 hours. C. A change has recently occurred in handwriting. D. Exhibits angry outbursts when the subject of dying is approached.
A change has recently occurred in handwriting.
50. The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back, and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition? A Biliary duct obstruction. B Surgical site infection. C Acute pancreatitis. D Hepatorenal failure.
Acute pancreatitis. This is correct because acute pancreatitis is an inflammation of the pancreas that can be caused by gallstones, alcohol abuse, trauma, infection, or drugs. The symptoms of acute pancreatitis may include fever, upper abdominal pain that radiates to the back, nausea, vomiting, and elevated amylase and lipase levels. These are consistent with the client's presentation and suggest that the cholecystectomy may have triggered an attack of acute pancreatitis.
32. A client with metastatic cancer reports a pain level of 10 on a scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care? A. Frequently evaluate the clients pain. B. Replace transdermal analgesic patches every 72 hours. C. Administer analgesics on a fixed and continuous schedule. D. Monitor client for break through pain.
Administer analgesics on a fixed and continuous schedule. Administering analgesics on a fixed and continuous schedule is the most important intervention that the nurse should include in this client's plan of care, because it can provide consistent and adequate pain relief for the client with metastatic cancer, who is likely to have chronic and severe pain. The nurse should follow the principles of cancer pain management, such as using the WHO analgesic ladder, titrating the dose according to the pain intensity, and using a multimodal approach that combines opioids, non-opioids, and adjuvants.
40. A client experiences residual effects following an acute attack of Ménière's disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective? A Blood pressure of 120/80 mm Hg. B Ambulates easily without vertigo. C Oxygen saturation level of 99%. D Headache rated at 0 on 0 to 10 scale.
Ambulates easily without vertigo. Ambulating easily without vertigo is a sign that the antihistamine is effective. Vertigo is a common symptom of Ménière's disease, which is a disorder of the inner ear that causes episodes of spinning sensation, hearing loss, and tinnitus. Antihistamines can help reduce the fluid buildup in the inner ear and relieve vertigo.
41. A client with a cervical spinal injury (C7) is experiencing autonomic dygreflexia. The nurse should first assess the client for which precipitating factor? A A severe pounding headache. B An acutely distended bladder. C Skeletal traction misalignment. D Profuse forehead diaphoresis.
An acutely distended bladder One of the most common triggers is a distended bladder. When the bladder becomes full, it sends signals to the spinal cord, but due to the injury, these signals are unable to pass beyond the level of injury. This results in uncontrolled sympathetic activation, leading to symptoms such as hypertension, sweating, and headache.
51. A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next? A Administer a PRN analgesic. B Assess right raajal pulse volume. C Implement distraction techniques. D Measure the blood pressure.
Assess right raajal pulse volume. An increase in pain after cast placement could indicate complications such as compartment syndrome, which is a serious condition that occurs when increased pressure within a confined space (such as the area within the cast) compromises circulation and tissue perfusion. Assessing the radial pulse volume on the affected arm is crucial to evaluate perfusion distal to the fracture site.
3. (1 of 6) Patient Data The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m^2
Based on the finding, indicate whether the finding represents a modifiable risk factor, a non modifiable risk factor, or is unrelated to type 2 diabetes mellitus. Choose Modifiable risk-factor, Non-modifiable risk factor, or Unrelated - Body mass index (BMI) 28 kg/m2 - Cannabis use - Occupational fume exposure - High density lipoprotein 43 mg/dL (1.11 mmol/L) - Sister with type 2 diabetes mellitus
4. (2 of 6) Patient Data The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m^2
Based on the laboratory data, the client has ____ related to _____ Options for 1: diabetes mellitus, hypoglycemia, pre-diabetes, and ? Options for 2: impaired glucose tolerance, occupational exposure, lack of insulin, and ?
