Medical-Surgical HESI Study Questions (Saunders HESI 7th Edition)

The nurse is performing hourly neurologic checks for a client with a head injury. Which new assessment finding warrants immediate action by the nurse? A unilateral pupil that is dilated and nonreactive to light.BClient cries out when awakened by a verbal stimulus.CClient demonstrates a loss of memory of the events leading up to the injury.DOnset of nausea, headache, and vertigo.

A unilateral pupil that is dilated and nonreactive to light. Rationale: Any change in pupil size and reactivity is an indication of increasing intracranial pressure and should be reported to the healthcare provider immediately. Option B is a normal response to being awakened. Options C and D are common manifestations of head injury and are of less immediacy than option A.

The nurse notes that a client who is scheduled for surgery the next morning has an elevated blood urea nitrogen (BUN) level. Which condition is most likely to have contributed to this finding? Myocardial infarction 2 months agoBAnorexia and vomiting for the past 2 daysCRecently diagnosed type 2 diabetes mellitusDSkeletal traction for a right hip fracture

Anorexia and vomiting for the past 2 days Rationale: The blood urea nitrogen (BUN) level indicates the effectiveness of the kidneys in filtering waste from the blood. Dehydration, which could be caused by vomiting, would cause an increased BUN level. Option A would affect serum enzyme levels, not the BUN level. Option C would primarily affect the blood glucose level; renal failure that could increase the BUN level would be unlikely in a client newly diagnosed with type 2 diabetes. Effects of option D might affect the complete blood count (CBC) but would not directly increase the BUN level.

The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally about self-care. Which teaching points will the nurse include in the client's plan of care? (Select all that apply.) Apply heat packs to your knees as needed for pain.BSupport your knees while you are in bed with a pillow or a rolled towel.CTake 1000 mg of acetaminophen every 4 hours, as needed for pain.DWalk no less than 3 miles every day.EGet 7-8 hours of sleep every night.FEat a balanced diet, including fish with omega-3 fatty acids.

Apply heat packs to your knees as needed for pain.BSupport your knees while you are in bed with a pillow or a rolled towel. Get 7-8 hours of sleep every night.FEat a balanced diet, including fish with omega-3 fatty acids. Rationale:The maximum daily dose of acetaminophen is 4 g, the instruction includes up to 6 g/per day. The best type of exercise does not place additional stress on the knee joints, such as biking or swimming. Apply heat to increase circulation and ice packs to decrease swelling. Support to the knees can take the strain off of the joint. Getting rest will help with coping with the pain of the disease. Eating a balanced diet may help with weight loss; additional weight places strain on the joint.

The client is return demonstrating wrapping of the left limb amputated above the knee. The nurse evaluates the client is starting the wrapping method correctly when the client places the end of the bandage at which point? AAround the waistBAt the inner aspect of the left stumpCAt the outer aspect of the left stumpDAt the left groin area

Around the waist Rationale:The waist is the anchor point for the bandage for an above the knee amputation.

The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? Document this expected decrease in drainage.BClamp the chest tube while assessing for air leaks.CMilk the tube to remove any excessive blood clot buildup.DAssess for kinks or dependent loops in the tubing.

Assess for kinks or dependent loops in the tubing. Rationale: The least invasive nursing action should be performed first to determine why the drainage has diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or dependent loops.

The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan? Your Answers: AReduce the daily intake of animal fat to 10% of the diet within 6 weeks.BExhibit regular, soft-formed stool within 1 month.CDemonstrate the irrigation procedure correctly within 1 week.DAttend an ostomy support group within 2 weeks.

Attend an ostomy support group within 2 weeks. Rationale: Attending a support group will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary.

A client with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1-10 scale, with a blood pressure of 124/78 mm Hg, pulse of 88 beats/min, and respirations of 20 breaths/min. The PACU recovery prescription is "Morphine, 2-4 mg IV push, while in recovery for pain level over 5." Which action should the nurse take first? Give the medication as prescribed to decrease the client's pain.BCall the anesthesia provider for a different medication for pain.CUse nonpharmacologic techniques before giving the medication.DReassess the pain level in 30 minutes and medicate if it remains elevated.

Call the anesthesia provider for a different medication for pain. Rationale:The nurse should call the provider for a different medication because morphine is a histamine-releasing opioid and should be avoided when the client has asthma. Option A is unsafe because it puts the client at risk for an asthma exacerbation. Even if the drug were safe for the client, options C and D both disregard the prescription and the client's need for pain relief in the immediate postoperative period.

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the healthcare provider after assessing the client? Leukocytosis and febrileBPolycythemia and cracklesCPharyngitis and sputum productionDConfusion and tachycardia

Confusion and tachycardia Rationale: The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia.

A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. Which action should the nurse take first? Advise the client to come to the clinic immediately for further assessment.BInstruct the client to discontinue use of the drug and to make an appointment at the clinic.CSuggest that the client learn to accept the cough as a side effect to a necessary prescription.DEncourage the client to keep taking the drug until seen by the healthcare provider.

Encourage the client to keep taking the drug until seen by the healthcare provider. Rationale:Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the medication. Immediate evaluation is not needed. Antihypertensive medications should not be stopped abruptly because rebound hypertension may occur. Option C is demeaning because the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect.

The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all that apply.) Facial muscle spasmsBSudden facial painCUnilateral facial weaknessDDifficulty in chewingETinnitusFHearing difficulties

Facial muscle spasmsBSudden facial pain Rationale:Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V). The remaining symptoms are not related to trigeminal neuralgia.

When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly? AlbuminBCalciumCGlucoseDAlkaline phosphatase

Glucose Rationale: TPN solutions contain high concentrations of glucose, so the blood glucose level is often monitored as often as q6h because of the risk for hyperglycemia. Option A is monitored periodically because an increase in the albumin level, a serum protein, is generally a desired effect of TPN. Option B may be added to TPN solutions, but calcium imbalances are not generally a risk during TPN administration. Option D may be decreased in the client with malnutrition who receives TPN, but abnormal values, reflecting liver or bone disorders, are not a common complication of TPN administration.

The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? PolyuriaBPolydipsiaCWeight lossDInfection

Infection Rationale: Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g. sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults.

A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of 102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment? (Select all that apply.) Nausea and vomitingBLoss of appetiteCAbdominal crampingDGuarding with abdominal palpationELow urine outputFCool, clammy skin

Nausea and vomitingBLoss of appetiteCAbdominal crampingDGuarding with abdominal palpation Rationale:The client is showing signs of peritonitis with the sudden spike in temperature. Low urine output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical emergency and the healthcare provider must be notified immediately.

The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first? Measure the urine specific gravity.BObtain IV fluids for infusion per protocol.CPrepare for insertion of a central venous catheter.DAuscultate the client's breath sounds.

Obtain IV fluids for infusion per protocol. Rationale: The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B.

The nurse assesses a client who has been prescribed furosemide for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic? Tall, spiked T wavesBA prolonged QT intervalCA widening QRS complexDPresence of a U wave

Presence of a U wave Rationale: A U wave is a positive deflection following the T wave and is often present with hypokalemia (low potassium level). Options A, B, and C are all signs of hyperkalemia.

The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which action should the nurse take first? Administer an antidysrhythmic medication.BStart cardiopulmonary resuscitation.CPrepare for mechanical ventilation.DAssess the client's pulse oximetry.

Start cardiopulmonary resuscitation.\ Rationale:Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately until the crash cart arrives. Options A and C are appropriate, but CPR is the priority action until a defibrillator is available, which is the most effective treatment for ventricular fibrillation. The client is dying, and option D does not address the seriousness of this situation.

A client diagnosed with angina pectoris complains of chest pain while ambulating in the hallway. Which action should the nurse take first? Support the client to a sitting position.BAsk the client to walk slowly back to the room.CAdminister a sublingual nitroglycerin tablet.DProvide oxygen via nasal cannula.

Support the client to a sitting position. Rationale: The nurse should safely assist the client to a resting position and then perform options C and D. The client must cease all activity immediately, which will decrease the oxygen requirement of the myocardial muscle. After these interventions are implemented, the client can be escorted back to the room via wheelchair or stretcher.

The clinic nurse is preparing to teach a client about having a cardiac catheterization. What assessment must the nurse include in the teaching plan? A"Do you have glaucoma?"B"Do you take any medication for Type II diabetes?"C"Is your advance directive in order?"D"Do any of your family members have heart disease?"

"Do you take any medication for Type II diabetes?" Rationale:The iodine dye from the catheterization and metformin can cause the client to develop lactic acidosis. Metformin is held 24 hours before the procedure and up to 48 hours after the procedure. There are no risks for those who have glaucoma. Having an advance directive in place is the standard of care. History of heart disease helps establish risk factors. Since the client is preparing for a heart catheterization, the client has the disease.

The clinic nurse is providing postoperative teaching for a client scheduled for a myringoplasty. Which client statements indicate to the nurse that the teaching has been effective? (Select all that apply.) "I can wash my hair in the shower when I get home."B"I will avoid forceful and deep coughing until my post-op checkup."C"I must lay flat on my non-operative side for the first 12 hours after surgery."D"My hearing may be less or muffled until the packing comes out."E"I need to only take the first two doses of antibiotics and save the rest for another time."

"I will avoid forceful and deep coughing until my post-op checkup."C"I must lay flat on my non-operative side for the first 12 hours after surgery."D"My hearing may be less or muffled until the packing comes out." Rationale:The client must keep the ear bandage clean and dry until the packing is removed. Showering and hair washing is discouraged. As with all prescriptions for antibiotics, the client must take the full course of treatment. The remaining client statements do indicate effective teaching.

The nurse in the emergency room assesses a client with a head trauma and notes a Glasgow Coma Scale (GCS) score of 5. What actions will the nurse take to ensure the client's safety? (Select all that apply.) Place the client in the supine position.BAssess airway and suction secretions as needed.CChange the client's position every 2 hours.DAvoid mouth care, to avoid stimulating a seizure.EMonitor for drainage from the ears.

Assess airway and suction secretions as needed.CChange the client's position every 2 hours. Monitor for drainage from the ears. Rationale:The client should be at least sitting at a 45 degree angle to avoid aspiration and increased intracranial pressure. Provide frequent mouth care as the client is unable to do so at this time. The remaining actions are appropriate for the client with a GCS score of 5.

A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the priority nursing actions for this client? (Select all that apply.) Assess lung sounds.BLook for equal and bilateral expansion of the chest.CMonitor skin color.DEvaluate the need for suctioning.ETell the family the client is expected to fully recover.FMake sure the ventilator alarms are set.

Assess lung sounds.BLook for equal and bilateral expansion of the chest.CMonitor skin color.DEvaluate the need for suctioning. Make sure the ventilator alarms are set. Rationale:The outcome of the client is too early to relay to the family. The nurse must not offer false reassurance. The remaining actions are correct for a client on a ventilator.

Which foods will the nurse recommend for the client with tuberculosis being discharged to home? (Select all that apply.) Bean soupBSpinachCApplesDBananasEDark chocolateFShellfish

Bean soupBSpinach Dark chocolateFShellfish Rationale:Apples and bananas are good sources of fiber but are low in protein and iron. The remaining foods are high in iron along with organ meats, all legumes, red meat, pumpkin seeds, quinoa, turkey, broccoli, and tofu.

The nurse is concerned about infection for a client after an esophagogastrostomy for esophageal cancer. Which actions should the nurse include in the client's plan of care? (Select all that apply.) Frequent oral care every 2 hours while awake.BUse incentive spirometer every 2 hours.CEmpty contents from NG tube every 8 hours.DAmbulate within 1 hour of return from the PACU.ELimit visitors until postoperative day 2.

Frequent oral care every 2 hours while awake.BUse incentive spirometer every 2 hours.CEmpty contents from NG tube every 8 hours. Rationale:One hour post-op is too soon to ambulate for this client. Visitors help support the patient and are encouraged to visit. Oral care is necessary as the client will be NPO. To decrease the risk of infection postoperatively, implement routine pulmonary exercises. The client will have an NG tube in place, likely to intermittent suction, to decompress the stomach post-surgery.

The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA). What actions will the nurse include in the client's plan of care? (Select all that apply.) AFrequent vital signs.BDetermine if the client is allergic to aspirin.CAssist out of bed 2 hours after return from the procedure.DOffer fluids of choice.EAssess distal pulses on the side of the procedure.FMonitor infusion of IV nitroglycerine.

Frequent vital signs.BDetermine if the client is allergic to aspirin. Offer fluids of choice. Monitor infusion of IV nitroglycerine. Rationale:The client's incisional leg needs to stay straight for 6-8 hours to decrease the risk of hemorrhage from the incision site. Pulses must be assessed bilaterally for a point of comparison. The remaining actions are included in the care plan for the client after a PTCA.

What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client? Just above the xiphoid process, on the upper third of the sternumBBelow the xiphoid process, midway between the sternum and the umbilicusCJust above the xiphoid process, on the lower third of the sternumDBelow the xiphoid process, midway between the sternum and the first rib

Just above the xiphoid process, on the lower third of the sternum Rationale: The correct placement of the hands for chest compressions in CPR is just above the notch where the ribs meet the sternum on the lower part of the sternum. Option A is too high. Option B would not compress the heart. Option D would likely cause damage to both structures, possibly causing a puncture of the heart, and would not render effective compressions.

A 43-year-old homeless, malnourished client with a history of alcoholism is transferred to the ICU. The nurse palpates a heart rate of 160 beats/min, and the client's blood pressure is 90/54 mm Hg. Based on these findings, which IV medication should the nurse administer? Amiodarone (Cordarone)BMagnesium sulfateCLidocaine (Xylocaine)DProcainamide (Pronestyl)

Magnesium sulfate Rationale:The client with chronic alcoholism is likely to have hypomagnesemia. Option B is the recommended drug for torsades de pointes, which is a form of polymorphic ventricular tachycardia (VT) usually associated with a prolonged QT interval that occurs with hypomagnesemia. Options A and D increase the QT interval, which can cause the torsades to worsen. Option C is the antiarrhythmic of choice in most cases of drug-induced monomorphic VT, not torsades.

A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. What action should the nurse immediately? Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow.BTurn the client prone to place pressure on the abdominal wound to help staunch the bleeding.CMaintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound.DPut the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging.

Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. Rationale:Placing the client in a supine position reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. Option A compromises diaphragmatic expansion and inhibits pressoreceptor activity. Option B places the client at risk of evisceration of the abdominal wound and increased bleeding. Option D will not stop internal bleeding in the liver and spleen caused by the gunshot wound.

A 58-year-old client who has no health problems asks the nurse about receiving the pneumococcal vaccine. Which statement given by the nurse would offer the client accurate information about this vaccine? The vaccine is given annually before the flu season to those older than 50 years.BThe immunization is administered once to older adults or those at risk for illness.CThe vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection.DThe vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.

The immunization is administered once to older adults or those at risk for illness. Rationale: It is usually recommended that persons older than 65 years and those with a history of chronic illness should receive the vaccine once in their lifetime. Some recommend receiving the vaccine at 50 years of age. The influenza vaccine is given once a year. Although the vaccine might be given to a person traveling overseas, that is not the main rationale for administering the vaccine. The vaccine is usually given once in a lifetime, but with immunosuppressed clients or clients with a history of pneumonia, revaccination is sometimes required.

While at a home game, the mother of a 6-year-old is heard screaming, "My child is having an asthma attack! Can anyone help?" The nurse arrives and finds the child gasping for breath with circumoral cyanosis. What are the nurse's next actions? (Select all that apply.) Yell, "Call 911."BAsk the mother if she has the child's bronchodilator.CStart cardiopulmonary respirations.DAsk the mother if the child is allergic to bee stings.EStay with the child and mother until the ambulance arrives.FSit the child straight up in Fowler's position.

Yell, "Call 911."BAsk the mother if she has the child's bronchodilator. Stay with the child and mother until the ambulance arrives.FSit the child straight up in Fowler's position. Rationale:CPR is not needed at this time as the child is still moving air. An allergy to bee stings is related to anaphylactic shock, which is not the situation here. The remaining actions are correct for asthma.

The client returns to the unit after abdominal surgery with a 5″ × 9″ absorbent dressing in place to the mid abdomen. The nurse notes a spot of red staining centrally on the dressing. What is the nurse's next action? Note the size of the stain in the chart.BCircle the stain with an ink pen.CRemove the dressing to assess the source of the bleeding.DPlace a pressure dressing on the existing dressing.

Circle the stain with an ink pen. Rationale:By circling the existing stain upon admission to the unit, the nurse can then assess any increase, though subtle, in the amount of drainage over time. The size of the stain will need to be noted in the chart, but it is not the first action. The nurse removes the dressing under the prescription of the healthcare provider or in an emergency. Neither of those conditions exist in the question. The dressing in place is an absorbent dressing. There is no need for a further dressing until the existing dressing becomes saturated.

The nurse is preparing a client for discharge after a right total knee replacement. Which client statements about use of a walker indicate to the nurse the teaching was effective? (Select all that apply.) "I will walk in the middle of the walker."B"I will make sure all four feet of the walker are on the floor before I use the hand pieces."C"I will move my right foot forward into the walker, and then my left foot."D"I will collapse the walker and put it in the chair opposite the bed at night."E"I will use a silicone-based cleaning product to clean the hand pieces and rubber tips."

"I will walk in the middle of the walker."B"I will make sure all four feet of the walker are on the floor before I use the hand pieces."C"I will move my right foot forward into the walker, and then my left foot." Rationale:The nurse is teaching about use of a walker. Having the walker collapsed at night does not help with nighttime ambulation to the restroom. The client is at risk for falling. Silicone is a slippery material and placing silicone on the rubber tips of the walker places the client at risk for falling. The remaining client statements about use of a walker are correct.

Which instruction is best for the nurse to provide to a client with emphysema and chronic fatigue? "Pace your activities and schedule rest periods."B"Increase the amount of oxygen you use at night."C"Obtain medical evaluation for antibiotic therapy."D"Reduce your intake of fluids containing caffeine."

"Pace your activities and schedule rest periods." Rationale: Manifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods. Option B may result in a decreased drive to breathe. The client is not exhibiting any symptoms of infection, so option C is not necessary. Option D is less beneficial than option A.

Zolpidem tartrate, 1.75 mg PRN at bedtime, is prescribed for rest. The scored tablets are labeled 3.5 mg per tablet. What dose should the nurse plan to administer? __________

0.5 Rationale:1.75 is ordered. 3.5 is available. 1.75/3.5 time one tab equals. 0.5 or one half tablet.

The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question? Antianginal with a therapeutic effect of vasodilationBAnticholinergic with a side effect of pupillary dilationCAntihistamine with a side effect of sedationDCorticosteroid with a side effect of hyperglycemia

Anticholinergic with a side effect of pupillary dilation Rationale: Clients with angle-closure glaucoma should not take medications that dilate the pupil because this can precipitate acute and severely increased intraocular pressure. Options A, C, and D do not cause increased intracranial pressure, which is the primary concern with angle-closure glaucoma.

One day after a Billroth II surgery, the client suddenly grabs his right chest and becomes pale and diaphoretic. Vital signs are assessed as blood pressure 100/80 mm Hg, pulse 110 beats/min, and respirations 36 breaths/min. Which action is most important for the nurse to take? Provide a paper bag for his hyperventilation.BAdminister a prescribed PRN analgesic.CHave the client drink a glass of sweetened fruit juice.DApply oxygen at 2 L via nasal cannula.

Apply oxygen at 2 L via nasal cannula. Rationale:Pulmonary embolism and pneumothorax are risks associated with major abdominal surgery. The nurse should immediately provide oxygen while performing further assessment. A rapid respiratory rate should not be treated as hyperventilation. Option B should not be administered until more ominous causes are ruled out or treated. There is no evidence that the client is hypoglycemic.

The nurse is providing care to a client with a central venous catheter. The healthcare provider orders multiple labs. Using the discard method, what steps will the nurse use to draw the blood samples? (Select all that apply.) APrepare the catheter hub with an antiseptic solution according to facility protocol.BAttach a syringe to the hub containing 2 mL of normal saline and flush the line.CAttach the vacutainer sleeve or 20 mL syringe to the catheter hub.DWithdraw waste blood and discard it in an appropriate container.EDraw the amount of blood needed for the laboratory samples.FFlush the line with no more than 2 mL of normal saline to flush the line.

Attach a syringe to the hub containing 2 mL of normal saline and flush the line. Flush the line with no more than 2 mL of normal saline to flush the line. Rationale:The amount of normal saline flush solution is incorrect. Two milliliters is too small an amount. The minimum amount is 5 mL, or according to the policies of the institution. The remaining steps are correct.

An older client comes to the outpatient clinic complaining of left calf pain. The nurse notices a reddened area on the calf of the right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? AMeasure the client's calf circumference.BAuscultate the client's breath sounds.CObserve for ecchymosis and petechiae.DObtain the client's blood pressure.

Auscultate the client's breath sounds. Rationale: All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds because the client may have a pulmonary embolus secondary to the thrombophlebitis. Option A may provide data that support the nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. Option D is always useful in evaluating the client's response to a problem but is of less immediate priority than breath sound auscultation.

Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns? Midnight censusBOncoming shift censusCAverage daily censusDHourly census

Average daily census Rationale: An average daily census is determined by trend data and takes into account seasonal and daily fluctuations, so it is the best method for determining staffing needs. Options A and B provide data at a certain point in time, and that data could change quickly. It is unrealistic to expect to obtain an hourly census, and such data would only provide information about a certain point in time.

The client is admitted to an inpatient unit from the Emergency Department with a swollen, reddened area to the left calf which is warm and painful to the touch. The results of the remaining tests are pending. What admission prescriptions does the nurse anticipate from the healthcare provider? (Select all that apply.)

Bed rest Anticoagulant therapy. Warm moist compress to the area of calf tenderness tid. Rationale:The left leg needs to be elevated above the level of the heart, not the right leg. Massaging the area of tenderness could dislodge the clot and cause a pulmonary embolism. Avoid the use of the knee gatch or a pillow under the knee as that could cause stasis in the lower leg. The remaining are recommendations for the client with a deep vein thrombosis.

The nurse initiates neurologic checks for a client who is at risk for neurologic compromise. Which manifestation typically provides the first indication of altered neurologic function? Change in level of consciousnessBIncreasing muscular weaknessCChanges in pupil size bilaterallyDProgressive nuchal rigidity

Change in level of consciousness Rationale: A decrease or change in the level of consciousness is usually the first indication of neurologic deterioration. Options B and C may also occur but are much less likely to be the first sign of neurologic compromise. Option D is often a sign of meningitis.

A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? Replace the stoma appliance every day.BUse warm tap water to irrigate the ileostomy.CChange the bag when the seal is broken.DMeasure and record the ileostomy output.

Change the bag when the seal is broken. Rationale:A seal must be maintained to prevent leakage of irritating liquid stool onto the skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is not needed.

During the shift report, the charge nurse informs a nurse of a reassignment to another unit for the day. The nurse begins to sigh deeply and tosses about her belongings when preparing to leave. What is the best immediate action for the charge nurse to take? Continue with the shift report and talk to the nurse about the incident at a later time.BAsk the nurse to call the house supervisor to see if she must be reassigned.CStop the shift report and remind the nurse that all staff are floated equally.DInform the nurse that her behavior is disruptive to the rest of the staff.

Continue with the shift report and talk to the nurse about the incident at a later time. Rationale: Continuing with the shift report is the best immediate action because it allows the nurse who was floated some cooling off time. Later (after the nurse has cooled off) the charge nurse should discuss the conduct of the nurse in private. Option B encourages the nurse to shirk the float assignment. Option C is disruptive. Reprimanding the nurse in front of the staff would increase the nurse's hostility, so the nurse should be counseled in private.

During the change of shift report, the charge nurse reviews the infusions being received by clients on the oncology unit. The client receiving which infusion should be assessed first? Continuous IV infusion of magnesiumBOne-time infusion of albuminCContinuous epidural infusion of morphineDIntermittent infusion of IV vancomycin

Continuous epidural infusion of morphine Rationale: All four of these clients have the potential to have significant complications. The client with the morphine epidural infusion is at highest risk for respiratory depression and should be assessed first. Option A can cause hypotension. The client receiving option B is at lowest risk for serious complications. Although option D can cause nephrotoxicity and phlebitis, these problems are not as immediately life threatening as option C.

Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate therapy? Increase in rheumatoid factorBDecrease in hemoglobin levelCIncrease in blood glucose levelDDecrease in erythrocyte sedimentation rate (ESR; sed rate)

Decrease in hemoglobin level Rationale: Methotrexate is an immunosuppressant. A common side effect is bone marrow depression, which would be reflected by a decrease in the hemoglobin level. Option A indicates disease progression but is not a side effect of the medication. Option C is not related to methotrexate. Option D indicates that inflammation associated with the disease has diminished.

The home health nurse is assessing a male client being treated for Parkinson disease with carbidopa-levodopa. The nurse observes that he does not demonstrate any apparent emotion when speaking and rarely blinks. Which action should the nurse take first? Perform a complete cranial nerve assessment.BInstruct the client that he may be experiencing medication toxicity.CDocument the presence of these assessment findings.DAdvise the client to seek immediate medical evaluation.

Document the presence of these assessment findings. Rationale: A mask-like expression and infrequent blinking are common clinical features of parkinsonism. The nurse should document these expected findings. Options A and D are not necessary. Signs of toxicity of levodopa-carbidopa include dyskinesia, hallucinations, and psychosis.

For the client undergoing hemodialysis, the nurse suspects the client has an air embolism. What symptoms lead the nurse to this conclusion? (Select all that apply.) ADyspneaBB/P 168/92 mm HgCChest painDAnxietyEO2 saturation of 98%FBlue nail beds

Dyspnea Chest painDAnxiety Blue nail beds Rationale:For the client experiencing an air embolism, the nurse will see hypotension and not hypertension. The O2 saturation will also fall with an air embolism. The remaining are signs of an air embolism

The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? AUrine specific gravity of 1.03BFrothy, tea-colored urineCClay-colored stoolsDElevated serum amylase and lipase levels

Elevated serum amylase and lipase levels Rationale: Obstructive cholelithiasis and alcoholism are the two major causes of pancreatitis, and elevated serum amylase and lipase levels indicate pancreatic injury. Option A is a normal finding. Options B and C are expected findings related to jaundice.

The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.) Encourage alcohol and smoking cessation.BSuggest supplementing diet with vitamin E.CPromote regular weight-bearing exercises.DImplement a home safety plan to prevent falls.EPropose a regular sleep pattern of 8 hours nightly.

Encourage alcohol and smoking cessation. Promote regular weight-bearing exercises.DImplement a home safety plan to prevent falls. Rationale:Options A, C, and D are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss. Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis.

Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.) Encourage annual physical and Pap smear.BTake antiviral medication as prescribed.CUse condoms to avoid transmission to others.DWarm sitz baths may relieve itching.EUse Nystatin suppositories to control itching.FUse a douche with weak vinegar solution to decrease itching.

Encourage annual physical and Pap smear.BTake antiviral medication as prescribed.CUse condoms to avoid transmission to others.DWarm sitz baths may relieve itching. Rationale:The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and option (F) is used to treat Trichomonas.

Which nursing action is necessary for the client with a flail chest? Withhold prescribed analgesic medications.BPercuss the fractured rib area with light taps.CAvoid implementing pulmonary suctioning.DEncourage coughing and deep breathing.

Encourage coughing and deep breathing. Rationale:Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing. This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. Option C should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. Option A should not be withheld. Option B should not be applied because the fractures are clearly visible on the chest radiograph.

A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? Follow exposure precautions.BEncourage regular meals.CCollect all urine.DAvoid touching the client.

Follow exposure precautions Rationale: Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others. Option B is a good suggestion to promote adequate nutrition but is not as important as option A. Option C is unnecessary. Contact with the client is permitted but should be brief to limit radiation exposure.

The nurse is preparing teaching for nursing students who are participating in a flu vaccine clinic at a local school. Who should receive the vaccine? (Select all that apply.) AHealthcare personnelBThose who are allergic to eggsCIndividuals who are over 50 years oldDIndividuals with chronic health conditionsEThose who live in nursing homesFInfants under 6 months of age

Healthcare personnel Individuals who are over 50 years oldDIndividuals with chronic health conditionsEThose who live in nursing homes Rationale:The current recommendation is those who are allergic to eggs can receive the flu vaccine if it is administered in a healthcare environment that can quickly deliver treatment for anaphylaxis. Infants over 6 months van receive the flu shot, but not under 6 months. The remaining options are recommended to receive the flu vaccine.

The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately? (Select all that apply.) Reactivity of deep tendon reflexesBHeart rate and respiratory rateCMemory of recent eventsDAbility to open the eyes spontaneouslyEDizzinessFRinging in the ears

Heart rate and respiratory rateCMemory of recent eventsDAbility to open the eyes spontaneouslyEDizzinessFRinging in the ears Rationale:The level of consciousness (LOC) should be established immediately when a head injury has occurred. Deep tendon reflexes are not an indicator of LOC or concussion. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms are intact. The remaining assessments are included in the concussion protocol.

An 81-year-old client has emphysema. The client lives at home with a cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client's tongue is somewhat cracked and his eyeballs appear sunken. Which nursing action is indicated? Help the client determine ways to increase fluid intake.BObtain an appointment for the client to have an eye examination.CInstruct the client to use oxygen at night and increase the humidification.DSchedule the client for tests to determine his sensitivity to cat hair.

Help the client determine ways to increase fluid intake. Rationale: Clients with COPD should ingest 3 L of fluids daily but may experience a fluid deficit because of shortness of breath. The nurse should suggest creative methods to increase the intake of fluids, such as having fruit juices in disposable containers readily available. Option B is not indicated. Humidified oxygen will not effectively treat the client's fluid deficit, and there is no indication that the client needs supplemental oxygen at night. These symptoms are not indicative of option D and may unnecessarily upset the client, who depends on his pet for socialization.

Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? Stress incontinenceBInfectionCPainless gross hematuriaDPeritonitis

INfection Rationale: Infection is the major complication resulting from stasis of urine and subsequent catheterization. Option A is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure. Option C is the most common symptom of bladder cancer. Option D is the most common and serious complication of peritoneal dialysis.

The nurse on a medical-surgical unit is receiving a client from the post-anesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? If suctioning will be needed for drainage of the woundBIf the family would prefer a private or semiprivate roomCIf the client also has a Hemovac in placeDIf the client's wound is infected

If the client's wound is infected Rationale: The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected. Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room. A Penrose drain does not require option A. Although option B is helpful information, it does not have the priority of option D. A Hemovac is used to drain fluid from a dead space and is not a determinant for the room assignment.

A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. Which action should the nurse take based on this observation? Assess for bilateral jugular vein distention.BIncrease oxygen flow via nasal cannula.CAdminister PRN furosemide.DAuscultate for a pleural friction rub.

Increase oxygen flow via nasal cannula. Rationale:This client should have the oxygen flow immediately increased to promote oxygenation of the myocardium. Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia exacerbated by hypokalemia. The nurse would expect the client in congestive heart failure to have some degree of option A, which does not exacerbate the ectopy. Option C could create a more severe hypokalemia, which could increase the ectopy. The client is not exhibiting signs of option D.

An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to take for this client? Initiate airborne infection precautions.BPlace a surgical mask on the client.CDon an isolation gown and latex gloves.DStart protective (reverse) isolation precautions.

Initiate airborne infection precautions. Rationale:This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions, which are indicated for TB, should be used with this client. Option B is used with droplet precautions. There is no evidence that option C or D would be warranted at this time.

For the client with a prescription for enteral feeding after surgery, the nurse checks the gastric aspirate and notes the pH is 5.2. What is the next nurse's action? Call for a chest X-ray.BInitiate the procedures for the feeding.CTell the client the feeding will be delayed.DInject 10 mL of air down the NG tube.

Initiate the procedures for the feeding. Rationale:Other than taking a chest X-ray before initiating every enteral feeding, checking the pH of the stomach contents is another way of determining if the NG tube is still in the stomach. As long as the aspirate is less than 5.5 and the tube has remained secure, the reasonable assumption is the tube is in the stomach. Procedures to start the feeding can begin. Calling for a chest X-ray is appropriate if the nurse suspects the NG tube has been dislodged. There is no need to delay the feeding. Injecting air into a NG tube only determines patency, not placement.

Which abnormal laboratory finding indicates that a client with diabetes needs further evaluation for diabetic nephropathy? HypokalemiaBMicroalbuminuriaCElevated serum lipid levelsDKetonuria

Microalbuminuria Rationale: Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation. Hyperkalemia, not option A, is associated with end-stage renal disease caused by diabetic nephropathy. Option C may be elevated in end-stage renal disease. Option D may signal the onset of diabetic ketoacidosis (DKA).

Which nursing action would be appropriate for a client who is newly diagnosed with Cushing syndrome? Monitor blood glucose levels daily.BIncrease intake of fluids high in potassium.CEncourage adequate rest between activities.DOffer the client a sodium-enriched menu.

Monitor blood glucose levels daily. Rationale: Cushing syndrome results from a hypersecretion of glucocorticoids in the adrenal cortex. Clients with Cushing syndrome often develop diabetes mellitus. Monitoring of serum glucose levels assesses for increased blood glucose levels so that treatment can begin early. A common finding in Cushing syndrome is generalized edema. Although potassium is needed, it is generally obtained from food intake, not by offering potassium-enhanced fluids. Fatigue is usually not an overwhelming factor in Cushing syndrome, so an emphasis on the need for rest is not indicated. A low-calorie, low-carbohydrate, low-sodium diet is not recommended.

