HESI Review Question Combined Pt. 2

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement? A. Move the client to a quiet place on the unit B. Encourage the client to use the punching bag C. Use firmness and direct the client to sit for awhile D. Suggest to the client that he take a walk

A. Move the client to a quiet place on the unit

The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. What action should the nurse take next? A. Open the roller clamp on the tubing B. Label the bag of IV solution C. Attach the tubing to the saline lock D. Flush the saline lock with saline

A. Open the roller clamp on the tubing

The laboratory findings for a client with chronic kidney disease (CKD) include elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. Based on these findings, which action should the nurse implement? A. Provide high protein snacks B. Administer PRN oxygen C. Schedule frequent rest periods D. Monitor glucose levels q4 hours.

A. Provide high protein snacks

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? A. Report serum albumin and globulin levels B. Provide diet low in phosphorus C. Note signs of swelling and edema D. Monitor abdominal girth E. Increase oral fluid intake to 1,500 mL daily

A. Report serum albumin and globulin levels C. Note signs of swelling and edema D. Monitor abdominal girth

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

A. Review the client's most recent serum electrolyte values C. Report mental status changes to the healthcare provider E. Assess the client's breath sounds and oxygen saturation

An older male client was successfully treated for Herpes zoster (shingles) with an antiviral medication reports that he is now experiencing pain on his trunk where the lesions were located. Which action should the nurse take? A. Review the medication record to determine when the last analgesic was administered B. Reassure the client that the infection is resolved and the pain should soon disappear C. Teach the client about the importance of completing the full course of antiviral medication D. Contact the healthcare provider about the need to resume the client's antiviral medication

A. Review the medication record to determine when the last analgesic was administered

Which snack selection indicates to the nurse that a school-age boy with gastroesophageal reflux understands his dietary restrictions? A. Sugar cookies B. Pizza C. Chocolate milkshake D. Tacos

A. Sugar cookies

What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? A. "When I get out of bed quickly, I feel a little dizzy." B. "The dressing over my incision feels like it is too tight C. "I'm most comfortable when the head of the bed is raised" D. "This IV infusion makes me urinate more often than usual"

A. When I get out of bed quickly, i feel a little dizzy

A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control

C) Administer the prescribed analgesia

In planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort

C) Security

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide? A. "Does your child seem mentally slower than his peers also?" B. "Haven't you been feeding him according to recommended daily allowances for children?" C. "His smaller size is probably due to the heart disease" D. "You should not worry about the growth tables. They are only averages for children."

C. "His smaller size is probably due to the heart disease"

The nurse is caring for a client who is admitted to the emergency center after a motor vehicle collision. The client begins to experience a decreased level of consciousness and the pupils do not respond equally to light. Which vital signs changes indicate the client is manifesting Cushing's triad? A. Blood pressure of 80/40 mmHg, weak heart rate of 40 beats/minute, Cheyne-Stokes respirations of 10 breaths/minute B. Blood pressure 180/120 mmHg, weak heart rate of 92 beats/minute, Kussmaul respirations of 18 breaths/minute C. Blood pressure of 180/80 mmHg, bounding heart rate of 50 beats/minute, respirations of 30 breaths/minute with apneic episodes D. Blood pressure of 90/60 mmHg, strong heart rate of 60 beats/minute, eupneic respirations of 16 breaths/minute

C. Blood pressure of 180/80 mmHg, bounding heart rate of 50 beats/minute, respirations of 30 breaths/minute with apneic episodes

A 62-year-old male client tells the nurse that he has a high-density lipoprotein (HDL) level of 85 mg/dl. Which action should the nurse take? A. Encourage the client to reduce consumption of fatty foods B. Ask the client about hereditary cardiac risk factors C. Confirm that this value is helpful in reducing cardiac risk D. Explain that the client may need medication therapy

C. Confirm that this value is helpful in reducing cardiac risk

The parents of a 6 year old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? A. Provide a list of alternative activities that are less likely to cause the child to experience fatigue B. Explain that their child is too young to understand the risks associated with swimming C. Encourage the parents to allow the child to continue attending swimming lessons with supervision D. Suggest that the child be encouraged to participate in a team sport to encourage socialization

C. Encourage the parents to allow the child to continue attending swimming lessons with supervision

he nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take? A. Instruct the PN that this technique promotes infection in elderly females B. Recommend a complete bath to cleanse the perineal area more fully C. Evaluate the effectiveness of this measure to stimulate client voiding D. Suggest contacting the healthcare provider for a prescription for catheter insertion

