Cha 1 HESI EAQs
The nurse provides discharge teaching to a client with a history of angina. The nurse instructs the client to call for emergency services immediately if the client's pain exhibits which characteristic? A) Causes mild perspiration B) Occurs after mild exercise C) Continues after rest and nitroglycerin D) Precipitates discomfort in the arms and jaw
Continues after rest and nitroglycerin
Which clinical manifestations in a client indicate hyper functional thyroid gland? Select all that apply A. Anemia B. Diarrhea C. Weight loss D. Decreased appetite E. Distant heart sounds
Diarrhea, weight loss
A 10-year-old child undergoes open heart surgery to repair a cardiac defect. The healthcare provider informs the parents that antibiotics are required before any dental work is performed. Later the parents ask the nurse why this is necessary. When responding, the nurse explains that this is done to prevent what type of infection? A) Gingivitis B) Pericarditis C) Myocarditis D) Endocarditis
Endocarditis
A child has been diagnosed with hemophilia type A after experiencing excessive bleeding from a minor trauma. The parents ask what symptoms of bleeding they should be looking for in the future. What symptoms should the nurse list? Select all that apply A. Epistaxis B. Hematuria C. Hemarthrosis D. Easy bruising E. Frequent fevers F. Fast clotting of injuries G. Dark-colored tarry stools
Epistaxis, hematuria, hemarthrosis, easy bruising, dark-colored tarry stools
The nurse teaching as health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? A) Pregnancy B) Inactivity C) Aerobic exercise D) Tight clothing
Inactivity
How should a nurse expect a clients anxiety to be manifested physiologically? A. Constricted pupils B. Narrowed bronchioles C. Decreased blood pressure D. Increased blood glucose level
Increased blood glucose level
A nurse is caring for a client with right-sided heart failure. Which assessment findings are key features of right-sided heart failure? Select all that apply. A) Collapsed neck veins B) Distended abdomen C) Dependent edema D) Urinating at night E) Cool extremities
Distended abdomen, dependent edema, urinating at night
Which does the nurse state is a secondary cause of adrenal insufficiency? A. Hemorrhage B. Tuberculosis C. Pituitary tumors D. Metastatic cancer
Pituitary tumors
A nurse is teaching an older adult client about managing chronic pain with acetaminophen. Which client statement indicates that the teaching is effective? A. "I can drink beer with this, but not wine." B. "I need to limit my intake of acetaminophen to 650mg a day." C. "I should take an emetic if I accidentally overdose on the acetaminophen." D. "I have to be careful about which over-the-counter cold preparations I take when I have a cold."
"I have to be careful about which over-the-counter cold preparations I take when I have a cold."
A nurse is caring for an older adult who is taking acetaminophen for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? A. Alcohol B. Caffeine C. Saw palmetto D. St. John's wort
Alcohol
A client exhibits physical symptoms in response to stress. What nursing intervention may help the client reduce this physiological response to stress? A. Limiting discussions about the problem B. Providing information regarding medical care C. Teaching the client how to eliminate stress at home D. Assisting the client in developing new coping mechanisms
Assisting the client in developing new coping mechanisms
A nurse identifies premature ventricular complexes (PVCs) on a client's cardiac monitor. What does the nurse conclude that these complexes are a sign of? A) Atrial fibrillation B) Cardiac irritability C) Impending heart block D) Ventricular tachycardia
Cardiac irritability
Which statement is true regarding cortisol? A. Cortisol metabolizes free fatty acids B. Cortisol stimulates gluconeogenesis C. Cortisol stimulates protein synthesis D. Cortisol levels decline in stressful conditions
Cortisol stimulates gluconeogenesis
Which treatment intervention should be provided to a client diagnosed with Cushing's disease? A. Increase cortisol levels B. Increase sodium levels C. Decrease blood glucose levels D. Decrease serum calcium levles
Decrease blood glucose levels
What client response muse the nurse monitor to determine the effectiveness of amiodarone? A) Absence of ischemic chest pain B) Decrease in cardiac dysrhythmias C) Improvement in fasting lipid profile D) Maintenance of blood pressure control
Decrease in cardiac dysrhythmias
On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? A) Muscle twitching B) Mental instability C) Deep and rapid respiration's D) Tachycardia and cardiac dysrhythmias
Deep and rapid respiration's
A client develops iron-deficiency anemia. Which of the client's laboratory tests results should the nurse expect to be decreased? A. Ferritin level B. Platelet count C. White blood cell count D. Total iron-binding capacity
Ferritin level
A client is returned to the surgical unit immediately after placement of a coronary artery stent that was accomplished via access through the femoral artery. What should the nurse consider the priority when assessing this client? A) Acute pain B) Impaired mobility C) Impaired swallowing D) Hematoma formation
Hematoma formation
While receiving a blood transfusion, a client develops flank pain, chills, and fever. What type of transfusion reaction does the nurse conclude that the client is probably experiencing? A. Allergic B. Pyrogenic C. Hemolytic D. Anaphylactic
Hemolytic
A nurse is caring for a client admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder? A. Diarrhea and Pyrex is B. Edema and hypertension C. Moon face and hirsutism D. Hypoglycemia and hypotension
Hypoglycemia and hypotension
The nurse is assessing a client experiencing diabetic ketoacidosis (DKA). Which unique response associated with DKA that is not exhibited with hyperglycemia hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing the client? A) Fluid loss B) Glycosuria C) Kussmaul respiration's D) Increased blood glucose level
Kussmaul respiration's
When assessing a client, the nurse Auscultate a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sounds from which valve? A) Aortic B) Mitral C) Pulmonic D) Tricuspid
Pulmonic
The spouse of a client who had emergency coronary artery bypass surgery asks why there is a dressing on the client's left leg. How should the nurse explain the dressing? A) "This is the access site for the heart-lung machine." B) "A filter is inserted in the leg to prevent embolization." C) "A vein in the leg was used to bypass the coronary artery." D) "The arteries in the extremities are examined during surgery."
"A vein in the leg was used to bypass the coronary artery
A nurse is teaching a 12-year-old child about a bone marrow aspiration. What statement indicates that the preadolescent needs further explanation of the procedure? A. "I'll have to rest after the procedure" B. "My hip will be sore after the procedure" C. "You'll put a tight bandage on me where the needle goes" D. "The doctor is going to stick a needle into the middle of one of my hip bones"
"I'll have to rest after the procedure"
A nurse concludes that the teaching about sickle cell anemia has been understood when an adolescent with the disorder makes which statement? A. "I'll start to have symptoms when I drink less fluids" B. "I'll start to have symptoms when I have fewer platelets" C. "I'll start to have symptoms when I decrease the iron in my diet" D. "I'll start to have symptoms when I have fewer white blood cells"
"I'll start to have symptoms when I drink less fluids"
A pregnant client tells the nurse in the prenatal clinic that although she and her husband do not have the disease, she has a 1-year-old daughter with sickle cell anemia. She asks the nurse, "will this baby also have sickle cell anemia?" How should the nurse respond? A. "The chance that another child will have sickle cell anemia is 25%" B. "Only one child in a family is affected, so the others probably will be alright" C. "The most likely conclusion is that your children will have your sickle cell anemia" D. "If your partner has the sickle cell gene, 50% of your children will have sickle cell anemia"
"The chance that another child will have sickle cell anemia is 25%"
The nurse is teaching a group of students about neuromuscular manifestations of alkalosis with Hypocalcemia. Which statements provided by a student nurse indicate the need for further teaching? A. "The client would show signs of twitching" B. "The client would show signs of hyporeflexia" C. "The client would show signs of paresthesias" D. "The client would show signs of muscle cramping" E. "The client would show signs of skeletal muscle weakness"
"The client would show signs of hyporeflexia"and "the client would show signs of paresthesias"
A client has undergone nasal hypophysectomy surgery. During post-operative care, which finding indicates cerebrospinal leakage? A) Dry mouth B) Rigidity of neck muscles C) Fall in blood pressure upon standing D) A yellow edge around nasal discharge
A yellow edge around nasal discharge
The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. What should the nurse include in the teaching plan? Select all that apply A) The client should obtain a finger stick blood glucose reading before each meal B) The client does not need to follow a specific diet until insulin is required C) The teaching plan should include signs and symptoms of hypoglycemia D) The teaching plan does not need to include signs and symptoms of hypoglycemia, as the client is no on insulin E) The teaching plan should include sick day rules
A) The client should obtain a finger stick blood glucose reading before each meal C) The teaching plan should include signs and symptoms of hypoglycemia E) The teaching plan should include sick day rules
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expected that the client's initial treatment will include which medication? A) Aspirin B) Midazolam C) Gabapentin D) Alprazolam
Aspirin
After a surgical thyroidectomy a client exhibits carpopedal spasm and some tremors. The client complains of tingling in the fingers and around the mouth. What medication should the nurse expect the primary health care provider to prescribe after being notified of the client's adaptations? A. Potassium iodide B. Calcium gluconate C. Magnesium sulfate D. Potassium chloride
Calcium gluconate
A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first? A) Check for a pulse B) Start cardiac compressions C) Prepare to defibrillate the client D) Administer oxygen via an ambu bag
Check for a pulse
A client who has been receiving palliative care for cancer has deteriorated and now needs end-of-life care. The nurse identifies that which types of care will now be removed from the treatment plan? Select all that apply A. Chemotherapy B. Repositioning C. Regular oral care D. Blood transfusions E. Radiation therapy
Chemotherapy, blood transfusion, radiation therapy
A nurse is caring for a client who just had coronary artery bypass graft surgery. For which complication should the nurse monitor the client in the immediate postoperative period? A) Dysrhythmias, especially atrial fibrillation B) Postpericardiotomy syndrome with fever and friction rub C) Mediastinitis with body sternum and increased white blood cell count D) Increased hemoglobin and hematocrit levels with a risk for embolization
Dysrhythmias, especially atrial fibrillation
A nurse is caring for a client with Addison disease. Which information should the nurse include in a teaching plan to encourage this client to modify dietary intake? A) Increased amounts of potassium are needed to replace renal losses B) Increased protein is needed to heal the adrenal tissue and thus cure the disease C) Supplemental vitamins are needed to supply energy and assist in regaining the lost weight D) Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium
Extra salt is needed to replace the amount being lost caused by lack of sufficient aldosterone to conserve sodium
A client who was admitted with a diagnosis of acute lymphoblastic leukemia is receiving chemotherapy. Which assessment findings would alert the nurse to the possible development of thrombocytopenia? Select all that apply A. Fever B. Diarrhea C. Headache D. Hematuria E. Ecchymosis
Headache, hematuria, ecchymosis
A nurse is caring for a client after a thyroidectomy. Which symptoms indicating thyroid storm should the nurse monitor the client for? Select all that apply A. Increased heart rate B. Increased temperature C. Decreased respiration's D. Increased pulse deficit E. Decreased blood pressure
Increased heart rate, increased temperature
After reviewing the reports of a client, the nurse suspects hypofunctioning of the adrenal gland. Which findings are consistent with hypofunctioning of the adrenal gland? Select all that apply A. Increased serum calcium B. Decreased serum cortisol C. Decreased serum sodium D. Decreased serum potassium E. Increased serum glucose
Increased serum calcium, decreased serum cortisol, and decreased serum sodium
Which is the priority nursing action when admitting a client to the emergency department during cardiac arrest from the ventricular fibrillation? A) Treating pain B) Assessing respiration's C) Initiating defibrillation D) Monitoring blood pressure
Initiating defibrillation
After a discussion with the primary healthcare provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond? A) The diameter of the aorta is enlarged B) The wall between the right and left ventricles is open C) It is a narrowing of the entrance to the pulmonary artery D) It is a connection between their pulmonary artery and the aorta
It is a connection between their pulmonary artery and the aorta
A nurse is teaching the parents of an 8-year-old child who is taking a high dose of oral prednisone for asthma. What critical information about prednisone will be included? A. It protects against infection B. It should be stopped gradually C. An early growth spurt may occur D. A moon-shaped face will develop
It should be stopped gradually
A client is scheduled for an adrenalectomy. What does the nurse expect that the plan of care will include? A) Low-protein diet B) Parenteral corticosteroids C) Preoperative 24-hour urine specimen D) Withholding all medications 48 hours before surgery
Parenteral corticosteroids
In anticipation of a client returning to their room following a subtotal thyroidectomy, what intervention would be the highest priority for the nurse to perform? A. Have sterile dressing supplies in the room B. Place a tracheostomy set at the bedside C. Lock the client's bed in supine position until surgeon orders a different position D. Have pencil and paper in the room so the client can communicate their needs in writing
Place a tracheostomy set at the bedside
A nurse is assessing a client for dehydration. The client has had diarrhea and vomiting for 48 hours. Which assessment findings alert the nurse that the client is dehydrated? Select all that apply A. Protruding eyeballs B. Postural hypotension C. The client reporting eating an average of 3 meals a day D. The skin on the client's forehead remains tented after being pinched E. Within four days, the client gained two pounds of weight
Postural hypotension and The skin on the client's forehead remains tented after being pinched
What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? Select all that apply. A. Providing adequate fluids within easy reach B. Reporting an increasing urine specific gravity C. Administering prescribed erythromycin D. Assessing for and reporting changes in neurological status E. Monitoring for constipation, weight loss, hypotension, and tachycardia
Providing adequate fluids with easy each, assessing for & reporting changes in neurological status, monitoring for constipation/weight loss/hypotension/tachycardia
A client receives a prescription for morphine via patient-controlled analgesia (PCA). Before beginning administration of this medication, what should the nurse assess first? A. Temperature B. Blood pressure C. Respiration's D. Urinary Output
Respiration's
The nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which finding in the client is consistent with the diagnosis? A) Preservation of salt B) Retention of water C) Decrease of vasopressin D) Presence of pedal edema
Retention of water
The nurse is caring for a client with chronic pain who is on opioid treatment, the client has constipation, nausea, vomiting, level 3 sedation, respiratory of 8 breaths per minute, and pruritus. Which conditions of the client should the nurse consider as the highest priority? Select all that apply A. Pruritus B. Sedation C. Constipation D. Respiratory Rate E. Nausea and vomiting
Sedation and respiratory rate
The nurse assesses a newborn and observes central cyanosis. What type of congenital heart defect usually results in central cyanosis? A) Shunting of blood from right to left B) Shunting of blood from left to right C) Obstruction of blood flow from the left side of the heart D) Obstruction of blood flow between the left and right sides of the heart
Shunting of blood from right to left
A client with type 1 diabetes comes to the clinic because of concerns regarding erratic control of blood glucose with the prescribed insulin therapy. The client has been experiencing a sudden fall in blood glucose level, followed by a sudden episode of hyperglycemia. Which complication of insulin therapy should the nurse conclude that the client is experiencing? A) Somogyi effect B) Dawn phenomenon C) Diabetic ketoacidosis D) Hyperosmolar nonketotic syndrome
Somogyi effect
To prepare a client for surgery, which explanation by a nurse would be accurate related to pneumatic compression devices? A) They help the venous blood return to the heart B) They will not cause discomfort, but gently massage the legs C) They are used instead of anticoagulant therapy D) They must be worn until the first time the client gets out of bed