A client who received a nephrotoxic drug is admitted with acute renal failure and asks the nurse if dialysis will always be needed. Which pathophysiologic consequence should the nurse explain that supports the need for temporary dialysis until acute tubular necrosis subsides? AzotemiaBOliguriaCHyperkalemiaDNephron obstruction

Nephron obstruction Rationale:CKD is characterized by progressive and irreversible destruction of nephrons, frequently caused by hypertension and diabetes mellitus. Nephrotoxins cause acute tubular necrosis, a reversible acute renal failure, which creates renal tubular obstruction from endothelial cells that are sloughed or become edematous. The obstruction of urine flow will resolve with the return of an adequate glomerular filtration rate, and when it does, dialysis will no longer be needed. Options A, B, and C are manifestations seen in the acute and chronic forms of kidney disease.

In assessing a client with an arteriovenous (AV) shunt who is scheduled for dialysis today, the nurse notes the absence of a thrill or bruit at the shunt site. What action should the nurse take? Advise the client that the shunt is intact and ready for dialysis as scheduled.BEncourage the client to keep the shunt site elevated above the level of the heart.CNotify the healthcare provider of the findings immediately.DFlush the site at least once with a heparinized saline solution.

Notify the healthcare provider of the findings immediately. Rationale: Absence of a thrill or bruit indicates that the shunt may be obstructed. The nurse should notify the healthcare provider so that intervention can be initiated to restore function of the shunt. Option A is incorrect. Option B will not resolve the obstruction. An AV shunt is internal and cannot be flushed without access using special needles.

The nurse is observing an unlicensed assistive personnel (UAP) performing care for a bedridden client with advanced Huntington disease. Which care measures are most important for the nurse to supervise? (Select all that apply.) Oral careBBathingCFoot careDCatheter careEEnteral feeding

Oral care Enteral feeding Rationale:The client with Huntington disease experiences problems with motor skills such as swallowing and is at high risk for aspiration, so the highest priority for the nurse to observe is the UAP's ability to perform oral care and feeding safely. Options B, C, and D do not necessarily require registered nurse (RN) supervision because they do not ordinarily pose life-threatening consequences.

A 25-year-old client was admitted yesterday after a motor vehicle collision. Neurodiagnostic studies have shown a basal skull fracture in the middle fossa. Assessment on admission revealed both halo and Battle signs. Which new symptom indicates that the client is likely to be experiencing a common life-threatening complication associated with a basal skull fracture? Bilateral jugular venous distentionBOral temperature of 102°FCIntermittent focal motor seizuresDIntractable pain in the cervical region

Oral temperature of 102°F Rationale:Clients with basilar skull fractures are at high risk for infection of the brain, as indicated by an increased oral temperature, because the fracture leaves the meninges open to bacterial invasion. Clients may experience options C and D, but these findings do not pose as great a life-threatening risk as infection. Jugular distention is not a typical complication of basal skull fractures.

A 62-year-old client who lives alone tripped on a scatter rug resulting in a fractured hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur? Failing eyesight resulting in an unsafe environmentBRenal osteodystrophy resulting from chronic kidney disease (CKD)COsteoporosis resulting from declining hormone levelsDCerebral vessel changes causing transient ischemic attacks

Osteoporosis resulting from declining hormone levels Rationale: The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years. Option A may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. Option B is not a common condition of older people but is associated with CKD. Although option D may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis.

The nurse hears the presence of secretions in the lungs and determines the client, post thoracotomy, needs to be suctioned. What steps will the nurse include in the suctioning procedure? (Select all that apply.) Perform hand hygiene.BPosition in no less than a semi-Fowler's position.CLubricate the suction catheter with a petroleum-based product.DInsert the catheter with the suction on.EListen for breath sounds.FHyperoxygenate the client.

Perform hand hygiene.BPosition in no less than a semi-Fowler's position. Listen for breath sounds.FHyperoxygenate the client. Rationale:The suction catheter does need to be lubricated, but with a water-based product, not a petroleum-based product. The suction catheter needs to be inserted with the suction off, not on. Suction should be applied intermittently while withdrawing the catheter. The remainder are steps in the suction process.

A client is admitted to the hospital with severe lower left abdominal pain, nausea, vomiting, fever, and chills. Which nursing action has the highest priority? Place the client on NPO status.BAssess the client's temperature.CObtain a stool specimen.DAdminister IV fluids.

Place the client on NPO status. Rationale: A client is showing signs of acute severe diverticulitis and is at risk for peritonitis and intestinal obstruction. The nurse should make the client NPO to reduce risk of intestinal rupture. Options B, C, and D are important but are less of a priority than option A, which is implemented to prevent a severe complication.

During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which action should the nurse take first? Prepare the client for a pericardial tap.BAdminister intravenous furosemide.CAssist the client to cough and breathe deeply.DInstruct the client to restrict oral fluid intake.

Prepare the client for a pericardial tap. Rationale:The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap. Lasix IV is not indicated for treatment of pericarditis. Because the client's breath sounds are clear, option C is not a priority. Fluids are frequently increased in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as option A.

The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? Restore skin integrity.BPrevent infection.CPromote healing.DImprove nutrition.

Prevent infection. Rationale:The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, options A and C are unattainable goals. Option D is important but of less priority than option B.

Which consideration is most important when the nurse is assigning a room for a client being admitted with progressive systemic sclerosis (scleroderma)? Provide a room that can be kept warm.BMake sure that the room can be kept dark.CKeep the client close to the nursing unit.DSelect a room that is visible from the nurses' desk.

Provide a room that can be kept warm. Rationale: Abnormal blood flow in response to cold (Raynaud phenomenon) is precipitated in clients with scleroderma. Option B is not a significant factor. Stress can also precipitate the severe pain of Raynaud phenomenon, so a quiet environment is preferred to option C, which is often very noisy. Option D is not necessary.

A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision? a. Notify the family that the resident will have to be discharged if his behavior does not improve. b. Notify administration of the PN's insubordination and need for counseling about her statements. c. Ask the PN what she has done to encourage the resident to believe that she is his daughter. d. Reassign the PN until the resident can be assessed more completely for reality orientation.

Reassign the PN until the resident can be assessed more completely for reality orientation. Rationale: Temporary reassignment is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. Option A is not the best option because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination. Implying that the PN is somehow creating the situation is inappropriate until a further evaluation has been conducted.

A client with type 2 diabetes takes metformin daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? NPO except for metformin and regular snacksBNPO except for oral antidiabetic agentCNovolin N insulin subcutaneously twice dailyDRegular insulin subcutaneously per sliding scale

Regular insulin subcutaneously per sliding scale Rationale: Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery. Option A increases the risk of vomiting and aspiration. Options B and C provide less precise control of the blood glucose level

A client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? Irrigate the nasogastric tube with sterile normal saline.BReposition the client on her side.CAdvance the nasogastric tube 5 cm.DAdminister an intravenous antiemetic as prescribed.

Reposition the client on her side. Rationale: The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client, should be attempted first, followed by options A and C, unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require option D.

A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? Hypoactive bowel sounds with abdominal distention.BClient reports continued pain of 8 on a 10-point scale.CRespiratory rate of 12 breaths/min, with O2 saturation of 85%.DClient reports nausea after receiving the medication.

Respiratory rate of 12 breaths/min, with O2 saturation of 85%. Rationale:Administration of a Schedule II opioid analgesic can result in respiratory depression, which requires immediate intervention by the nurse to prevent respiratory arrest. Options A, B, and D require action by the nurse but are of less priority than option C.

The nurse is providing care to a client admitted with asthma whose theophylline level is 25 mcg/mL. What findings will the nurse be looking for in the client's assessment? (Select all that apply.) Pulse of 54 bpmBRestlessnessCTremorsDBlue nail bedsEPalpitations

RestlessnessCTremors Palpitations Rationale:Theophylline toxicity occurs when the blood level exceeds 20 mcg/mL. Signs of toxicity include restlessness, nervousness, tremors, palpitations, and tachycardia. A low pulse rate and blue nail beds are not associated with theophylline toxicity.

A client with cirrhosis develops increasing pedal edema and ascites. Which dietary modification is most important for the nurse to teach this client? Avoid high-carbohydrate foods.BDecrease intake of fat-soluble vitamins.CDecrease caloric intake.DRestrict salt and fluid intake.

Restrict salt and fluid intake. Rationale: Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and ascites. Options A, B, and C will not affect fluid retention.

The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? Hang the solution at the current rate.BRefrigerate the solution until needed.CPrepare the solution with new tubing.DReturn the solution to the pharmacy.

Return the solution to the pharmacy. Rationale:Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not indicated because the solution should not be administered.

