Study for HESI and NCLEX

Red blood cells (RBCs) M, F?

(M)4.7-6.1, (F)4.2-5.4

Platelets

150-400

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

2, 4, 5 (Because there is less oxygen available, the nurse may observe signs of decreased perfusion to peripheral tissues with decreased cardiac output, decreased urinary output, and restlessness or decreased level of consciousness. Gingival bleeding and purpura on the chest are not symptoms of organ ischemia)

White blood cells (WBCs)

5-10

The graduate nurse is teaching a patient about Crohn's disease. The new nurse is correct in identify-ing what complication as being the result of cobble-stone lesions of the small intestine? A. Malabsorption of nutrients B. Severe diarrhea of 15 to 20 stools per day C. A high probability of developing intestinal cancer D. An inability of the body to absorb water

A

The nurse has just received report on four clients. Which client should the nurse assess first? A. A client with pericarditis with pain relieved by leaning forward B. A client with fractured ribs with pain reported at 8/10 on a 1 to10 scale C. A client with stable angina who is awaiting discharge instructions D. A client with heart failure who needs transporting for an echocardiogram

A (fractured ribs are extremely painful. The pericarditis patient we are worried about cardiac tamponade. they will alse need NSAIDS to prevent cardiac taumponaud. so since that is missing we need to see that patietn first)

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

A (hemodyalisis is to remove potassium)

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

A (this is v tach. yo need to assess the pulse to see what you should do)

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

A, B, D, E.

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

A, E (anthrax isnt contact unless there are open leisons)

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

A. (The problem is protein, you should not do that. they have to take enzymes with every meal.)

The nurse is caring for a client in shock of unknown etiology and observes the above rhythm on the moni-tor. What is the nurse's first priority intervention? A. Check for a carotid pulse. B. Defibrillate the patient with 360 joules of energy. C. Administer an intravenous saline bolus. D. Give two breaths via Ambu® bag

A. check patient and not monitor

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

ABC (prednison interferres with bs becasue it casues a false high, atenalol will block the blood sugar, antibiotics will lower blood sugar, pantoprazol sodium isnt a problem)

A 60-year-old client who has a history ofhypertension, heart failure, and sleep apnea is admitted to the acute care unit. Which finding(s) would relate most directly to a diagnosis of acute decompensated heart failure? (Select all that apply.) A. Respiratory rate of 25 breaths/min B. Orthopnea C. S3 heart sound D. Dry, nonproductive cough E. Heart rate of 69 and irregular

ABC (resp rate of 25- stuggling to breathe, orthopnea- yes, s3 heart sound- there is some extra regurgitation. cough would be productive, because heart failure has extra fluid.)

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

ABCE (they shouldnt have that much pain 2 days later after operation. not concerned about 3 tspns of blood. the temperature indicates infection)

(START OF GI) While obtaining the health history of a client and reviewing his medical records, which data will alert the nurse that the patient has an increased risk of developing peptic ulcer disease? (Select all that apply.) A. Excess ofgastric acid or a decrease in the natural ability ofthe GI mucosa to protect itselffrom acid and pepsin B. Invasion of the stomach and/or duodenum by Helico-bacter pylori C. Viral infection, allergies to certain foods, immunologic factors, and psychosomatic factors D. Taking certain drugs, including corticosteroids and antiinflammatory medications E. Having allergies to foods containing gluten in their ingredients

ABD

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

AC (RN is the only one who can do blood transfusions, a PNcan give a B12 injection, the client resolving from sickle cell is unstable, a PN can do wound care, the UAP can take the one who had blood transfusions yesterday because it was yesterday)

Which clinical manifestations would the nurse expect to assess in a client experiencing Graves' disease? (Select all that apply.) A. Tachycardia B. Decreased sweating C. Insomnia D. Increased respiratory rate E. Muscular aches and pain

ACD (graves disease is fast)

________ questions require the nurse to: Interpret data and collect additional information Identify and communicate nursing diagnoses Determine the health team's ability to meet the client's needs

Analysis

_______________ questions address the gathering and verification of data.

Assessment

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

B (it is the nurses responsibility to assess the pain)

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

B (store having liquidation sale- becasue it is trying to get everything out)

A 36-year-old married man with a body mass index (BMI) of33 states that he wants to lose weight. In addi-tion to dietary intake and level of physical activity, what data are most necessary for the nurse to collect before planning care? A. Draw blood for determination of a resting metabolic rate. B. Determine who prepares the meals. C. Identify the client's educational level. D. Ascertain the client's smoking history.