C. Evaluate the effectiveness of this measure to stimulate client voiding

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? A. Drank a glass of water in the past 2 hours B. Verbalizes a fear of being in a confined space C. Experiences facial swelling after eating crab D. Reports left chest wall pain prior to admission

C. Experiences facial swelling after eating crab

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety? A. Assess for discomfort when procedure is completed B. Verify that the client has given informed consent C. Instruct the client to keep hands under the sterile field D. Pour cleansing solution onto the sterile cloth field

C. Instruct the client to keep hands under the sterile field

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?A. Initiate seizure precautions B. Assess neurological status every 8 hours C. Limit oral water intake D. Administer a hypertonic IV fluids as prescribed

C. Limit oral water intake

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? A. Blood pressure of 122/74 mmHg B. White blood count of 19,000mm3 C. Moderate amount of foul-smelling lochia D. Oral temperature of 100.2F

C. Moderate amount of foul-smelling lochia

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Platelet count B. Serum sodium level C. Neutrophil count D. Hematocrit

C. Neutrophil count

One day after abdominal surgery, a client with obesity reports pain and heaviness in the right calf. Which action should the nurse implement? A. Encourage ambulation in the room B. Palpate the femoral pulse C. Observe for unilateral swelling D. Apply a warm compress to the area

C. Observe for unilateral swelling

The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. Which action should the nurse take first? A. Instruct the UAP to raise the bed level B. Provide gloves for the UAP to apply C. Offer to help reposition the client D. Place the side rails in an up position

C. Offer to help reposition the client

While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take? A. Start progressive mobilization B. Request a nutrition consult C. Request a wound culture and sensitivity D. Force oral fluids

C. Request a wound culture and sensitivity

Following a total knee replacement, a client is discharged from the hospital with a prescription for warfarin. In reviewing discharge teaching, the client tells the nurse that he will avoid eating foods high in potassium, such as bananas and melon. How should the nurse respond? A. Discuss necessary fluid restrictions as well as food restrictions B. Explain that no dietary restrictions are needed with warfarin C. Review teaching about the effects of foods rich in Vitamin K D. Provide a written list of additional foods high in potassium K

C. Review teaching about the effects of foods rich in Vitamin K

Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness

D) A preschooler with intermittent episodes of alertness

What is the most important consideration when teaching parents how to reduce risks in the home? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home

D) Age of children in the home

The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence, and denies any family history of epilepsy. What is the best response by the nurse? A) "Do not worry. Epilepsy can be treated with medications." B) "The seizure may or may not mean your child has epilepsy." C) "Since this was the first convulsion, it may not happen again." D) "Long term treatment will prevent future seizures."

B) "The seizure may or may not mean your child has epilepsy."

Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160

B) Pale mucosa of the eyelids and lips

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? A. Assist the client to lie back in bed B. Administer a nebulizer treatment C. Call for an Ambu resuscitation bag D. Increase oxygen to 6 liters/minute

B. Administer a nebulizer treatment

When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention? Select all that apply A. Sloughing tissue around wound edges B. Complaint of increased pain and pressure C. Change in the quality of the peripheral pulses D. Loss of sensation to the left lower extremity E. Weeping serosanguineous fluid from wounds

B. Complaint of increased pain and pressure C. Change in the quality of the peripheral pulses D. Loss of sensation to the left lower extremity

During a clinic visit, a client with a kidney transplant asks, "What will happen if chronic rejection develops?" Which response is best for the nurse to provide? A. A different combination of immunosuppressant medications will be implemented B. Dialysis would need to be resumed if chronic rejection becomes a reality C. Dialysis may be necessary until the chronic rejection can be reversed D. The immunosuppressant medication will be increased until the rejection subsides

B. Dialysis would need to be resumed if chronic rejection becomes a reality

A client arrives for an annual physical exam and complains of having calf pain. The client's health history reveals peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms? A. Were your legs ever suddenly swollen, red, warm, and painful? B. Does the calf pain occur when walking short distances? C. Did you receive treatment for weeping ulcers on lower legs? D. Have you experienced ankle edema and varicose veins?

B. Does the calf pain occur when walking short distances?

A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50mL/hr. The client's urine specific gravity is 1.035. Which action should the nurse implement? A. Assess bowel sounds in all quadrants B. Encourage popsicles and fluids of choice C. Evaluate postural blood pressure measurements D. Obtain a specimen for urinalysis

B. Encourage popsicles and fluids of choice

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. the nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? A. Ask family members to remain with the client in the evenings from 1700 to 2100pm B. Ensure that the client is assigned to the room close to the nurses' station C. Postpone administration of nighttime medications until after 2300pm D. Administer a prescribed PRN benzodiazepine at the onset of a confused state

B. Ensure that the client is assigned to the room close to the nurses' station

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include? A. Swaddle the infant in a blanket for sleeping B. Ensure that the infant's crib mattress is firm C. Place the infant in a prone position whenever possible D. Prop the infant with a pillow when in a side-lying position

B. Ensure that the infant's crib mattress is firm

A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? A. Patch one eye B. Evaluate swallow C. Reorient often D. Range of motion

B. Evaluate swallow

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL is alert and diaphoretic. What action should the charge nurse take? A. Assess client for polyuria and polyphagia B. Give the client a glass of orange juice C. Notify the healthcare provider D. Collect a blood sample for hemoglobin A1c

B. Give the client a glass of orange juice

The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? A. Peripheral pallor of the skin B. Increased pulse rate C. Clenched fists D. Restlessness E. Increased temperature F. Increased respiratory rate

B. Increased pulse rate C. Clenched fists D. Restlessness F. Increased respiratory rate

A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Assess for symptoms of AIDS dementia B. Monitor for secondary infections C. Identify local HIV support groups D. Observe for adverse drug reactions

B. Monitor for secondary infections

An older adult who is in his early 70s is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the client's living well. Which action should the nurse take? A. Facilitate a family meeting with the palliative care team B. Notify the healthcare provider of the clients wishes C. Place a certified copy of the living well in the client's room D. Alert the nursing staff of the clients do not resuscitate status

B. Notify the healthcare provider of the clients wishes

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care the nurse finds the radiation implant in the bed. What action should the nurse take? A. Apply double gloves to retrieve the implant for disposal B. Place the implant in a lead container using long-handled forceps C. Reinsert the implant into the vagina D. Call the radiology department

B. Place the implant in a lead container using long-handled forceps

The nurse is providing care for a child who is brought to the emergency department a few days after a laceration to the leg from a barbed wire fence. The child has not received any tetanus immunizations and is manifesting early signs of muscular rigidity with spasms and jaw clenching or trismus. Which intervention should be the nurse's highest priority for this child? A. Suction oropharyngeal secretions B. Prepare for intubation with mechanical ventilation C. Minimize stimulation from sound, light, and touch D. Monitor IV infusions

B. Prepare for intubation with mechanical ventilation

An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first?A. Document neurologic changes B. Reduce environmental stimuli C. Administer prescribed neuroleptic D. Review medications for interactions

B. Reduce environmental stimuli

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy? A. Report any allergies to shellfish or iodine B. Report any painful urination, blood in urine, or fever C. Lay prone for 24 hours after the procedure D. Avoid strenuous activity and sports for at least 2 weeks

B. Report any painful urination, blood in urine, or fever

A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication? A. Monitor your blood pressure regularly B. Report unusual bruising or bleeding C. Elevate your feet if swelling occurs D. Check your pulse rate every day

B. Report unusual bruising or bleeding

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum creatinine of 4.5 mg/dL C. Serum sodium of 145 mEq/L D. White blood cell count of 12,000mm3

B. Serum creatinine of 4.5 mg/dL

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? A. Leukocytes, neutrophils, and thyroxine B. Serum potassium, calcium, and phosphorus C. Blood pressure, heart rate, and temperatue D. Erythrocytes, hemoglobin, and hematocrit

B. Serum potassium, calcium, and phosphorus

When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this findings be most significant?A. Crying B. Sitting upright C. Vomiting D. Straining on stool

B. Sitting upright

A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? A. Bring a bedside commode to the client B. Stand on the client's right side as he walks C. Walk directly behind the client to prevent a fall D. Give the client a cane to hold in his right hand

B. Stand on the client's right side as he walks

The nurse is teaching a client newly diagnosed with systemic lupus erythematosus (SLE). Which information is accurate for the nurse to provide? A. The client can expect to progressively lose function in a fairly predictable sequence B. The disease is characterized by alternating periods of flare-ups and remissions C. Once an acute attack subsides, the client can expect to feel fine again D. Systemic lupus erythematosus (SLE) is a chronic, incurable, terminal illness

B. The disease is characterized by alternating periods of flare-ups and remissions

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions?

1. Stop the infusion 2. Assess vital signs 3. Contact the healthcare provider 4. Document reaction to the drug 5. Initiate an adverse event report

A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial assessment, the nurse would anticipate which of the following assessment findings? A) Lethargy B) Heat intolerance C) Diarrhea D) Skin eruptions

A) Lethargy

While caring for a toddler with croup, which initial sign of croup requires the nurse's immediate attention? A) Respiratory rate of 42 B) Lethargy for the past hour C) Apical pulse of 54 D) Coughing up copious secretions

A) Respiratory rate of 42

Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies? A) Risk for injury B) Risk for knowledge deficit C) Altered thought process D) Disturbance in self-esteem

A) Risk for injury

client with leukemia who is receiving a myleosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client's plan of care? A. Assess urine and stool for occult blood B. Monitor for signs of activity intolerance C. Require visitors to wear respiratory masks D. Obtain client's temperature q4 hours

A. Assess urine and stool for occult blood

The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available? A. Bacterial meningitis B. Viral encephalitis C. Septic shock D. Brain abscess

A. Bacterial meningitis

The nurse is teaching a primigravida about preeclampsia. Which findings are indicators of preeclampsia and should be reported to the healthcare provider? A. Blurred vision B. Headache C. Lack of appetite D. Urinary frequency E. Chills and fever F. Swollen hands

A. Blurred vision B. Headache F. Swollen hands

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)? A. Body mass index B. Breath sounds C. Self-description of pain D. Level of consciousness

A. Body mass index

The nurse includes assessment for fat embolism syndrome (FES) in the plan of care for a client with a fractured femur. Which findings should the nurse include that are often the earliest indication of a FES? A. Confusion, restlessness B. Petechial rash C. Tachycardia, fever D. Pulmonary crackles

A. Confusion, restlessness

An adult woman who was recently diagnosed with type 2 DM is seen in the clinic for laboratory tests. The client's height is 5 feet 2 inches and weight is 165 pounds. Her recent laboratory findings are described above. In planning nutrition teaching for this client, what diet modifications should the nurse recommend?Labs:Creatinine 1.0 mg/dLBUN 16 mg/dlDiagnostics:Total cholesterol 250 mg/dlLDL 175 mg/dlHDL 35 mg/dlTriglyceride 250 mg/dlFlowsheets:Glucose 150 mg/dlA1c 9% A. Decrease processed carbohydrate in diet B. Eliminate alcohol intake except for special occasions C. Restrict protein to 10% of total calories in diet D. Increase dietary fiber such as whole grains E. Reduce daily fat intake to 10% of total calorie

A. Decrease processed carbohydrate in diet B. Eliminate alcohol intake except for special occasions D. Increase dietary fiber such as whole grains

An unlicensed assistive personnel (UAP) is a sign to provide personal care for a client whose prescribed activity is bed rest in a bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond? A. Determine the client's level of mobility and need for assistance B. Instruct the UAP that all clients deserve equal care C. Advise the client to maintain bedrest so that safety can be insured D. Assign another UAP to care for the client

A. Determine the client's level of mobility and need for assistance

The nurse is assessing a client who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the healthcare provider immediately? A. Diminished breath sounds over the trocar insertion site B. Equal bilateral chest expansion C. Scattered crackles unchanged from baseline D. Respiratory rate of 22 breaths/minute

A. Diminished breath sounds over the trocar insertion site

Which instruction should the nurse provide a pregnant client who is reporting heartburn? A. Eat small meals throughout the day to avoid a full stomach. B. Take an antacid at bedtime and whenever symptoms worsen. C. Maintain a sitting position for two hours after eating. D. Limit fluids between meals to avoid overdistension of the stomach

A. Eat small meals throughout the day to avoid a full stomach.

Which type of leukocyte is involved with allergic responses and the destruction of parasitic worms? A. Eosinophils B. Neutrophils C. Lymphocytes D. Monocytes

A. Eosinophils

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A. Explain that counseling will be provided to give her information about her cancer risk B. Offer assurance that there are a variety of effective treatments for breast cancer C. Gather additional information about the client's family history for all types of cancer D. Provide information about survival rates for women who have this genetic mutation

A. Explain that counseling will be provided to give her information about her cancer risk

After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take? A. File a detailed incident report with the specific hiring facility B. Warn the colleague that their actions are unprofessional C. Comment anonymously about the action on a staff discussion board D. Communicate the colleague's actions to the unit charge nurse

A. File a detailed incident report with the specific hiring facility

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? A. Gently close the eyes B. Remove resuscitation equipment from the room C. Take out dentures and place in a labeled cup D. Apply a body shroud E. Place a small pillow under the head

A. Gently close the eyes B. Remove resuscitation equipment from the room E. Place a small pillow under the head

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self care? A. Have the client vocalize the instructions provided B. Ensure that someone will stay with the client for 24 hours C. Speak clearly and face the client for lip reading D. Provide written instructions for eye drop administration

A. Have the client vocalize the instructions provided

Which woman should the nurse consider at the highest risk for cervical cancer? A. History of unprotected sex with multiple partners B. Postmenopausal for 5 years with intermittent vaginal spotting C. Taking birth control pills after 40 years of age D. Multiparous delivery of infants more than 9 pounds