A client who reports feeling chronically fatigued has a hemoglobin of 11.0 g/dL (110 mmol/L), hematocrit of 34% (0.34 volume fraction), and microcytic and hypochromic red blood cells (RBCs). Based on these findings, which dinner selection should the nurse suggest to the client? Reference Range Hemoglobin (Hgb) [16 to 18 g/dL (160 to 180 g/L)] Hematocrit (Hct) [42% to 52% (0.42 to 0.52 volume fraction)] A Beef steak with steamed broccoli and orange slices. B Cheese pasta and a lettuce and tomato salad. C Grilled shrimp and seasoned rice with asparagus salad. D Broiled white fish with a baked sweet potato.
Beef steak with steamed broccoli and orange slices.
39. Five months following treatment for herpes zoster, an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. Which action should the nurse implement? A Determine if the client has had a shingles vaccination. B Perform a complete mental status exam. C Teach the client about phantom pain symptoms. D Complete an assessment of the client's pain.
Complete an assessment of the client's pain This is correct because completing an assessment of the client's pain is the most important action for the nurse to implement. Pain assessment involves collecting information about the location, intensity, quality, duration, frequency, and aggravating or relieving factors of the pain, as well as its impact on the client's daily activities and quality of life. This can help the nurse identify the cause and severity of the pain, as well as plan and evaluate appropriate interventions.
43. History and Physical: The client is a 19-year-old female college student. She has had type 1 diabetes mellitus for 14 years. She is currently in the endocrinology clinic for a follow-up visit. Nurses' Notes: The client is concerned about her feet, reporting that they itch so much that she gets distracted in school. Upon assessment, scaliness and cracking skin between the toes on the left foot are noted. Laboratory Results: Hemoglobin AlC (today) Result = 8.2% Reference Range = 4 to 5.9% Hemoglobin AlC 3 months ago) Result = 7.5% Reference Range = 4 to 5.9%
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and to parameters the nurse should monitor to assess the client's progress. Actions to take: -Prepare the client for cryotherapy -Perform a sensory test on both feet -Instruct the client to = change to clean, dry socks -Place a warm compress on the foot -Request an order for griseofulvin Potential Conditions: -Tinea pedis -Plantar warts -Diabetic neuropathy -Paronychi Parameteres to Monitor: =Blood glucose =Spread to other areas of the body =Capillary refill on toes =Nail growth and color =Pedal pulses
10. A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make? A Representative of a decline in the client's condition. B Indication of the onset of joint degeneration. C Confirmation of the autoimmune disease process. D Evidence of spread of the disease to the kidneys.
Confirmation of the autoimmune disease process. Rheumatoid factor is an antibody that is produced by the immune system and can bind to normal tissues, causing inflammation and damage. Rheumatoid factor is a marker of the autoimmune disease process that underlies rheumatoid arthritis, which is a chronic condition that affects the joints and other organs. A high level of rheumatoid factor can confirm the diagnosis of rheumatoid arthritis and indicate the severity of the disease.
59. Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH3) level of 220 g/dL (157.1 umol/dL). Which action should the nurse take? Reference Range: Ammonia [10 to 80 g/dL (6 to 47 pmol/L)] A. Report the number of diarrhea stools to the healthcare provider (HCP). B. Replace total volume voided with oral or IV fluids. C. Hold the next dose of lactulose. D. Continue the prescribed dose of lactulose.
Continue the prescribed dose of lactulose. Lactulose works by acidifying the colonic contents, which promotes the conversion of ammonia (NH3) to ammonium (NH4+). Ammonium is less readily absorbed from the colon into the bloodstream, reducing systemic ammonia levels. This action helps alleviate the neurotoxic effects of ammonia on the brain, thereby improving neurological symptoms associated with hepatic encephalopathy.
47. Following a motor vehicle accident, a client with chest trauma receives a chest tube to relieve a hemothorax. Two hours following the chest tube insertion, the nurse observes the water level in the water-seal chamber is rising during inspiration and falling during expiration. Which action should the nurse implement? A Inspect the tube insertion site for leaking. B Lift and clear drainage from the chest tube. C Continue to monitor the drainage system. D Auscultate lungs for unequal breath sounds.