Which statement reflects the highest priority nursing diagnosis for an older client recently admitted to the hospital for a new-onset cardiac dysrhythmia? Diarrhea related to medication side effectsBAnxiety related to fear of recurrent anginal episodesCAltered nutrition related to high serum lipid levelsDRisk for injury related to syncope and confusion

Risk for injury related to syncope and confusion Rationale: The loss of cardiac function in aging decreases cardiac output, so dysrhythmias, particularly tachycardias, are poorly tolerated. With onset of a tachycardic or bradycardic dysrhythmia, cardiac output is compromised further, placing the client at risk of syncope and falling, as well as confusion. Option A is of high priority but less so than maintaining client safety. Clients may experience option B as a result of a newly diagnosed cardiac condition, but this nursing diagnosis does not have the priority of option D. Option C also does not have the priority of option D.

The nurse teaches a client with type 2 diabetes nutritional strategies to decrease obesity. Which food items chosen by the client indicate understanding of the teaching? (Select all that apply.) White breadBSalmonCBroccoliDWhole milkEBanana

SalmonCBroccoli Banana Rationale:Options B, C, and E provide fresh fruits, lean meats and fish, vegetables, whole grains, and low-fat dairy products. All are recommended by the American Diabetes Association (ADA) and are a part of the My Plate guidelines recommended by the U.S. Department of Agriculture (USDA). Whole milk is high in fat and is not recommended by the ADA. White bread is milled, a process that removes the essential nutrients. It should be avoided for weight loss and is a poor choice for the client with diabetes.

The X-ray for the client in the emergency department (ED) reveals a right-sided rib fracture. What information will the nurse include in the client's discharge instructions? (Select all that apply.) Splint your right side with your right arm.BYou may have to sleep sitting up for a while.CReturn to the ED if you develop difficulty in breathing.DUse shallow breaths until the pain subsides.EUse 2 L of oxygen by nasal cannula when you have shortness of breath.

Splint your right side with your right arm.BYou may have to sleep sitting up for a while.CReturn to the ED if you develop difficulty in breathing Rationale:Shallow breaths do not promote adequate oxygenation. The client should splint the area and breathe as normally as possible to maintain adequate oxygenation. Shortness of breath should not occur with a rib fracture and is a sign of a pneumothorax. The client will not be sent home with O2 by nasal cannula if the only health issue is a fractured rib.

The nurse is providing care to a client admitted to the emergency room with a blood glucose level of 40 mg/dL and is semiconscious. What are the nurse's next actions? (Select all that apply.) Place 4 sugar cubes under the tongue.BPlace 1 tablespoon of honey in the client's cheek.CStart an IV of Normal Saline.DObtain a 50% dextrose solution.EAdminister glucagon as per the standing order.FTurn the client to the side.

Start an IV of Normal Saline.DObtain a 50% dextrose solution.EAdminister glucagon as per the standing order.FTurn the client to the side. Rationale:Oral carbohydrates, such as sugar and honey, should never be given to the semiconscious or unconscious clients with low blood sugar levels, for concern for aspiration. Glucagon can be administered immediately, followed by starting an IV. Await the orders for the 50% dextrose solution. Place the client in a side lying position as there is a risk for vomiting and aspiration with these clients.

The nurse is teaching a group of elders at a senior center. Which is the most significant safety implication for this group that the nurse will include in the teaching plan? Change in heightBHair lossCStooped postureDAge spots

Stooped posture Rationale: Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. This age-related change can put the older adult at risk for falls. Options A, B, and D are age-related changes but are not high safety concerns.

What is the most important nursing priority for a client who has been admitted for a possible kidney stone? Reducing dairy products in the dietBStraining all urineCMeasuring intake and outputDIncreasing fluid intake

Straining all urine Rationale: Straining all urine is the most important nursing action to take in this case. Encouraging fluid intake is important for any client who may have a kidney stone, but it is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. Option C is not the highest priority action. Option A is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial.

The nurse is assessing a client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? The client's amylase level is three times higher than the normal level.BThe client has a carpal spasm when taking a blood pressure.COn a 1-10 scale, the client tells the nurse that her epigastric pain is at 7.DThe client states that she will continue to drink alcohol after going home.The client has a carpal spasm when taking a blood pressure.

The client has a carpal spasm when taking a blood pressure. Rationale: A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40-75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign.

A home health nurse is assessing a 70-year-old male client who is convalescing at home following a hip replacement. The nurse is concerned that the client may develop pressure ulcers. Which physical characteristic of aging puts the client at risk? 16% increase in overall body fatBReduced melanin productionCThinning of the skin, with loss of elasticityDCalcium loss in the bones

Thinning of the skin, with loss of elasticity Rationale: Thin nonelastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. Option B causes gray hair. Option D can contribute to broken bones, but it is probably not a factor in pressure ulcer formation.

The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the healthcare provider before the chest tube is removed? Tidaling of water in water seal chamberBBilateral muffled breath sounds at basesCTemperature of 101°FDAbsence of chest tube drainage for 2 days

Tidaling of water in water seal chamber Rationale:Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the healthcare provider before the chest tube is removed to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. Option B may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. Option C usually indicates an infection, which may not be related to the chest tube. Option D is an expected finding.

A hospitalized client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. The client begins to cough and produces a moderate amount of white sputum. Which action should the nurse take first? Auscultate the client's breath sounds.BTurn off the continuous feeding pump.CCheck placement of the nasogastric tube.DMeasure the amount of residual feeding.

Turn off the continuous feeding pump. Rationale: A productive cough may indicate that the feeding has been aspirated. The nurse should first stop the feeding to prevent further aspiration. Options A, C, and D should all be performed before restarting the tube feeding if no evidence of aspiration is present and the tube is in place.

A nurse is assisting an 82-year-old client with ambulation and is concerned that the client may fall. Which area contains the older person's center of gravity? Head and neckBUpper torsoCBilateral armsDFeet and legs

Upper torso Rationale: Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. The head and neck and feet and legs are not the center of gravity in the older adult. Although the arms comprise a part of the upper torso, they do not reflect the best and most complete answer.

Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old who is in good health overall? Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts.BChemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels.CUrinalysis reveals slight protein in the urine and bacteriuria, with pyuria.DSerum electrolytes reveal a decreased sodium level and increased potassium level.

Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. Rationale: In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be normal findings in an older adult.

The clinic nurse is teaching a client newly diagnosed with Raynaud's Syndrome. What instructions will the nurse include in the client's teaching plan? (Select all that apply.) Place your hands in 130°F/54.4°C water until warmed through.BWear warm clothing and socks when you are cold.CUse finger guards when using a knife to avoid cutting your hands.DTake your medication only when you feel the tingling in your fingers.EAvoid stressful situations at work and in your home life.

Wear warm clothing and socks when you are cold.CUse finger guards when using a knife to avoid cutting your hands. Avoid stressful situations at work and in your home life. Rationale:Water at 130°F/54.4°C can cause burns at 30 second exposure. Because of the numbness and tingling the client may not be able to sense burning. Vasodilators are often prescribed for these clients, especially during the cold months. The therapy needs to be continuous for the maximum effect. The remaining instructions will benefit the client with Raynaud's.

Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A"Get immunization against human papillomavirus (HPV)."B"Change your tampon frequently."C"Empty your bladder after intercourse."D"Obtain a yearly flu vaccination."

"Change your tampon frequently." Rationale:Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. Option A helps prevent cervical cancer, not toxic shock syndrome. Option C can lessen the incidence of urinary tract infection. Option D can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven.

The nurse is completing an admission interview for a client with Parkinson disease. Which question will provide additional information about manifestations that the client is likely to experience? "Have you ever experienced any paralysis of your arms or legs?"B"Do you have frequent blackout spells?"C"Have you ever been frozen in one spot, unable to move?"D"Do you have headaches, especially ones with throbbing pain?"

"Have you ever been frozen in one spot, unable to move?" Rationale: Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move. Parkinson disease does not typically cause option A, B, or D.

The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A"Hold the medication in your mouth for a few minutes before swallowing it."B"Do not drink or eat milk products for 1 hour prior to taking this medication."C"Dilute the medication with juice to reduce the unpleasant taste and odor."D"Take the medication before meals to promote increased absorption."

"Hold the medication in your mouth for a few minutes before swallowing it." Rationale:Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary.

The nurse is giving preoperative instructions to a 14-year-old client scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place? "I will read all the teaching booklets you gave me before surgery."B"I have had surgery before, so I know what to expect afterward."C"All the things people have told me will help me take care of my back."D"Let me show you the method of turning I will use after surgery."

"Let me show you the method of turning I will use after surgery." Rationale: The outcome of learning is best demonstrated when the client not only verbalizes an understanding but also provides a return demonstration. A 14-year-old client may or may not follow through with option A, and there is no measurement of learning. Option B may help the client understand the surgical process, but the type of surgery may have been very different, with differing postoperative care. In option C, the client may be saying what the nurse wants to hear without expressing any real understanding of what to do after surgery.