A. History of unprotected sex with multiple partners

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L, glucose 54mg, and potassium 5.3 mEq/L. When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? A. Hydrocortisone B. Regular insulin C. Broad spectrum antibiotic D. Potassium chloride

A. Hydrocortisone

The nurse is caring for a client admitted for evaluation of a descending aortic aneurysm. While outside the room documenting, the nurse hears the client screaming. The client tells the nurse that the pain is "sharp, like something inside is ripping and tearing." The client also reports dizziness. Which of the following is the likely cause? A. Impending rupture of the aneurysm B. The client is having a panic attack C. Clotting of the aneurysm D. The client is hallucinating from the opioids

A. Impending rupture of the aneurysm

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? A. Initiate the dosage lockout mechanism on the PCA pump B. Assess the client's ability to use a numeric pain scale C. Assess the abdomen for bowel sounds D. Instruct the client to use the medication before the pain becomes severe

A. Initiate the dosage lockout mechanism on the PCA pump

Which intervention is most important for the nurse to include in the plan of care for a client who is being mechanically ventilated and is receiving continuous enteral feedings? A. Maintain the head of the bed elevated at 45 degrees B. Check the feeding tube placement q8hours C. Assess the gastric residual volume q4hours D. Obtain a chest x-ray PRN for adventitious lung sounds

A. Maintain the head of the bed elevated at 45 degrees

The nurse identifies an electrolyte imbalance, crackles on auscultation and an elevated blood pressure in a client with progressive heart disease. Which intervention should the nurse include in the plan of care? A. Measure ankle circumference B. Record usual eating patterns C. Evaluate for muscle cramping D. Document abdominal girth

A. Measure ankle circumference

The charge nurse in an extended care facility in organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)? A. Measure the client's body weight each morning B. Establish blood pressure parameters for client monitoring C. Evaluate a staff member providing wound care D. Evaluate client teaching through return demonstration

A. Measure the client's body weight each morning

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask and requiring staff to observe airborne, as well as standard precautions? A. A female adolescent admitted with multiple genital herpes simplex II lesions B. An older client with scabies who is admitted from an extended care facility C. Twin siblings admitted with scarlet fever that is complicated with pneumonia D. A client with a positive Mantoux and sputum cultures results positive for AFB

D. A client with a positive Mantoux and sputum cultures results positive for AFB

The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? A. A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race B. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheter C. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied

D. An 82-year-old client with Alzheimer's disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied

The nurse is caring for a client with chronic obstructive disease (COPD) who uses oxygen at 2L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? A. Determine if the client is experiencing any anxiety B. Auscultate the client's bilateral lung sounds and oxygen saturation C. Notify the healthcare provider about the client's distress D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula

D. Assess the delivery mechanism of the oxygen tank, tubing, and cannula

A male client who fell of a roof has right and left femur fractures and crushing injuries to both ankles. he is supine with bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hours. When asked to evaluate his pain on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has received morphine 2mg IV hourly. His vial signs are heart rate 130 beats/minute, respirations 32 breaths/minute, blood pressure 180/90 mmHg. Which intervention is most important for the nurse to implement?A. Request the healthcare provider to consider a different analgesic B. Evaluate the traction for amount of tension applied to each extremity C. Determine if client is experiencing cumulative effects of the total dosage D. Assess the extremities for signs of compartment syndrome q2 hours

D. Assess the extremities for signs of compartment syndrome q2 hours

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. What action should the nurse implement first? A. Provide a printed health care assessment form B. Ask the family member to answer the questions C. Defer the health history until the client is less anxious D. Assess the surroundings for noise and distractions

D. Assess the surroundings for noise and distractions

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

D. Compulsion

Which conditions are most likely to respond to treatment with antihistamines? A. Bronchitis B. Myocarditis C. Otitis media D. Contact dermatitis E. Allergic rhinitis

D. Contact dermatitis E. Allergic rhinitis

A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? A. Regular contractions occurring every 10 minutes B. Sterile vaginal exam revealing 3cm dilation C. Biophysical profile results showing oligohydramnios D. Fetal heart tones located in upper right quadrants

D. Fetal heart tones located in upper right quadrants

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

D. Full bladder

A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer' IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute. In addition to reporting the findings to the surgeon, which action should the nurse implement first? A. Measure and document the client's urinary output. B. Request the client's reserved unit of packed red blood cells. C. Prepare for the placement of central venous catheter. D. Increase the infusion rate of Lactated Ringer's solution.