B (what is important to determine before planning care? the cook may not follow the diet)

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

B,E (Oliguric phase is less than 400 ml in 24 hours, otassium goes up when kidneys are injured, sodium usually doesnt go up with potassium, it would ddecrease. We would see meta acid.)

The cardiac monitor alarm goes off, and the nurse arrives to find the 59-year-old client slumped in the chair. Place the nurse's actions in order of priority for this client from first to last. A. Activate the code team and obtain defibrillator. B. Determine unresponsiveness. C. Assess the cardiac rhythm using the "quick look" paddles. D. Assess for a pulse (carotid). E. Open airway and give two rescue breaths by bag-valve mask. F. Move the client to a flat position in bed or on the floor. G. Begin compressions.

BADFGEC

The charge nurse is planning client assignments for the unit. The collaborative care team consists of an RN, a PN, and a UAP. Which client (s) should be assigned to the PN? (Select all that apply.) A. A client with a history of heart failure who has had no urinary output for the past 2 hours B. A client with a history of angina who requires his morning medications C. A client recently admitted and anticipating oral antibi-otics for cellulitis D. A client with a history of Raynaud syndrome who is pending a dressing change E. A client with an acute deep vein thrombosis who requires a heparin hourly infusion

BCD (hear failure without urinary output is unstable. a PN can have apt who is already admitted who is stable, PN cannot give heparin IV )

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

BCD (there are two paratyroids on each side- its the size of a rice grain, it regulates calcium.)

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

BDAC (remember rule of nines. b partial and full thickness. d is confused. a we dont know how complicated they are. superficial burns arent too bad)

The registered nurse (RN) assigns the practical nurse (PN) a client with diabetes. Which findings should the RN instruct the PN to report immediately? Select all that apply. A. Fingerstick blood sugar of13.59 mmol/L (247 mg/dL) B. Cold, clammy skin C. Crackles at the end of inspiration D. Numbness in the fingertips and toes E. Unsteady gait, slurred speec

BE (what can a PN not do? they should report if 250. cold clammy skin can lead to diaphoresis. the lungs arent functioning correctly with diabetes, all diabetics have numbness)

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

C

Which laboratory result for a preoperative client would prompt the nurse to contact the healthcare provider? A. Platelet count: 151109/L (151,000/mm3) B. White blood cell (WBC) count: 85109/L (8500/mm3) C. Serum potassium level: 2.8 mmol/L (mEq/L) D. Urine specific gravity: 1.030

C

(START OF GU) A client who has type 1 diabetes returns to the clinic for follow-up after dietary counseling. The client states that he has been managing his diabetes very closely. Which lab result indicates that the client is maintain-ing tight control of the disease? A. Fasting blood sugar changes from 7.5 to 6 mmol/L (135 to 110 mg/dL). B. Self-monitoring of blood glucose at bedtime changes from 2.5 to 5 mmol/L (45 to 90 mg/dL). C. Glycosylated hemoglobin (hemoglobin A1C) changes from 9% to 6%. D. Urine ketones change from 0 to

C (A1C shows the tightest control)1

The nurse is caring for a client with peritonitis. Which information should the nurse report immediately to the healthcare provider? A. Blood pressure readings of 92/64, 110/70, and 100/68 over the past hour B. Urine output of 300 mL over the past 8 hours C. Rebound tenderness and pain the client rates as a 7 on a 0 to 10 scale D. Dry mucous membranes and nausea

C (BP isnt drastically changing, UOP is normal, rebound tenderness and pain means that they might have a rupture.)