Continue to monitor the drainage system. Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.
54. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement? A. Ask the client to choose which medication is needed for the pain. B. Determine which prescription will have the quickest onset of action. C. Document the client's report of pain in the electronic medical record. D. Compare the client's pain scale rating with the prescribed dosing.
Determine which prescription will have the quickest onset of action. The nurse should determine which medication will provide the quickest relief from pain, which is the client's immediate need. Need to verify this answer
After initiating a steroid nebulizer treatment for a client with asthma in respiratory distress, which intervention is most important for the nurse to implement? A Determine exposure to asthmatic triggers. B Teach proper use of a rescue inhaler. C Elevate the head of bed to 90 degrees. D Monitor pulse oximetry every 2 hours.
Elevate the head of bed to 90 degrees. This is correct because elevating the head of bed to 90 degrees is the most important intervention for the nurse to implement. Elevating the head of bed to 90 degrees can help improve breathing and oxygenation by reducing pressure on the diaphragm and chest wall, increasing lung expansion and ventilation, and facilitating expectoration of mucus. This can enhance the effects of nebulizer treatment and reduce respiratory distress in a client with asthma.
56. The nurse is caring for a client with chemotherapy induced mucositis who is describing soreness of the tongue and oral tissues. Which is the best initial nursing action? A Obtain a soft diet for the client. B Administer a topical analgesic per protocol. C Encourage frequent mouth care. D Cleanse the tongue and mouth with swabs.
Encourage frequent mouth care. Encouraging frequent mouth care is the best initial nursing action for a client with chemotherapy-induced mucositis who is describing soreness of the tongue and oral issues. Frequent mouth care can help prevent or reduce the severity of mucositis by removing plaque, bacteria, and debris from the oral cavity, and by moisturizing and soothing the oral tissues. The nurse should instruct the client to use a soft toothbrush, a mild toothpaste, and a saline or bicarbonate rinse at least four times a day, and to avoid alcohol, tobacco, spicy, acidic, or hot foods and beverages.
35. The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? A. Uses only lactose free dairy products. B. Carefully cleans and peels all fresh fruit and vegetables. C. Enjoys fat free yogurt as an occasional snack food. D. No longer includes grains in daily diet.
Enjoys fat free yogurt as an occasional snack food. Enjoys fat-free yogurt as an occasional snack food:This is the correct answer. The DASH eating plan recommends the inclusion of low-fat or fat-free dairy products as part of a heart-healthy diet. Choosing fat-free yogurt as an occasional snack aligns with the principles of the DASH plan, which emphasizes low-fat dairy options.
36. A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings? A Exit site infection. B Peritonitis. C Atelectasis. D Outflow obstruction.
Exit site infection Redness, tenderness, and drainage around the catheter site are classic signs of an exit site infection in peritoneal dialysis. Exit site infections are a common complication of peritoneal dialysis and can lead to more serious complications, such as peritonitis, if not promptly treated. Preventing exit site infections through proper catheter care and hygiene is essential in peritoneal dialysis management.