The postoperative client states to the nurse, "I hate the feeling of those compression stockings as they inflate and deflate all the time. It keeps me awake." What is the nurse's best response? "They are for your own good."B"Your health care provider ordered them. You have no choice but to wear them."C"They are to help prevent blood clots. Do don't want that to happen, do you?"D"Tell me what you know about the intermittent compression stockings."

"Tell me what you know about the intermittent compression stockings." Rationale:The purpose of the intermittent compression stockings is to decrease the risk of blood clots forming in the legs. By assessing the client's knowledge about the devise, the nurse can determine if the client is aware of the potential for blood clots and the sequela that clots have. By answering "They are for your own good," the nurse dismisses the client's concerns. Having no choice about treatment does not acknowledge client autonomy. The "Do you want that to happen to you" is a statement using coercion by fear.

The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugsBAn accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exerciseCA stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modificationsDA recovering IV heroin user who contracted hepatitis more than 10 years ago

A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs Rationale: The diabetic teacher has assumed responsibility for self-care, so among those listed, he or she is the most likely to maintain optimum health. Option B has expressed a lack of interest in health promotion. Option C continues to demonstrate a high-risk cholesterol level despite a reported attempt at dietary modifications. Previous IV drug use and a history of hepatitis make this individual a health risk despite the fact that the individual is in recovery.

The nurse observes the chest tube drainage has exceeded 300 mL of bright red bloody fluid for the past 30 minutes in the client after a coronary artery bypass graft. What is the nurse's next action? Notify the healthcare provider.BAssess for restlessness.CAssess for pallor.DTell the charge nurse.

ANotify the healthcare provider. Rationale:This client is showing signs of hemorrhage, and must be evaluated by a healthcare provider. Pallor and restlessness indicate decreased oxygenation, and support the finding of a possible hemorrhage. The charge nurse will need to be notified, in the event that this client needs to return to the operating room.

A 74-year-old male client is admitted to the intensive care unit (ICU) with a diagnosis of respiratory failure secondary to pneumonia. Currently, the client is ventilator-dependent, with settings of tidal volume (VT) of 750 mL and an intermittent mandatory ventilation (IMV) rate of 10 breaths/min. Arterial blood gas (ABG) results are as follows: pH, 7.48; PaCO2, 30 mm Hg; PaO2, 64 mm Hg; HCO3, 25 mEq/L; and FiO2, 0.80. Which action should the nurse take first? AIncrease the ventilator VT to 850 mL.BDecrease the ventilator IMV to a rate of 8 breaths/min.CReduce the FiO2 to 0.70 and redraw ABGs.DAdd 5 cm positive end-expiratory pressure (PEEP).

Add 5 cm positive end-expiratory pressure (PEEP). Rationale:Adding PEEP helps improve oxygenation while reducing FiO2 to a less toxic level. Options A, B, and C will not result in improved oxygenation and could cause further complications for this client, who is experiencing respiratory failure.

A client with hypertension has been receiving ramipril, 5 mg PO, daily for 2 weeks and is scheduled to receive a dose at 0900. At 0830, the client's blood pressure is 120/70 mm Hg. Which action should the nurse take? Administer the prescribed dose at the scheduled time.BHold the dose and contact the healthcare provider.CHold the dose and recheck the blood pressure in 1 hour.DCheck the healthcare provider's prescription to clarify the dose.

Administer the prescribed dose at the scheduled time. Rationale: The client's blood pressure is within normal limits, indicating that the ramipril, an antihypertensive, is having the desired effect and should be administered. Options B and C would be appropriate if the client's blood pressure was excessively low (<100 mm Hg systolic) or if the client were exhibiting signs of hypotension such as dizziness. This prescribed dose is within the normal dosage range, as defined by the manufacturer; therefore, option D is not necessary.

When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN?A. A young adult with bacterial meningitis with recent seizuresB. An older adult client with pneumonia and viral meningitisC. A female client in isolation with meningococcal meningitisD. A male client 1 day postoperative after drainage of a brain abscess

B. An older adult client with pneumonia and viral meningitis Rationale: The most stable client is option B and should be assigned to the PN. Options A, C, and D are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care.

The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention? Cross-country skiingBScuba divingCHorseback ridingDKayaking

Cross-country skiing Rationale: Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D involve less.

The nurse is caring for a critically ill client with cirrhosis of the liver who has a nasogastric tube draining bright red blood. The nurse notes that the client's serum hemoglobin and hematocrit levels are decreased. Which additional change in laboratory data should the nurse expect? Increased serum albumin levelBDecreased serum creatinineCDecreased serum ammonia levelDIncreased liver function test results

Decreased serum ammonia level Rationale:The breakdown of glutamine in the intestine and the increased activity of colonic bacteria from the digestion of proteins increase ammonia levels in clients with advanced liver disease, so removal of blood, a protein source, from the intestine results in a reduced level of ammonia. Options A, B, and D will not be significantly affected by the removal of blood.

The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention? Ecchymosis over the right elbow areaBDeep unrelenting pain in the right armCAn edematous right elbowDThe presence of crepitus in the right elbow

Deep unrelenting pain in the right arm Rationale:Compartment syndrome is a condition involving increased pressure and constriction of the nerves and vessels within an anatomic compartment, causing pain uncontrolled by opioids and neurovascular compromise. Option A is an expected finding. Option C related to compartment syndrome cannot be seen, and any visible edema is an expected finding related to the injury. Option D is an expected finding.

A resident in a long-term care facility is diagnosed with hepatitis B. Which action should the nurse take with the staff caring for this client? Determine if all employees have had the hepatitis B vaccine series.BExplain that this type of hepatitis can be transmitted when feeding the client.CAssure the employees that they cannot contract hepatitis B when providing direct care.DTell the employees that wearing gloves and a gown are required when providing all care.

Determine if all employees have had the hepatitis B vaccine series. Rationale: Hepatitis B vaccine should be administered to all healthcare providers. Hepatitis A (not hepatitis B) can be transmitted by fecal-oral contamination. There is a chance that staff could contract hepatitis B if exposed to the client's blood and/or body fluids; therefore, option C is incorrect. There is no need to wear gloves and gowns except with blood or body fluid contact.

A 77-year-old client is admitted to the hospital with confusion and anorexia of several days' duration. Additional symptoms reported are nausea and vomiting, and current complaints of a headache. The client's pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to which medication? WarfarinBIbuprofenCNitroglycerinDDigoxin

Digoxin Rationale: Older persons are particularly susceptible to the buildup of cardiac glycosides, such as digoxin or digitoxin (medications derived from digitalis), to a toxic level in their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue. Options A, B, and C are unlikely to result in the symptoms described.

The nurse is performing a skin assessment on a client who is transferred from a long-term care facility to an in-patient hospital unit. The client is unable to move independently while in bed. The nurse observes reddened areas to the sacrum and on the heals bilaterally. What is the next nursing action? Document the size and shape of the reddened areas.BMassage the reddened areas with a hospital-approved lotion.CCall the nurse from the transferring facility to determine the client's baseline.DCulture the wounds.

Document the size and shape of the reddened areas. Rationale:The nurse must document any pressure wounds upon admission to establish the client's baseline and for insurance purposes. Insurance will not reimburse from hospital-acquired pressure ulcers. Massaging is not recommended as it may dislodge the existing tissue. A call is not a good use of the nurse's time as the pressure ulcers exist upon transfer, and the baseline is determined upon admission. The healthcare provider will order cultures, if needed.

A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? Assess for signs of jugular venous distention.BObtain the needed intravenous solution.CFlush the line with heparinized solution.DFlush the line with normal saline.

Flush the line with normal saline. Rationale: Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than option B.

The nurse notes for the client undergoing peritoneal dialysis during the outflow phase the draining dialysate suddenly stops. The outflow is one liter less than the inflow at this time. What is the next nursing action? Take the client's blood pressure.BTake the client's weight.CCall the healthcare provider (HCP).DHave the client change positions.

Have the client change positions. Rationale:The outflow should match the inflow. With repositioning fluid trapped within the peritoneum may be repositioned to the proximity of the abdominal catheter. While the vital signs and the weight may support the additional fluid, they do not address the cause of the reduced outflow. At this time, there is no medical emergency to notify the HCP.

A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before the scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? HypophosphatemiaBHypocalcemiaCHyponatremiaDHypokalemia

Hypocalcemia Rationale: Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D.

The nurse is caring for a client who is one day postacute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which action should the nurse take first? Obtain an IV pump for antiarrhythmic infusion.BIncrease the client's oxygen flow rate.CPrepare for immediate countershock.DGather equipment for endotracheal intubation.