D. Increase the infusion rate of Lactated Ringer's solution.

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? A. Notify the healthcare provider of the need to reposition the catheter B. Remove the catheter and apply direct pressure for 5 minutes C. Secure the catheter using aseptic techniques D. Initiate intravenous fluids as prescribed

D. Initiate intravenous fluids as prescribed

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first? A. Determine if the newborn is in the nursery B. Activate the lockdown procedure C. Ask the mother if any visitors were expected to arrive D. Match ID bands of all infants and mothers on the unit

D. Match ID bands of all infants and mothers on the unit

When caring for a client with a traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every 2 hours. For the past 8 hours the client's GCS score has been 14. What does this GCS finding indicate about this client? A. Rehabilitative prognosis is an expected full recovery B. Risk for irreversible cerebral damage related to increased ICP C. Insertion of an ICP monitoring device is necessary D. Neurologically stable without indications of an increased ICP

D. Neurologically stable without indications of an increased ICP

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance? A. Encouraging the client to join a support group B. Wearing gloves when interviewing the client C. Allowing the client to ventilate feelings D. Shaking the client's hand during an introduction

D. Shaking the client's hand during an introduction

An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider? A. Urine specific gravity is 1.040 B. Systolic blood pressure decreases 10 points when standing C. The client denies being thirsty D. Skin tenting occurs when the client's forearm is pinched

D. Skin tenting occurs when the client's forearm is pinched

An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care? A. Use hand and arm gestures to improve communication and comprehension B. Provide additional light in the room to promote sensory stimulation C. Place a clock and calendar in the room to improve orientation D. Teach the client to turn his head from side to side for visual scanning

D. Teach the client to turn his head from side to side for visual scanning

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? A. The client will express acceptance of their newly diagnosed health status. B. The nurse will encourage the client to walk thirty minutes every day C. The client's blood pressure readings will be less than 160/90 mmHg D. The client's skin on the lower legs will be intact at the next clinic visit

D. The client's skin on the lower legs will be intact at the next clinic visit

The nurse is caring for four clients. Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.2 mg/dL; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy who has a white blood cell count of 14,000 mm3. Which intervention should the nurse implement? A. Move Client D into an isolation room 24 hours before surgery B. Increase Client A's oxygen to 4 liters a minute per cannula C. Ask the dietician to add a banana to Client C's breakfast tray D. Verify that Client B has two units of packed cells available

D. Verify that Client B has two units of packed cells available

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

Red Bin

An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10 cm H2O mark with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Add sterile water to the suction control chamber B. Give blood from the collection chamber as autotransfusion C. Manipulate blood in tubing to drain into the chamber D. Increase wall suction to eliminate fluctuation in water seal

A. Add sterile water to the suction control chamber

An older woman with history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5 mg daily and has an international normalized ratio (INR) value of 5.0. Upon admission, which prescription should the nurse expect to implement? A. Administer Vitamin K injection B. Start continuous heparin infusion C. Continue warfarin at same dose D. Transfuse unit of packed red blood cells

A. Administer Vitamin K injection

The nurse assumes care of a postoperative adult client with diabetes mellitus and learns that the client has a current blood glucose level of 720 mg. When assessing the client what is the priority? A. Assess for vital signs of fluid volume deficit. B. Observe wound drainage characteristics. C. Measure the level of acute pain. D. Determine when the client last ate.

A. Assess for vital signs of fluid volume deficit.

The nurse is preparing to send a client to the cardiac catheterization lab for elective cardioversion. Which intervention should the nurse implement before the client leaves the medical unit? A. Document that the client has remained NPO B. Confirm monitor reading in synchronous mode C. Notify the rapid response team of the transfer D. Secure cardioversion pads on the client's chest

A. Document that the client has remained NPO

The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client's plan of care? A. Ensure adequate IV and oral fluid intake B. Provide ice packs to major joint areas C. Space analgesics to prevent addiction to narcotics D. Re-enforce the importance of nutritional balance

A. Ensure adequate IV and oral fluid intake

When conducting diet teaching for a client who was diagnosed with hypertension, which foods should the nurse encourage the client to eat? A. Fruits without sauce B. Canned soup C. Fresh or frozen vegetables without sauce D. Cottage cheese E. Pickled olives

A. Fruits without sauce C. Fresh or frozen vegetables without sauce D. Cottage cheese

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? A. Keep the nails trimmed short B. Apply baby lotion to the skin twice daily C. Bathe the child with bath oil D. Allow the child to wear only 100% cotton clothing

A. Keep the nails trimmed short

A client with a history of schizophrenia is admitted with diabetic ketoacidosis (DKA). Which nursing interventions should the nurse implement during the admission process for this client? A. Obtain psychiatric and medical admission records B. Hold psychotropic medications until glucose is regulated C. Interview client about reason for admission to hospital D. Prepare the client for involuntary commitment admission E. Review the list of home medications and dosages