14. (2 of 6) History and Physical: A 19-year-old female client presents to the emergency department reporting tightness in her chest and difficulty breathing. The client's friend, who accompanied the client to the emergency department, reports she was at a park playing soccer with a group of college friends when the symptoms started. The park is close to a residential area where a fire was burning and there was a moderate breeze in the air. The client reported itching eyes and coughing. Approximately 15 minutes into the game, the client stopped running and held her hand on her chest, saying it felt tight. The client had difficulty catching her breath. Home Medications • Albuterol/pratropium every 4 hours by inhaler PRN for shortness of breath, last dose 2 days ago
For each assessment finding, click to indicate which disease process it relates to bronchitis, asthma exacerbation, or pneumonia. Each row must have at least one, but may have more than one, response option selected. Choose from Pneumonia, Bronchitis, Asthma Exacerbation -- (1, both, or all) - Hypoxemia - Wheezing - Pleuritic chest pain - Prolonged expiration - Diaphoresis - Tachypnea - Dyspnea
53. History and Physical: The client is a 48-year-old male with gangrene of the right lower leg which has not been responsive to treatment. A below-the-knee amputation (BKA) of the right lower leg has been performed. The client has a history of peripheral vascular disease, high blood pressure, and has a pacemaker for 2nd degree heart block. Nurses' Notes: Day 3, 0700 The client is postoperative below-the-knee amputation right leg day 3. He is sitting up with his left leg and right leg residual limb hanging off the bed. There is patient-controlled analgesia (PCA) of morphine on demand in the left hand area; there is no redness at site. Flow Sheet: Day 3, 0700 | Vital signs Temperature 98.2° F (36.7° C), Heart rate 88 beats/minute Respirations 20 breaths/minute, Blood pressure 126/84 mm Hg Oxygen saturation 95% on room air, Pain is a 2 on a 0 to 10 pain scale, right leg incisional area
For each client activity, click to indicate whether the activity shows positive or negative health promotion postamputation due to extensive peripheral vascular disease. Choose Positive or Negative for each Client Activity below: = Executes pull-ups on trapeze bar = Turns side to side = Requests nurse to perform wound care = Avoids looking at residual limb = Inquires about blood pressure = Asks questions about self-care
6. (4 of 6) Patient Data The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m^2
For the nutrition education portion of the visit, the nurse focuses on _____ and ______ Word options: - avoiding potassium rich foods - decreasing portion sizes - ? - ?
2. The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider? A Calcium level and skin condition. B Hematocrit and blood pressure. C White blood cell count and pulse rate. D Serum amylase and level of consciousness.
Hematocrit and blood pressure Hematocrit and blood pressure are the most important information about the client that the nurse should tell the healthcare provider, because they are directly related to the AAA and the low back pain. Hematocrit is a measure of the percentage of red blood cells in the blood, and it may be decreased in cases of bleeding or anemia, which can occur if the AAA ruptures or leaks. Blood pressure is a measure of the force of the blood against the walls of the arteries, and it may be increased in cases of hypertension or stress, which can worsen the AAA or cause it to rupture. The nurse should monitor the client's hematocrit and blood pressure closely and report any changes to the healthcare provider.
60. The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse? A Redness and edema noted at the incision site. B High-pitched sound heard upon inspiration. C Apical heart rate of 100 to 110 beats/minute. D Pain rating of 8 on a scale of 0 to 10.
High-pitched sound heard upon inspiration. High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy. Some sites note: Redness and edema noted at the incision site.
28. Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take? A. Report the COVID-19 result to the local health department according to Centers for Disease Control and Prevention (CDC) guidelines. B. Teach the client to wear a mask, hand wash, and social distance to prevent spreading the virus. C. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. D. Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE).
Isolate the client from other clients, family, and healthcare workers not wearing proper personal protective equipment (PPE). This is correct because isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action for the nurse to take. This is to prevent transmission of COVID-19 to others who may be at risk of severe complications or death.
22. A client who fractured the right femur from a fall at home is placed in traction while awaiting surgery. When the client informs the nurse of the need to urinate, which intervention should the nurse implement? A. Log roll the client and place adult disposable briefs beneath the client. B. Release the traction so the client can use a bedpan. C. Maintain traction while the client uses a urinal. D. Insert an indwelling urinary catheter preoperatively.
Maintain traction while the client uses a urinal. Maintaining traction while the client uses a urinal is the correct intervention, as it can prevent the disruption of the fracture stabilization and allow the client to void comfortably and safely. Traction is a force that is applied to the fractured bone to reduce, align, and immobilize it. A urinal is a container that can be used to collect urine from the client, without requiring the client to get out of bed or change position.
34. A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition? A Meningococcal meningitis. B Cerebrovascular accident (CVA). C Intracerebral hemorrhage. D Rocky mountain spotted fever.
Meningococcal meningitis. Meningococcal meningitis is the most likely condition for the client who has a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. Meningococcal meningitis is a bacterial infection that causes inflammation of the membranes that cover the brain and spinal cord. The rash is a characteristic sign of meningococcal meningitis, which can appear as small red or purple spots that do not fade when pressed. The client may also have other symptoms such as nausea, vomiting, sensitivity to light, confusion, and seizures.
44. While caring for a client with full thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the healthcare provider, the nurse should evaluate which laboratory value? A Serum albumin. B Blood pH level. C Platelet count. D Neutrophil count.
Neutrophil count. Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, while a low neutrophil count can indicate a weakened immune system or a chronic infection. Neutrophil count is the most relevant laboratory value to evaluate wound infection.
45. While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? A Evaluate for evidence of incontinence. B Observe for prolonged periods of apnea. C Observe for lacerations to the tongue. D Document details of the seizure activity.
Observe for prolonged periods of apnea. This intervention is important for assessing the client's respiratory status during and after the seizure. Apnea can cause cardiac arrest and respiratory failure and hence a priority.
38. A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take? A Monitor for bloody diarrheal stools. B Obtain vital sign measurements. C Encourage ambulation in the room. D Measure capillary glucose level.
Obtain vital sign measurements. Obtaining vital sign measurements is the priority action for a client with a rigid abdomen and rebound tenderness. These signs indicate peritonitis, which is a serious complication of IBD that requires immediate attention. Vital signs can reveal signs of infection, inflammation, shock, and organ failure, which can guide the appropriate interventions and treatments.
42. While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately? A Perform a bedside pregnancy test. B Calculate gestation from last menstrual cycle. C Notify the surgical team to cancel the surgery. D Continue with surgery as scheduled.
Perform a bedside pregnancy test. This is correct because performing a bedside pregnancy test is the intervention that should be implemented immediately by the nurse. This is to confirm or rule out pregnancy and inform the surgical team of any possible risks or complications that may affect the client or the fetus.
58. A client has an absolute neutrophil count (ANC) of 500/mm (0.5 x 10%/L) after completing chemotherapy. Which intervention is most important for the nurse to implement? Reference Range: Neutrophils (ANC) [2,500 to 5,800/mm* (2.5 to 5.8 x 10%/L)] A Place the client in protective isolation. B Review need for pneumococcal vaccine. C Assess vital signs every 4 hours. D Implement bleeding precautions.
Place the client in protective isolation This is correct because placing the client in protective isolation is the most important intervention for the nurse to implement. Protective isolation, also known as reverse isolation or neutropenic precautions, is a set of measures that aim to protect the client from exposure to pathogens that may cause infections. These include wearing gloves, masks, gowns, and eye protection; using sterile equipment and techniques; avoiding contact with people who are sick or have infections; and restricting visitors and fresh flowers or fruits.
8. (6 of 6) Patient Data The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m^2
Review H and P, nurse's note, and laboratory results. Click to mark whether the client statement indicates understanding or no understanding of the education given. Choose Understanding or No understanding from the Client Statements below: - "I can never eat sugar again." - "If my fasting blood sugar is less than 100 mg/dL (5.6 mmol/L) next time, I can go back to my usual eating habits." - "If I make the changes we talked about, I will not get type 2 diabetes." -"If I have symptoms like increased thirst and urination, I should come in and get my blood sugar checked."
7. (5 of 6) Patient Data The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m^2
Review H and P, nurse's note, and laboratory results. What other nutritional recommendations) would be helpful for this client in reducing risk for type 2 diabetes mellitus? Select all that apply. A. Eliminate sugary beverages and juices from the diet B. Double the usual amount of protein in the diet C. Increase the amount of dietary fiber D. Minimize the number of refined grains in the diet E. Only select food items with no fat F. Take a cinnamon supplement
46. The nurse is caring for a client receiving thrombolytic therapy following an acute myocardial infarction (MI). Which nursing problem should the nurse identify as priority for this client? A Risk for injury related to effects of thrombolysis. B Deficient knowledge related to a new medication regimen. C Activity intolerance related to ischemia. D Ineffective breathing pattern related to adverse drug effects.
Risk for injury related to effects of thrombolysis. Clients receiving thrombolytic therapy are at an increased risk of bleeding, which can manifest as internal bleeding, hemorrhage at vascular access sites, gastrointestinal bleeding, or intracranial bleeding. The nurse's priority is to closely monitor the client for signs and symptoms of bleeding, such as sudden onset or worsening of headache, changes in level of consciousness, hematuria, melena, ecchymosis, or hematoma formation.
The nurse is preparing an older adult client for a magnetic resonance imaging (MRI) with contrast. Which laboratory value should the nurse report to the healthcare provider before the scan is performed? Reference Range: Glycosylated Hemoglobin [4% to 5.9%] Creatinine [0.6 to 1.2 mg/dL (53 to 106 umol/L)] Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)] Blood Urea Nitrogen [10 to 20 mg/dL (3.6 to 7.1 mmol/L)] A. Glycosylated hemoglobin of 8%. B. Serum creatinine of 1.9 mg/dL (168 umol/L). C. Blood urea nitrogen of 22 mg/dL (7.9 mmol/L). D. Fasting blood sugar of 200 mg/dL (11.1 mmol/L).
Serum creatinine of 1.9 mg/dL (168 umol/L). Serum creatinine of 1.9 mg/dL (169 umol/L) indicates moderate renal insufficiency, which is a reduced ability of the kidneys to filter and excrete waste products and fluids from the body. It can be caused by diabetes mellitus, hypertension, glomerulonephritis, or nephrotoxic drugs. Renal insufficiency can cause symptoms such as edema, anemia, electrolyte imbalance, and acidosis. It can also increase the risk of contrast-induced nephropathy, which is a sudden deterioration of kidney function after exposure to contrast media used for imaging studies such as MRI. Contrast-induced nephropathy can lead to acute kidney injury, dialysis requirement, or even death. Therefore, serum creatinine should be reported to the healthcare provider before MRI with contrast to assess the risk and benefit of the procedure and to take preventive measures such as hydration, medication adjustment, or alternative imaging modalities.
33. History and Physical A 59-year-old male client presents to the clinic reporting pain in the right great toe. The client reports that the pain feels like it is another attack of gout, which he has had on 2 other occasions in the last 4 months. The client reports to the nurse that the pain started about 9 days ago in the evening and that it got very painful and swollen shortly thereafter. In the past, the client's gout attacks have resolved without treatment after about 5 days, but the client reports that his condition has not improved and that he is unable to walk or work without excruciating pain in the great toe joint. The client has type 2 diabetes mellitus, osteoarthritis, hypertension, obesity, and sleep apnea. Currently, the client takes daily metformin, daily aspirin, daily enalapril, and ibuprofen as needed for pain. The client reports that he has never smoked or used tobacco products. He does not use r
Spider Web for Actions to Take, Potential Conditions, and Parameters to Monitor Actions to Take: Prepare to drain ascitic fluid Prepare for casting Begin ordered medications Begin exercise regime Education on gout prevention measures Potential Conditions: Gout Broken toe Vascular disease Cirrhosis Parameters to Monitor: = Compartment syndrome =Pain = Exercise compliance = Dietary compliance = Liver enzymes
26. The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should th nurse instruct the client to avoid? A. Spinach salad. B. Bananas. C. Sweet potatoes. D. Fish.
Spinach salad. Spinach is high in oxalates, which can contribute to the formation of calcium oxalate renal stones. Therefore, the client should be instructed to avoid spinach and foods high in oxalates.