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

C (The patient is getting transfused and the IV is transfused. based on the word inflamed you need to stop the transfusion and restart at another site. an inflamed IV site means infiltration, so its not the blood, its the site)

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

C (opposite of hyperthyroidism- everything is slow)

Which dysrhythmia(s) would defibrillation be most appropriate for? (Select all that apply.) A. Asystole B. Pulseless electrical activity C. Ventricular fibrillation D. Pulseless ventricular tachycardia E. Ventricular tachycardia F. Atrial fibrillation

C D (Asystole- dont because you have to have pulseless electrical activity, pulseless electric activity is the same as asystole, v tach you cardiovert or medicate)

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

C D (hallmark side effects of metformin. Do not tell someone to DC meds bc you arent a dr, increasing fiber and fluids will not help. this is not an emergency)

An elderly client's vital signs are 103° F (39.6° C), heart rate 109, respiratory rate 37, blood pressure 86/42. After an infusion of 1L of 0.9 N saline IV there are few changes in vital signs. The nurse assesses the client and determines that more fluid would be appropriate based on which parameter? Select all that apply. A. Urinary output of 40 mL in the last hour B. Central venous pressure of 5 mm Hg C. Heart rate increased from 109 to 129 when sitting. D. Peripheral pulse change from +2 to +1 E. Mean arterial pressure of 70 mm Hg

C D (normal cvp- 2-8 hr should not increase that much when sitting.)

A 62-year-old client who has a history of coronary heart disease was admitted to the acute care unit 2 days ago for management ofangina. During the assessment, the client states, "I feel like I have indigestion." In what order should the nurse implement care? (Arrange from first action to last.) A. Notify the rapid response team. B. Administer PRN (as needed) nitroglycerin prescription. C. Check the pulse, respirations, blood pressure, and oxy-gen saturation. D. Document assessment on the electronic medical record. E. Provide 2 L of oxygen via nasal cannula.

C, E, B, A, D (because they can talk that means that they can breathe.)

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

C. (we know they will have bowel sounds bc they poop)

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

D (an LPN can give an injection)

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

D (subcutaneous emphysema is expected, and is okay as long as it doesnt get worse)

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

D (what is the most important think you need to do before giving this? BCG vaccine is a live virus, so they will have a positive test and they can also get reinfected)

______________ questions focus on comparing the actual outcomes of care with the expected outcomes and on communicating and documenting findings.

Evaluation

________________ questions reflect the management and organization of care and the assignment and delegation of tasks. Be prepared for questions on client teaching.

Implementation

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

Inform the healthcare provider that the client has questions about the surgery.

Hemoglobin M, F?

M14-18, F12-16

Hematocrit M, F?

M42-52, F37-47

____________ questions ask about determining, prioritizing, and modifying outcomes of care.

Planning

An elderly man comes to the emergency department (ED) complaining of shortness of breath. The health-care provider (HCP) determines that the client has pneumonia. The client's condition deteriorates in the ED, and he now has impending respiratory failure. Which set of arterial blood gas (ABG) values demon-strates acute respiratory failure? A. pH-7.30; PCO2-52; PO2-56; HCO3-26 B. pH-7.35; PCO2-44; PO2-86; HCO3-28 C. pH-7.35; PCO2-62; PO2-66; HCO3-31 D. pH-7.30; PCO2-39; PO2-88; HCO3-22

a

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

a (make sure there is nothing else that should be done before calling the hcp out of the options)

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

a (primary cause of chest pain is lack of oxygen. he is diaphoretic so he is starting to die.)

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

a client from the previous shift with unstable angina. a cardiotomy client who is day 2 postoperative and who has chest tubes.