A. Obtain psychiatric and medical admission records C. Interview client about reason for admission to hospital E. Review the list of home medications and dosages

The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats/minute. Which action should the nurse take? A. Postpone the feeding until the infant's vital signs are stable B. Continue the insertion since this is a typical response C. Insert the feeding tube into the infant's nasal passage D. Pause and monitor for a continued drop of the heart rate

A. Postpone the feeding until the infant's vital signs are stable

A female child is brought to the emergency department after awakening with a bark-like cough and stridor. upon arrival to the hospital, her respirations are labored, and she is drooling. What action should the nurse implement? A. Prepare for emergency tracheotomy B. Assess the child for dehydration C. Examine oropharyngeal area for foreign body D. Collect midstream urine specimen

A. Prepare for emergency tracheotomy

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms? A. Positive Epstein-Barr, and malaise B. Ear pain and fever C. Elevated WBC and sedimentation rate D. Increased BUN and serum creatinine

B. Ear pain and fever

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? A. Resume normal physical activity B. Give a dose of regular insulin as prescribed C. Measure urine output over the next 24 hours D. Drink electrolyte fluid replacements

B. Give a dose of regular insulin as prescribed

A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as teh control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement? A. Withhold the heparin and continue the same dose of warfarin B. Increase the warfarin dose C. Decrease the heparin dose D. Increase the heparin dose and decrease the warfarin dose

B. Increase the warfarin dose

A client with metabolic syndrome plans to begin an exercise program. Which instruction is most important for the nurse to provide this client? A. Wear long sleeves and a hat when exercising outdoors in direct sunlight B. Monitor blood pressure and heart rate as exercise activity is increased C. Weight bearing exercises are most effective in improving bone strength D. Use hand-held weights to strengthen muscles and build muscle mass

B. Monitor blood pressure and heart rate as exercise activity is increased

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? A. Canned fruit in heavy syrup B. Natural whole almonds C. Plain, air-popped popcorn D. Lightly salted potato chips E. Cheddar cheese cubes

B. Natural whole almonds C. Plain, air-popped popcorn

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal? A. Regional relocation center for earthquake victims B. Vitamin supplements for high-risk pregnant women C. Lead screening for children in low-income housing D. Case management and screening for clients with HIV

B. Vitamin supplements for high-risk pregnant women

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client? A. Pain (acute) B. Knowledge deficit C. Anxiety D. Anticipatory grieving

C. Anxiety

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill". What question should the nurse ask the client next? A. When did these voices begin? B. Have you taken any hallucinogens? C. Are you planning to obey the voices? D. Do you believe the voices are real?

C. Are you planning to obey the voices?

A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? A. Elevate the foot of the bed B. Restrict the client's fluids C. Begin supplemental oxygen D. Prepare client for hemodialysis

C. Begin supplemental oxygen

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care? A. Depression B. Peripheral neuropathy C. Confusion D. Right lower abdominal pain

C. Confusion

A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs every 2 hours. Which finding should the nurse report immediately to the healthcare provider? A. Anorexia and abdominal distention B. Abdominal pain and vomiting C. Confusion and tremors D. Yellowing and itching of skin

C. Confusion and tremors

The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? A. Prepare the client for spinal anesthesia B. Empty the client's bladder using a straight catheter C. Convey to the client that birth is imminent D. Prepare the coach to accompany the client to delivery

C. Convey to the client that birth is imminent

In caring for a client with Cushing's Syndrome, which serum laboratory value is most important for the nurse to monitor? A. Creatinine B. Lactate C. Glucose D. Hemoglobin

C. Glucose

While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? A. Do you often have feelings of sadness? B. Are you having problems concentrating? C. Have you thought about taking your life? D. What problems are you facing right now?

C. Have you thought about taking your life?

After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? A. Take prednisone doses before meals on an empty stomach B. Wear sunglasses when exposed to bring sunlight C. If sequential doses are missed, notify the healthcare provider D. Schedule a monthly laboratory visit for a complete blood count

C. If sequential doses are missed, notify the healthcare provider

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement? A. Tell the client to stop the inappropriate behavior B. Complete an unusual occurrence report C. Leave the room and close the door quietly D. Ignore the behavior and hang the IV antibiotic

C. Leave the room and close the door quietly

In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care? A. Assess skin elasticity of the stump B. Observe for swelling around the stump C. Note amount and color of wound drainage D. Evaluate closest proximal pulse