They help the venous blood return to the heart
A nurse is conducting cholesterol screening for a manufacturing corporation during a health fair. A 50-year-old man who is 6 feet (183 cm) tall and weights 293 pounds (133 kg) puts out his cigarette and asks the nurse how to modify his risk factors for coronary artery disease. On which risk factors should the nurse help the client focus? Select all that apply A) Age B) Height C) Weight D) Smoking E) Family History
Weight & Smoking
When caring for a client with venous insufficiency, the nurse would implement which nursing measure? A) Apply abdominal girdle as needed B) Remove compression stockings for client ambulation C) Elevate the client's legs above heart level D) Keep the upper extremities elevated
Elevate the client's legs above heart level
An electrocardiogram is prescribed for a client complaining of chest pain. The nurse recognizes which as an early finding of an infarcted area of the heart? A) Flattened T waves B) Absence of P waves C) Elevated ST segments D) Disappearance of Q waves
Elevated ST segments
A client has a platelet count of 49,000/mL. The nurse should instruct the client to avoid which activity? A. Ambulation B. Blowing the nose C. Visiting with children D. The semi-Fowler's position
Blowing the nose
A client with heart disease has been reading on the internet about the anatomy and physiology of the heart and tells the nurse, "I'm so confused." The nurse reinforces the pattern of circulation in the body. Which client statement indicates a correct understanding? A) "Blood enters the heart through the ductus arteriosus, flows into the left side of the heart, and exits via the aorta into the systemic circulation." B) "Blood enters the heart from the inferior vena cava; it then flows through the left atrium into the left ventricle, then into the lungs, and back into the aorta." C) "Blood enters the heart from the aorta, flows into the right atrium and right ventricle, through the lungs, then into the left atrium and left ventricles, and finally exits through the superior vena cava." D) "Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricles, and exits out the aorta."
"Blood enters the right atrium via the superior and inferior vena cava, flows to the right ventricle and then into the lungs, returns from the lungs to the left atrium and left ventricles, and exits out the aorta."
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? A) "My ankles are swollen" B) "I am tired at the end of the day" C) "When I eat a large meal, I feel bloated" D) "I have trouble breathing when I walk rapidly"
"I have trouble breathing when I walk rapidly"
A client is admitted for a coronary artery bypass graft. The client states that the preoperative teaching materials contain information about pacemaker wires being inserted during surgery as a precautionary measure. The client asks, "What is the purpose of the pacemaker?" What is the best response by the nurse? A) "These pacing wires can be attached to a temporary pacemaker to shock the heart if it starts beating too fast." B) "This type of pacemaker will automatically defibrillate the heart if the heart forgets to beat." C) "The pacemaker will maintain constant cardiac rhythm" D) "In case of too slow of a heart rate, the epicardium leads are attached to a pacemaker to maintain a normal rate."
"In case of too slow of a heart rate, the epicardium leads are attached to a pacemaker to maintain a normal rate."
A student nurse is describing palliative care to a clients family. Which statement made by the student nurse indicates a need for correction by the registered nurse? A. "Palliative care is the same as hospice care" B. "Palliative care focuses on the care of the client" C. "Palliative care includes symptoms management in the client" D. "Palliative care is an inter professional approach to the delivery of care"
"Palliative care is the same as hospice care"
The student nurse demonstrates correct understanding of anemia related to chronic disease with which statement? A. "Red blood cells appear normal in size and color; however, there is a decreased amount produced" B. "The red blood cells have an increased life span with a decrease in normal function" C. "Administration of vitamins B12 and folate will help to treat this type of long term anemia." D "This is the mildest form of anemia and is easily corrected through administration of blood products."
