Adult HESI
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period?
10 seconds
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client?
Adjust based on the Sp02 Rationale: The client with COPD is often dependent on oxygen. The oxygen should be adjusted depending on the SpO2, which should be 88% to 92%.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding?
An increased pH and an increased HCO3- Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms experienced by the client would include hypoventilation and tachycardia.
A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client?
Assess VS Rationale: The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment.
Prinzmetal's angina results from spasm of the coronary vessels and is treated with
Calcium channel blockers
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?
Check for an air leak, because the bubbling should be intermittent. Rationale: Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve.
The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?
Document the findings. Rationale: Following cholecystectomy, drainage from the T-tube is initially bloody and then turns a greenish-brown color. The drainage is measured as output. The amount of expected drainage will range from 500 to 1000 mL/day. The nurse would document the output.
A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?
Fluid and electrolyte imbalance.
A frequent symptom of duodenal ulcer is pain that is relieved by ____________________
Food intake
The nurse should never irrigate or reposition the ________________ after gastric surgery, unless specifically prescribed by the health care provider.
Gastric tube
The nurse checks for residual before administering a bolus tube feeding to a client with a nasogastric tube and obtains a residual amount of 150 mL. What is the most appropriate action for the nurse to take?
Hold the feeding and reinstill the residual amount. Rationale: Unless specifically indicated, residual amounts greater than 100 mL require holding the feeding, but this is individualized and each agency's policy should be checked.
A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?
Increase intake of fluids
A client has a high level of carbon dioxide (CO2) in the bloodstream, as measured by arterial blood gases. The nurse anticipates that which underlying pathophysiology can occur as a result of this elevated CO2?
It will cause vasodilation in the brain's blood vessels Rationale: CO2 is one of the metabolic end products that can alter the tone of the blood vessels in the brain. High CO2 levels cause vasodilation, which may cause headache, whereas low CO2 levels cause vasoconstriction, which may cause lightheadedness.
The nurse is providing instructions to a client and the family regarding home care after right eye cataract removal. Which side should be the client lay on?
Lay on the left side.
The nurse is providing discharge instructions to a client following gastrectomy and should instruct the client to limit WHAT to assist in preventing dumping syndrome?
Limit fluid intake with meals
For TB patients, isoniazid therapy can cause elevations in WHAT enzymes?
Liver enzymes Normal AST range is 0-35
The nurse is caring for a client who is 1 day postoperative for a total hip replacement. Which is the best position in which the nurse should place the client?
On the nonoperative side with the legs abducted Rationale: Positioning following a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the health care provider's (HCP's) preference. Abduction is maintained when the client is in a supine position or positioned on the nonoperative side.
A health care provider (HCP) tells the nurse that a client's chest tube is to be removed. The nurse should bring which dressing materials to the bedside for the HCP's use?
Petrolatum gauze and sterile 4 × 4 gauze
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?
Potassium level of 3.0 mEq/L (3.0 mmol/L)
A client is scheduled to take ticlopidine. The nurse plans to take which action before implementing this medication therapy?
Review CBC labs Rationale: Review the results of the complete blood cell (CBC) count.
The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP?
Safely securing the safety device straps to the side rails Rationale: The safety device straps are secured to the bed frame and never to the side rails to avoid accidental injury in the event that the side rails are released
The nurse performs an admission assessment on a client with a diagnosis of tuberculosis. The nurse should check the results of which diagnostic test that will confirm this diagnosis?
Sputum culture
The nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. Which method is used to ensure that the ties are not too tightly placed?
The nurse places 1 finger loosely between the tie and the neck.
DKA typically occurs in type 1 or type 2 diabetes mellitus??
Type 1
The nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement?
Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.q
Buck's traction
a type of skin traction often applied after hip fracture before the fracture is reduced in surgery. Traction reduces muscle spasms and helps to immobilize the fracture.
The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving?
- Administer 3% NaCl - Fluid restriction - Administering vasopressin (ADH)
In the first 24-48 hours after an extremity is casted, how should that extremity be positioned?
A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage
The nurse creates a plan of care for a client with deep vein thrombosis. Which client bed position or activity in the plan should be included?
Bed rest with elevation of the affected extremity Rationale: For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain.
Furosemide works by acting to excrete sodium, potassium, and chloride in the ascending limb of the ____________________
Loop of Henle
A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or permanent _____________ _____________ after surgery
Nerve damage
Dawn phenomenon
an increase in blood glucose in the early morning, most likely due to increased glucose production in the liver after an overnight fast
sclerotherapy
chemical injection into a varicose vein that causes inflammation and formation of fibrous tissue, which closes the vein
Somogyi effect
early-morning hyperglycemia that occurs as a result of nighttime hypoglycemic episodes
Sengstaken-Blakemore tube
three-lumen tube used in treating esophageal bleeding.
The nurse is assigned to care for a client with acquired immunodeficiency syndrome (AIDS) suspected of having Kaposi's sarcoma. The nurse should prepare the client for which test to confirm this diagnosis?
Biopsy Rationale: Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Kaposi's sarcoma is the most common AIDS-related malignancy. It manifests as small purplish brown, raised lesions if they occur on the skin. Dyspnea occurs if they occur in the lungs. Lymph node swelling occurs if they are located in the lymph nodes. Kaposi's sarcoma also can occur in the gastrointestinal (GI) tract and manifests as an altered bowel pattern, including diarrhea or constipation. Chest x-ray, bronchoscopy, upper GI exam, colonoscopy, and computed tomography scan may be used to aid the diagnosis, but whether Kaposi's sarcoma manifests as a skin lesion or in the lungs or GI tract, the diagnosis is confirmed with a biopsy.
The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35. Based on this information, which action should the nurse take at this time?
Call the health care provider to request a prescription for a chest radiograph. Rational: If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. A pH of 7.35 indicates a neutral pH, which may indicate that the tube is no longer in the stomach. Based on this information, the nurse should call the health care provider to request a prescription for a chest radiograph to determine if placement is accurate.
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis?
Comatose state Deep, rapid breathing Elevated blood glucose level
The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?
Contact HCP
The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first?
Determine whether there are medication duplications. Rationale; Polypharmacy is a concern in the older client. Duplication of medications needs to be identified before medication interactions can be determined, because the nurse needs to know what the client is taking
disequilibrium syndrome
Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea and vomiting, twitching, and possible seizure activity. It is caused by rapid removal of solutes from the body during hemodialysis. At the same time, the blood-brain barrier interferes with the efficient removal of wastes from brain tissue. As a result, water goes into cerebral cells because of the osmotic gradient, causing brain swelling and onset of symptoms. It most often occurs in clients who are new to dialysis and is prevented by dialyzing for shorter times or at reduced blood flow rates.
A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding?
Dyspnea Rationale: Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss
The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan?
Encouraging Fluid Rationale: Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a urine output of 1.5 to 2 L/day; this requires about 3 L of fluid intake per day.
The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?
Increased respirations Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis