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

a client received medication prescribed for another client

The charge nurse is planning client assignments for the shift. The care team includes a RN, a PN, and UAP on the care team. Which client(s) could be assigned to the PN? (Select all that apply.) A. A client scheduled for a STAT x-ray after a fall on his hip B. A client receiving IV vancomycin (Vancocin) through a peripherally inserted central catheter (PICC) line C. A client with sickle cell crisis who was transferred from the intensive care unit to the acute care area and who is receiving hydromorphone (Dilaudid) via a patient-controlled analgesia pump D. A client with a pressure ulcer who was prescribed negative pressure (wound VAC) care E. A postoperative client who has been prescribed two units of packed red blood cells

a client scheduled for a STAT xray after a fall on his hip. a client with a pressure ulcer who was prescribed negative pressure care (wound vac) (a PN cant take care of a central line or vancomycin because it is a black box drug)

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

a, b, d, e.

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

administer the dose of oral phosphate (the serum calcium level is elevated. normal is 9-10.5. in hyperparathyroidism the prescribed med is used to lower serum calcium levels)

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

advise them to cease their communication (calmly remind the nurses that they are in a public elevator)

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

assess the clients medical record to determine his normal bowel pattern (accurate assessment allows the nurse to intervene before constipation and fecal impaction occur)

A 22-year-old client is admitted through the emergency department with a 2-day history of cough, fever, and fatigue. The medical history is positive for type I dia-betes and recent upper respiratory infection. Vital signs are heart rate 109, blood pressure 102/58, respi-ratory rate 24, temperature 104° F (40° C), and SpO2 of 92% on 2 L nasal cannula. Which prescription has the highest priority in this client's care? A. Initiate large bore IV access. B. Draw two sets of blood cultures. C. Administer the ordered IV antibiotics. D. Draw serum lactate and glucose levels.

b (based on the high temp and they are a type one diabetic. you need to get the blood cultures so that you can get the right antibiotics.)

A client who is 1 day postoperative from a left pneumo-nectomy is lying on his right side with the head of the bed (HOB) elevated 10 degrees. The nurse assesses his respiratory rate at 32 breaths/min. What action should the nurse take first? A. Further elevate HOB. B. Assist the client into the supine position. C. Measure the client'sO2 saturation. D. Administer intravenous (IV) PRN (as needed) morphine.

b (dont elevate HOB because it is going to cramp up the area of the bad lung. put them back in the neutral position then figure out how to move them.)

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

b (earliest change is loc. BP is after LOC)

The complete blood count (CBC) results for a client receiving chemotherapy are hemoglobin, 85 mmol/L (8.5 g/dL); hematocrit, 32%; WBC count, 6.5×109/ L (6,500 cells/mm3). Which meal choice is best for this client? A. Grilled chicken, rice, fresh fruit salad, milk B. Broiled steak, whole wheat rolls, spinach salad, coffee C. Smoked ham, mashed potatoes, applesauce, iced tea D. Tuna noodle casserole, garden salad, lemonade

b (the patient needs iron. cancer pts shouldnt have much fresh vegetables but they can have in small amounts)

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

b (the pt has chronic renal failure so they shouldnt have urine, so that is good. The nauseous pt meas lack of bowel motility)

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

b (the pt is going into DIC. the labs will just make them bleed more.)

(START OF RESPIRATORY) The nurse is precepting a nurse orientee caring for a client with a chest tube who is 12 hours postoperative from a left partial pneumonectomy. Which assess-ments will the nurse advise should be reported to the HCP immediately? (Select all that apply.) A. Pain level of 6 out of 10 on the left side B. Tracheal deviation toward the right side C. Drainage from the chest tube of50 mL in the last hour D. Oxygen saturation of 90% on 2L/min E. Vigorous bubbling in the suction chamber

b, e (you cant fix this. you have to tell the dr that there is a problem. pain is expected at 12 hours. tracheal deviation is a problem. drainage is okay. oxygen may be a problem because if you take it of it is probably lower. vigerous bubbling can indicate a leak or the patient is struggling to breath)

(START OF ADVANCED CLINICAL CONCEPTS) The nurse is the first responder at the scene of a mass casualty incident. The nurse is tasked to triage the vic-tims from highest to lowest priority. Arrange the vic-tims from highest to lowest priority. All options must be used. A. Victim A is an elder adult with agonal respirations and open head injury. B. Victim B is a confused adult with bright red blood pul-sating from a leg wound. C. Victim C is a young adult with multiple compound fractures of the arms and legs. D. Victim D is an adult with multiple shrapnel wounds of the face and arms complaining of abdominal pain. E. Victim E is a sobbing adult with several minor lacera-tions on the face, arms, and legs.

bdcea (a is last because agonal resps is dying breaths.)