"Red blood cells appear normal in size and color; however, there is a decreased amount produced"
A client who is suspected of having a silent myocardial infarction has an electrocardiogram (ECG) prescribed by the primary healthcare provider. While the nurse prepares the client for this procedure, the client asks, "Why was this rest prescribed?" Which is the best reply by the nurse? A) "This test will detect your heart sounds" B) "This test will reflect any heart damage" C) "This procedure helps us change your heart's rhythm" D) "This ECG will tell us how much stress your heart can tolerate"
"This test will reflect any heart damage"
Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes? A. Ketones in the blood but not in the urine B. Glucose in the urine but not hyperglycemia C. Hyperglycemia and urine negative for ketones D. Blood and urine positive for both glucose and ketones
Hyperglycemia and urine negative for ketones
A client has surgery to replace a prolapsed mitral valve. What should the nurse teach the client? A) The signs and symptoms of pericarditis B) The signs and symptoms of heart failure C) That cardiac surgery will have to be done eventually for the other valves D) That cardiac surgery will have to be done every six months to replace the valve
The signs and symptoms of heart failure
Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L (25 mmol/L). Which action should the nurse take? A) Obtain a prescription for a diuretic B) Have the client breathe into a rebreather bag C) Encourage the client to take deep, cleansing breaths D) Request a prescription for the administration of sodium bicarbonate
Encourage the client to take deep, cleansing breaths
A nurse is caring for a client admitted with cardiovascular disease. During the assessment of the client's lower extremities, the nurse notes the client has thin, shiny skin; decreased hair growth; and thickened toenails. What might this indicate? A) Venous insufficiency B) Arterial insufficiency C) Phlebitis D) Lymphedema
Arterial insufficiency
A client with a history of heart failure and hypertension is admitted with reports of syncope. The ECG rhythm strip shows sinus bradycardia, which prescribed medication should the nurse prepare to administer? A) Digoxin B) Enalapril C) Atropine D) Metoprolol
Atropine
A client is receiving patient-controlled analgesia (PCA) after surgery. What does the nurse identify as the primary benefit with this type of therapy? A. Client is able to self-administer pain-relieving drugs as necessary B. Amount of medication received is determined entirely by the client C. Amount of drug used for analgesia matches sleep-wake cycles D. Self-administration relieves the nurse of monitoring the client for pain relief
Client is able to self-administer pain-relieving drugs as necessary
What is the most definitive test to confirm a diagnosis of multiple myeloma? A. Bone marrow biopsy B. Serum test for Hypercalcemia C. Urine test for Bence Jones protein D. X-ray films of the ribs, spine, and skull
Bone marrow biopsy
An older adult client is diagnosed with left-sided congestive heart failure. Which assessments should the nurse expect to find? Select all that apply A) Dyspnea B) Crackles C) Hacking cough D) Peripheral edema E) Jugular distention
Dyspnea, crackles, hacking cough
The nurse reviews the medical record of a client who is eligible to receive end-of-life care. What are the criteria for a client to receive this type of care? Select all that apply A. When the client is nearing death B. When the expected death of the client is within 6 months C. When the client seeks no aggressive disease management D. When a family member has signed an informed consent form E. When the client has been issued a "do not resuscitate" order
Expected death of the client is within 6 months, client seeks no aggressive disease management, client has been issued a DNR order
A nurse is assessing a newborn with suspected retention of a fetal structure that will result in a congenital heart defect. Which fetal structures should undergo change after birth? Select all that apply. A) Mitral valve B) Foramen ovale C) Pulmonary veins D) Ductus arteriosus E) Pulmonary arteries
Foramen ovale and ductus arteriosus
An adolescent is found to have type 1 diabetes. The nurse plans to teach the adolescent that dietary control and exercise can help regulate the disorder. What additional information should the nurse include in the teaching plan? Select all that apply A. Insulin therapy B. Prophylactic antibiotics C. Blood glucose monitoring D. Oral hypoglycemic agents E. Adherence to the treatment regimen
Insulin therapy, blood glucose monitoring, adherence to the treatment regimen
A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer? Select all that apply A. Lack of hair B. Thickened toenails C. Pain at the ulcer site D. Diminished pedal pulse E. Brown skin discoloration
Lack of hair, thickened toenails, pain at the ulcer site, diminished pedal pulse