Increase the client's oxygen flow rate. Rationale: Increasing the oxygen flow rate provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. Option A can be delegated and is a lower priority action than option B. Defibrillation may eventually be necessary, but option C is not the immediate treatment for frequent PVCs. Option D may become necessary if the client stops breathing but is not indicated at this time.

A family member was taught to suction a client's tracheostomy prior to the client's discharge from the hospital. Which observation by the nurse indicates that the family member is capable of correctly performing the suctioning technique? Turns on the continuous wall suction to 190 mm Hg.BInserts the catheter until resistance or coughing occurs.CWithdraws the catheter while maintaining suctioning.DReclears the tracheostomy after suctioning the mouth.

Inserts the catheter until resistance or coughing occurs Rationale:Option B indicates correct technique for performing suctioning. Suction pressure should be between 80 and 120 mm Hg, not 190 mm Hg. The catheter should be withdrawn 1-2 cm at a time with intermittent, not continuous, suction. Option D introduces pathogens unnecessarily into the tracheobronchial tree.

Rationale:Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately until the crash cart arrives. Options A and C are appropriate, but CPR is the priority action until a defibrillator is available, which is the most effective treatment for ventricular fibrillation. The client is dying, and option D does not address the seriousness of this situation. Immediately after feeding.BJust prior to tube feeding.CContinuous inflation is required.DInflation is not required.

Just prior to tube feeding. Rationale:The cuff should be inflated before the feeding to block the trachea and prevent food from entering if oral feedings are started while a cuffed tracheostomy tube is in place. It should remain inflated throughout the feeding to prevent aspiration of food into the respiratory system. Options A and D place the client at risk for aspiration. Option C places the client at risk for tracheal wall necrosis.

During report, the nurse learns that a client with tumor lysis syndrome is receiving an IV infusion containing insulin. Which action should the nurse complete first? Review the client's history for diabetes mellitus.BObserve the extremity distal to the IV site.CMonitor the client's serum potassium and blood glucose levels.DEvaluate the client's oxygen saturation and breath sounds.

Monitor the client's serum potassium and blood glucose levels. Rationale: Clients with tumor lysis syndrome may experience hyperkalemia, requiring the addition of insulin to the IV solution to reduce the serum potassium level. It is most important for the nurse to monitor the client's serum potassium and blood glucose levels to ensure that they are not at dangerous levels. Options A, B, and D provide valuable assessment data but are of less priority than option C.

A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit take first?A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms.B. Move clients and visitors into the hallways and close all doors to clients' rooms.C. Visually confirm the location of the tornado by checking the windows on the unit.D. Assist all visitors with evacuation down the stairs in a calm and orderly manner. B. Move clients and visitors into the hallways and close all doors to clients' rooms.

Move clients and visitors into the hallways and close all doors to clients' rooms. Rationale: In the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury. Although option A may help decrease the amount of flying debris, it is not safe to leave clients in rooms with closed blinds; option B is a higher priority at this time. Hospital staff should stay away from windows to avoid injury and should focus on client evacuation into hallways rather than option C. Option D is not the first action that should be taken.

A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the healthcare provider about for reverification for this client? Vitamin K1, 5 mg IM dailyBHigh-calorie, low-sodium dietCFluid restriction to 1500 mL/dayDNembutal sodium at bedtime for rest

Nembutal sodium at bedtime for rest Rationale: Sedatives such as pentobarbital are contraindicated for clients with liver damage and can have dangerous consequences. Option A is often prescribed because the normal clotting mechanism is damaged. Option B is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease.

A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? Pedal pulses will be weak or absent in the left foot.BThe client will state that the left foot is usually warm.CFlexion and extension of the left foot will be limited.DCapillary refill of the client's left toes will be brisk.

Pedal pulses will be weak or absent in the left foot. Rationale: Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses. The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited, depending on the degree of damage, this is not always the case. Options B and D are signs of adequate perfusion of the foot, which would not be expected in this client.

A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid ventricular response. Based on this finding, the nurse anticipates assisting the physician with which treatment? a. Administer lidocaine, 75 mg intravenous push. b. Perform synchronized cardioversion. c. Defibrillate the client as soon as possible. d. Administer atropine, 0.4 mg intravenous push.

Perform synchronized cardioversion Rationale: With uncontrolled atrial fibrillation, the treatment of choice is synchronized cardioversion to convert the cardiac rhythm back to normal sinus rhythm. Option A is a medication used for ventricular dysrhythmias. Option C is not for a client with atrial fibrillation; it is reserved for clients with life-threatening dysrhythmias, such as ventricular fibrillation and unstable ventricular tachycardia. Option D is the drug of choice in symptomatic sinus bradycardia, not atrial fibrillation.

In assessing a client diagnosed with primary aldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance? SodiumBPhosphateCPotassiumDGlucose

Potassium Rationale: Clients with primary aldosteronism exhibit a profound decline in serum levels of potassium; hypokalemia; hypertension is the most prominent and universal sign. The serum sodium level is normal or elevated, depending on the amount of water resorbed with the sodium. Option B is influenced by parathyroid hormone (PTH). Option D is not affected by primary aldosteronism.

The nurse is interviewing a client who is taking interferon-alfa-2a and ribavirin combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse take first? Recommend mental health counseling.BReview the medication actions and interactions.CAssess for the client's daily activity level.DProvide information regarding a support group.

Review the medication actions and interactions. Rationale:Interferon-alfa-2a and ribavirin combination therapy can cause severe depression; therefore, it is most important for the nurse to review the medication effects and report these to the healthcare provider. Options A, C, and D might be implemented after the physiologic aspects of the situation have been assessed.

After attending a class on reducing cancer risk factors, a client selects bran flakes with 2% milk and orange slices from a breakfast menu. In evaluating the client's learning, the nurse affirms that the client has made good choices and makes what additional recommendation? Switch to skim milk.BSwitch to orange juice.CAdd a source of protein.DAdd herbal tea.

Switch to skim milk. Rationale: Dietary recommendations to reduce cancer risk include reduced consumption of fats, with increased consumption of fruits, vegetables, and fiber. Option A promotes reduced fat consumption. Orange slices provide more fiber than orange juice. Options B, C, and D are not standard recommendations for reducing cancer risk.

When educating a client after a total laryngectomy, which instruction would be most important for the nurse to include in the discharge teaching? Recommend that the client carry suction equipment at all times.BInstruct the client to carry writing materials at all times.CTell the client to carry a medical alert card that explains the condition.DCaution the client not to travel outside the United States alone.

Tell the client to carry a medical alert card that explains the condition. Rationale: Neck breathers carry a medical alert card that notifies healthcare personnel of the need to use mouth to stoma breathing in the event of a cardiac arrest in this client. Mouth-to-mouth resuscitation will not establish a patent airway. Options A and D are not necessary. There are many alternative means of communication for clients who have had a laryngectomy; dependence on writing messages is probably the least effective.

In caring for a client with acute diverticulitis, which assessment data warrant an immediate nursing action? The client has a rigid hard abdomen and elevated WBC.BThe client has left lower quadrant pain and an elevated temperature.CThe client is refusing to eat any of the meal and is complaining of nausea.DThe client has not had a bowel movement in 2 days and has a soft abdomen.

The client has a rigid hard abdomen and elevated WBC. Rationale:A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a medical emergency and should be reported to the healthcare provider immediately. Options B and C are expected clinical manifestations of diverticulitis. Option D does not warrant immediate intervention.

A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD? The client's father was diagnosed with COPD in his 50s.BA close family member contracted tuberculosis last year.CThe client smokes one to two packs of cigarettes per day.DThe client has been 40 pounds overweight for 15 years.

The client smokes one to two packs of cigarettes per day. Rationale: Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g. smoking or inhaling secondhand smoke) may increase the likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with cigarette smoking in the development of COPD.

When developing a discharge teaching plan for a client after the insertion of a permanent pacemaker, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met? AThe client demonstrates the procedures to change the rate of the pacemaker using a magnet.BThe client carries a card in his wallet stating the type and serial number of the pacemaker.CThe client tells the nurse that it is important to report redness and tenderness at the insertion site.DThe client states that changes in the pulse and feelings of dizziness are significant changes.

The client states that changes in the pulse and feelings of dizziness are significant changes. Rationale: Changes in pulse rate and/or rhythm may indicate pacer failure. Feelings of dizziness may be caused by a decreased heart rate, leading to decreased cardiac output. The rate of a pacemaker is not changed by a client, although the client may be familiar with this procedure as explained by his healthcare provider. Option B is an important step in preparing the client for discharge but does not demonstrate knowledge of the symptoms of pacer failure. Option C indicates symptoms of possible incisional infection or irritation but does not indicate pacer failure.