Which client should the nurse assess first? A. The client receiving oxygen per nasal cannula who is dyspneic on mild exertion and has a hemoglobin of 70 mmol/L (7 g/dL) B. The client receiving IV aminoglycosides per central venous catheter (CVC) who complains of nausea and has a trough level below therapeutic levels C. The client with a chest tube that drained 150 mL in the last hour D. The client receiving chemotherapy whose temperature is 37.2° C (98.9° F) and who has a WBC count of 2.5109/L (2500/mm3)

c (drainage should not be above 70)

The nurse is monitoring the status of a client recover-ing from a myocardial infarction. Which symptom indicates an evolving problem? A. A steady pulse of 88 beats/min B. Rising systolic pressure from 110 to 120 mm Hg C. Three premature ventricular contractions/min D. Central venous pressure of 8 mm Hg

c (that is making the heart unstable)

A client recovering from ARDS is awake and alert, has residual fatigue and generalized weakness. His current vital signs are heart rate 83, blood pressure 104/64, respiratory rate 25, SpO2 on 2 L/min nasal oxygen air is 92%. Which vital sign value should unlicensed assistive personnel report immediately to the nurse? A. Heart rate of 88 beats per minute B. Blood pressure of 104/64 mm Hg C. Respiratory rate of 25 breaths per minute D. SpO2 92%

c (the patient is recovering from ARDS so the spo2 should be above 90 not 95. we need to know why they are breathing fast)

A client has advanced cirrhosis of the liver with an acute exacerbation of hepatic encephalopathy. What type of food might be limited in his diet? A. Fruits B. Vegetables C. Meats D. Bread

c. (avoid meats becasue of protein)

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

d (MAP is low- so we want to increase the intravenous rate of the fluid)

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

d (a is black. they are dying bc of the agonal respirations)

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

d (chemo patients dont stay alone)

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

d (diaphoresis - die)

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

determine the behaviors that resulted in the need for admission (an involuntary admission is based on the risk for harm to self or others, therefore assessment of harmful behaviors is the highest priority)

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

during round the nurse talks about the problem the UAP created by not performing a fingerstick glucose test on the client (although sharing information is important, rounds is not the time to hold staff accountable)

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

encourage the nurse to be accountable for her own behavior (the nurses behavior is disruptive and inappropriate, and the priority action is to help the nurse accept accountability for her own behaviors)

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

have you received any preoperative pain medication? (recent administration of an analgesic may preclude the client from being able to sign the surgical consent)

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

perform sterile wound irrigation (this skill requires more expertise than a UAP has but less judgement than weaning the client, therefore it is the best choice for the PNs assignment)

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

taking vital signs for an older client with left humeral and left tibial fractures (the task encompasses measuring vital signs and does not require expertise of the nurse to be performed. The right arm is not injured.)

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

the client is awake and alert, which makes the living will irrelevant and nonbinding (if the client is remained alert and awake, the living will is irrelevant to medical decision making. The potential risks and benefits of intubation need to be presented to the client)

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

the clients actions place her at high risk for harming herself (restraints may be applied to protect the client from injury, after all other measures to protect the client have been attempted)

When providing care for a client you should start with what?

the least invasive intervention

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

the parameters of the states nurse practice act (the nurse did not act within the parameters of the nurse practice act because the nurse should take action and assess a client with a problem. This is not within the scope of practice for the UAP. the charge nurse should take immediate action to remedy this unsafe situation)