D. Evaluate closest proximal pulse

The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication? A. Difficulty locating the uterine fundus B. Excessive lochia C. Saturation of more than one pad per hour D. Hypertension

D. Hypertension

An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Explain the purpose of each medication the client is currently taking C. Ask the client to write feelings in a journal and then review it together D. Play a board game with the client and begin talking about stressors

D. Play a board game with the client and begin talking about stressors

To prevent medication errors by an older client who is sometimes confused, which intervention by the home health nurse is likely to be most effective? A. Have an alert family member administer medications B. Encourage taking medications at the same times daily C. Instruct the client to wear glasses when reading labels D. Provide education both verbally and in written format

D. Provide education both verbally and in written format

An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? A. History of smoking over the past 6 months B. Sleep patterns during the previous few weeks C. Activity level prior to onset of symptoms D. Recent compliance with prescribed medications

D. Recent compliance with prescribed medications

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled "750 mcg/2.4mL". How many mL should the nurse administer? Round to nearest tenth.

0.2 mL Review!

Well caring for a toddler receiving oxygen via facemask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? A. Use a topical lidocaine analgesic for cracked lips B. Use a water soluble lubricant on affected oral and nasal mucosa C. Ask the mother what she usually uses on the child's lips and nose D. Apply a petroleum jelly to the child's nose

B. Use a water soluble lubricant on affected oral and nasal mucosa

Following a house fire, an adult male is admitted to the emergency department with partial and full thickness burns. He used a blanket to cover his head and face, but his skin is burned on the dorsal surfaces of both arms and hands, and his anterior legs. Using the Rule of Nines to assess the extent of the client's burns, what percentage of burned body surface area should the nurse document? A. 50% B. 27% C. 9% D. 36%

B. 27%

The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic hepatitis B immunizations? A. A child daycare worker who has a history of type 2 diabetes mellitus B. An office worker who requires hemodialysis for chronic kidney disease (CKD) C. A restaurant chef who was diagnosed one year ago with hepatitis A D. A sales person who travels internationally and eats food in foreign countries.

B. An office worker who requires hemodialysis for chronic kidney disease (CKD)

A male client suffering from depression has been taking an antidepressant medication for two days. He tells the nurse that he is smiling more and feeling better. Which response is best for the nurse to provide? A. Feeling hopeful is a good sign that your depression is improving. B. Antidepressants usually begin to improve your mood after 2 to 4 weeks. C. Antidepressants can cause mild mood swings within several days D. Antidepressants can stabilize your mood within several days.

B. Antidepressants usually begin to improve your mood after 2 to 4 weeks.

The nurse is assessing a client's breath sounds. Which medication from the client's prescriptions will have the most positive effect on this respiratory finding?Sound: wheezing A. Chloroquine B. Enalapril C. Albuterol D. Losartan

C. Albuterol

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? A. Administer PRN oral analgesics to a client with a history of chronic pain B. Transport a client who is receiving IV fluids to the radiology department C. Supervise a newly hired graduate nurse during an admission assessment D. Complete ongoing focused assessments of a client with wrist restraint

C. Supervise a newly hired graduate nurse during an admission assessment

A male client on the psychiatric unit is making sexual advances towards a female nurse. Which action should this nurse implement first? A. Document as specifically as possible the client's behavior in the nurse's notes B. Discuss with the client why he is making sexual advances toward the nurse C. Tell the client in a matter-of-fact manner to stop the sexual advances D. Request an immediate team meeting to discuss the inappropriate behavior

C. Tell the client in a matter-of-fact manner to stop the sexual advances

During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? A. The census report has not been completed B. A client's wife has asked to speak with the charge nurse C. One staff member has not reported to work D. A bucket of water was spilled in the hallway

D. A bucket of water was spilled in the hallway

The nurse should be most concerned about risk for injury (falls) after administering which medication? A. Pantoprazole B. Famotidine C. Clarithromycin D. Promethazine

D. Promethazine

An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse? A. Gather information regarding how long it will take for the children to arrive B. Explain that the client will start to lose consciousness and the body systems will slow down C. Reassure the spouse that the healthcare provider will notify when to call the children D. Offer to discuss the client's health status with each of the adult children

Explain that the client will start to lose consciousness and his body system will slow down. Rationale: Expected signs of approaching death include noticeable changes in the client's level of consciousness and a slowing down of body systems. The nurse should answer the spouse's questions about the signs of imminent death rather than offering reassurance that may or may not be true. Other options listed may be implemented but the nurse should first answer the spouse's question directly.

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses

D) Pupil responses

A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg the nurse calculates infusion rate for the heparin solution at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to how many mL/hour?

Review*** 18