55. The nurse is admitting a client with possible tuberculosis (TB). The client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB? A. Chest x-ray or computed tomography (CT). B. Positive purified protein derivative (PPD) skin test. C. Hemoccult test on sputum collected from hemoptysis. D. Sputum culture positive for Mycobacterium tuberculosis.
Sputum culture positive for Mycobacterium tuberculosis. Sputum culture positive for Mycobacterium tuberculosis is the definitive diagnostic test for TB. It involves collecting a sample of sputum, which is the mucus coughed up from the lungs, and culturing it in a laboratory to see if Mycobacterium tuberculosis, the bacteria that causes TB, grows. This test is highly specific for TB, meaning that a positive result is almost always indicative of TB infection. It is also sensitive, meaning that it can detect TB infection even when there are few bacteria present
11. An older adult client with symptoms of osteoarthritis asks the nurse which form of exercise would be most beneficial. Which is the best response by the nurse? A Tennis or racquetball will increase your muscle strength. B Swimming is an excellent exercise for you. C Limit your exercise to just your daily activities. D Jogging or running are excellent aerobic exercises.
Swimming is an excellent exercise for you. Swimming is an excellent exercise for an older adult client with osteoarthritis. Swimming is a low-impact aerobic exercise that can strengthen the muscles, improve the cardiovascular fitness, and enhance the flexibility of the joints without putting too much pressure or stress on them. Swimming can also reduce the pain and stiffness of osteoarthritis by providing a soothing and relaxing effect on the body. The nurse should recommend swimming as a safe and effective exercise for the client.
15. (3 of 6) History and Physical: A 19-year-old female client presents to the emergency department reporting tightness in her chest and difficulty breathing. The client's friend, who accompanied the client to the emergency department, reports she was at a park playing soccer with a group of college friends when the symptoms started. The park is close to a residential area where a fire was burning and there was a moderate breeze in the air. The client reported itching eyes and coughing. Approximately 15 minutes into the game, the client stopped running and held her hand on her chest, saying it felt tight. The client had difficulty catching her breath. Home Medications • Albuterol/pratropium every 4 hours by inhaler PRN for shortness of breath, last dose 2 days ago
The nurse evaluates the client's risk factors for asthma exacerbation. Drag from Word Choices to complete the sentence. The nurse recognizes that _______, __________, and ________ are likely triggers for asthma exacerbation in this client's case. Options for one: - missed doses of inhaler - use of a nonsteroidal antiinflammatory drug - smoke inhalation - exposure to cigarette smoke - viral infection
17. (5 of 6) History and Physical: A 19-year-old female client presents to the emergency department reporting tightness in her chest and difficulty breathing. The client's friend, who accompanied the client to the emergency department, reports she was at a park playing soccer with a group of college friends when the symptoms started. The park is close to a residential area where a fire was burning and there was a moderate breeze in the air. The client reported itching eyes and coughing. Approximately 15 minutes into the game, the client stopped running and held her hand on her chest, saying it felt tight. The client had difficulty catching her breath. Home Medications • Albuterol/pratropium every 4 hours by inhaler PRN for shortness of breath, last dose 2 days ago
The nurse evaluates the client's statement and teaches the client about the medications. The nurse prepares to give the ordered medications and ensure proper understanding. For each medication, chose the most likely option for the drug classification and the client teaching that will be performed. Medications: - Montelukast - Albuterol - Fluticasone / vilanterol
13. (1 of 6) History and Physical: A 19-year-old female client presents to the emergency department reporting tightness in her chest and difficulty breathing. The client's friend, who accompanied the client to the emergency department, reports she was at a park playing soccer with a group of college friends when the symptoms started. The park is close to a residential area where a fire was burning and there was a moderate breeze in the air. The client reported itching eyes and coughing. Approximately 15 minutes into the game, the client stopped running and held her hand on her chest, saying it felt tight. The client had difficulty catching her breath. Home Medications • Albuterol/pratropium every 4 hours by inhaler PRN for shortness of breath, last dose 2 days ago
The nurse is assigned to care for this client and reads the triage note before entering the room. What finding(s) are cues for a respiratory problem? Select all that apply. A. Heart rate of 99 beats/minute B. Respirations of 28 breaths/minute C. Sitting upright D. Restlessness E. Dyspnea F. Medication compliance G. Tightness in the chest H. Pulse oxygenation of 85% I. Body mass index of 29.2 kg/m2
16. (4 of 6) History and Physical: A 19-year-old female client presents to the emergency department reporting tightness in her chest and difficulty breathing. The client's friend, who accompanied the client to the emergency department, reports she was at a park playing soccer with a group of college friends when the symptoms started. The park is close to a residential area where a fire was burning and there was a moderate breeze in the air. The client reported itching eyes and coughing. Approximately 15 minutes into the game, the client stopped running and held her hand on her chest, saying it felt tight. The client had difficulty catching her breath. Home Medications • Albuterol/pratropium every 4 hours by inhaler PRN for shortness of breath, last dose 2 days ago
The nurse is awaiting new orders for medical management of the client's condition and considers which interventions can be completed now. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. The nurse uses a _____________ technique to help the client calm down. The nurse guides the client to perform _____________ breathing in an effort to improve oxygenation by maintaining _____________ pressure and slowing respiratory rates.
49. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this disease process? A Frequent use of chewable and liquid antacids for indigestion. B Severe abdominal cramps and diarrhea after eating spicy foods. C Upper mid abdominal pain described as gnawing and burning D Marked loss of weight and appetite over the last 3 or 4 months.
Upper mid abdominal pain described as gnawing and burning Peptic ulcer disease involves the formation of open sores in the lining of the stomach or the duodenum. The characteristic symptom of PUD is abdominal pain, typically located in the upper mid abdomen. This pain is often described as gnawing, burning, or aching in nature. The pain may occur shortly after eating, especially when the stomach is empty (gastric ulcer), or it may occur 2-3 hours after eating, typically at night (duodenal ulcer).
5. (3 of 6) Patient Data The client is a 58-year-old male who wants to be screened for diabetes mellitus. The client has a sister who has type 2 diabetes mellitus. He has a history of depression, which is treated with paroxetine 10 mg PO every day. The client also discloses that he occasionally takes cannabis in edible form. He denies smoking or drinking. He works in a chemical factory where he is occasionally exposed to fumes. The client's body mass index (BMI) is 28 kg/m^2
What item(s) should be included in the treatment regimen for this client? Select all that apply. A Exercise planning B Weight reduction treatment C Long acting insulin D Short acting insulin E Nutrition education F Extra carbohydrates G Oral antidiabetic
23. ( of 6) History and Physical: ___________________________________________________________________ diabetes mellitus, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end stage renal disease (ERSD). She has been on hemodialysis three times a week for the last month. She presented to the emergency department with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reported she had bouts of nausea and had a poor appetite and was not able to go for her scheduled dialysis. The client also reports that her doctor had recently started her on lisinopril for blood pressure control, but it doesn't seem to help. She was diagnosed with hyperkalemia with potassium level of 5.9 mEq/L (5.9 mmol/L) and transferred to the intermediate medicine unit (IMU) for treatment and monitoring.
What nursing action(s) is are appropriate for the client at this time? Select all that apply. A. Call the healthcare provider to notify changes in vital signs B. Check blood glucose level STAT C. Administer calcium gluconate STAT D. Perform a 12 lead electrocardiogram (ECG) STAT E. Request for more frequent blood glucose F. Clarify order of lisinopril with the healthcare provider G. Perform a focus cardiovascular assessment H. Draw potassium level STAT I. Teach client to take slow and deep brea J. Administer nausea medication