A client who has been taking spironolactone is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply A. Lethargy B. Thready, weak pulse C. Muscle weakness D. Hyperactive deep tendon reflexes E. Numbness and tingling of the hands and feet
Lethargy, thready/weak pulse, muscle weakness
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
Metabolic acidosis
A client who is postoperative hip replacement is receiving morphine by patient-controlled analgesia and has a respiratory rate of 6 breaths/min. What interventions should the nurse anticipate? A. Nasotracheal suction B. Mechanical ventilation C. Naloxone administration D. Cardiopulmonary resuscitation
Naloxone administration
A nurse is planning an evening snack for a child receiving NPH insulin. What is the reason for this nursing action? A) It encourages the child to stay on the diet B) Energy is needed for immediate utilization C) Extra calories will help the child gain weight D) Nourishment helps counteract late insulin activity
Nourishment helps counteract late insulin activity
A nurse identifies that a client may be dehydrated. Which clinical manifestations would the client exhibit? Select all that apply A. Oliguria B. Dyspnea C. Hypotension D. Pulmonary crackles E. Tenting tissue turgor
Oliguria, hypotension, & tenting tissue turgor
A nurse is caring a for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective? A) Pain subsides as a result of arteriole and venous dilation B) Pulse rate increases because the cardiac output has been stimulated C) Sublingual area tingles because sensory nerves are being triggered D) Capacity for activity improves as a response to increased collateral circulation
Pain subsides as a result of arteriole and venous dilation
A young child with acute nonlymphoid leukemia is admitted to the pediatric unit with a fever and neutropenia. What are the most appropriate nursing interventions to minimize the complications associated with neutropenia? A. Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques B. Encouraging a well-balanced diet, including iron-rich foods, and helping the child avoid overexertion C. Avoiding rectal temperatures, limiting injections, and applying direct pressure for 5 minutes after venipuncture D. Offering a moist, bland, soft diet; using toothettes rather than a toothbrush; and pricing a frequent saline mouthwash
Placing the child in a private room, restricting ill visitors, and using strict hand washing techniques
A client is admitted to the hospital for a subtotal thyroidectomy. When discussing postoperative drug therapy with the client, what will the nurse include in the teaching? A. Take the iodine daily to increase the formation of thyroid hormone B. Understand that medication will be temporary until the body adjusts to post surgical activities C. Take the propylthiouracil that is prescribed to stimulate the secretion of thyroid-stimulating hormone D. Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone
Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone
When monitoring a client for Hyponatremia, which assessment findings should the nurse consider significant? Select all that apply A. Thirst B. Seizures C. Erythema D. Confusion E. Constipation
Seizures & Confusion
The nurse is caring for a client who is on a cardiac rhythm monitor. The nurse notes that the client's P waves are of normal configuration and that each P wave is followed by a QRS complex. All intervals are normal as well, but the client's heart rate is 112 beats per min. How will the nurse interpret this rhythm? A) Sinus arrhythmia B) Sinus tachycardia C) Junctional tachycardia D) Ventricular tachycardia
Sinus tachycardia
While performing a physical assessment in a client, the registered nurse (RN) notices reddish linear streaks in the nail bed. Which systemic condition can the registered nurse (RN) suspect in the client based on these assessment findings? A) Syphilis B) Iron deficiency anemia C) Subacute bacterial endocarditis D) Chronic obstructive pulmonary disease
Subacute bacterial endocarditis
A client with hyperthyroidism asks the nurse about the tests that will be prescribed. Which diagnostic tests should the nurse include in a discussion with this client? A. Thyroxine (T4) and x-ray films B. Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T3) C. Thyroglobulin level and PO2 D. Protein-bound iodine and sequential multichannel autoanalyzer (SMA)
Thyroid-stimulating hormone (TSH) assay and triiodothyronine (T3)
A nurse is caring for a client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply A) Polyuria B) Truncal obesity C) Hypotension D) Sleep disturbance E) Thin arm and legs
Truncal obesity, sleep disturbance, thin arms/legs
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? (Select all that apply.) A. Anorexia B. Vomiting C. Constipation D. Muscle weakness E. Irregular heart rate
Vomiting, muscle weakness, irregular heart rate
