Exit HESI

The postoperative client is placed on a clear liquid diet. Which selections will the nurse select for the client? (Select all that apply.) A. Apple juice B. Popsicles C. Vanilla pudding D. Tomato soup E. Gelatin F. Black coffee

correct answer: A,B,E,F rationale: Clear liquids are transparent and liquid at room temperature. Tomato soup and vanilla pudding are included in a full liquid diet.

The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that apply.) A. Compress the chest once between the nipples with two fingers. B. Note any obstruction or absence of breathing. C. Deliver five backslaps between the shoulder blades. D. Place the infant over the nurse's arm. E. Perform a blind finger sweep.

correct answer: B,C,D rationale: The fingers are placed at the same location on an infant as chest compressions for CPR; however, the nurse must deliver five chest thrusts, after the five back slaps. Blind sweeps are not used as this action may push the object deeper into the throat. The remaining steps are correct.

An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A. Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardia

correct answer: D 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.

What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A. Reducing dairy products in the diet B. Straining all urine C. Measuring intake and output D. Increasing fluid intake

correct answer: B 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 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? A. Myocardial infarction 2 months ago B. Anorexia and vomiting for the past 2 days C. Recently diagnosed type 2 diabetes mellitus D. Skeletal traction for a right hip fracture

correct answer: B 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.

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? A. Amiodarone (Cordarone) B. Magnesium sulfate C. Lidocaine (Xylocaine) D. Procainamide (Pronestyl)

correct answer: B 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 with chronic asthma is admitted to the PACU complaining of pain at a level of 8 on a 1 to 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 to 4 mg IV push, while in recovery for pain level over 5." Which action should the nurse take first? A.Give the medication as prescribed to decrease the client's pain. B. Call the anesthesia provider for a different medication for pain. C. Use nonpharmacologic techniques before giving the medication. D. Reassess the pain level in 30 minutes and medicate if it remains elevated.

correct answer: B 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.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse take next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.

correct answer: B rationale: This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status to be sure that the client understands and can legally provide consent for surgery. Option A does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin.

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse to intervene with the UAP's approach? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

correct answer: B rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.

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

correct answer: B rationale: A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 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 terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about thoughts and feelings about death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility.

correct answer: B rationale: The nurse should first assess the client's feelings about death and determine the extent to which this statement expresses the client's true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options C and D are both premature interventions and should not be implemented until further assessment is obtained.

The nurse is preparing to insert an IV, and cap off the IV with an intermittent infusion devise for an 80-year-old who is prescribed IV antibiotics every 8 hours. The client is taking po fluids well. What supplies will the nurse take into the room for this procedure? (Select all that apply.) A. A 16 gauge IV catheter B. Normal saline in a 10 mL syringe C. Clear plastic sterile bandage D. Skin preparation antiseptic swab E. 1000 mL bag of normal saline

correct answer: B,C,D rationale:Items not needed to insert an IV for intermittent antibiotic therapy for an 80-year-old are a 16 gauge intracath; the intracath is too large. Large bore intracaths are for rapid infusions. A small bag of NS, e.g. 250 mL, will be needed to flush the line. The remaining items are needed to start an IV.

The client 12 hours after a laparotomy reports to the nurse a pain rating of 7 to 10. The nurse reviews the medication orders and it is another hour before the client can have another dose of pain medication. What actions can the nurse take to assist the client? (Select all that apply.) A. Administer the IV pain medication an hour early B. Assist the client into side-lying, curled position C. Obtain a warm pack to apply to the site of the incision. D. Suggest to the client taking 10 deep breaths, in through the nose and out through the mouth E. Help the client with sustained concentration of a personally pleasant topic

correct answer: B,C,D,E rationale: The nurse would be not following the health care provider's prescription if the pain medication were delivered an hour early. The nurse could call for an additional dose of medication for break-through pain, but administering medication early is prescribing without authority. The remaining selections are all non-pharmacologic measures for pain relief.

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.) A. Reactivity of deep tendon reflexes B. Heart rate and respiratory rate C. Memory of recent events D. Ability to open the eyes spontaneously E. Dizziness F. Ringing in the ears

correct answer: B,C,D,E,F 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.

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.) A. Place your hands in 130°F/54.4°C water until warmed through. B. Wear warm clothing and socks when you are cold. C. Use finger guards when using a knife to avoid cutting your hands. D. Take your medication only when you feel the tingling in your fingers. E. Avoid stressful situations at work and in your home life.

correct answer: B,C,E 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.

The client states to the nurse, "This medication makes my mouth so dry." What are the nurse's suggestions to quench the client's thirst? (Select all that apply.) A. Drink 2, 8 ounce glasses of lemon-lime soda every day. B. Infuse your water with fresh citrus fruits to quench your thirst. C. Freeze strawberries and water together in popsicle mold. D. Add ginger ale to your daily glass of juice every day. E. Keep a few pieces of hard candy with you to suck on.

correct answer: B,C,E rationale: Sodas do not tend to be thirst quenching because of the amount of sugar in them that draws fluid into the GI system. Citrus infused water quenches thirst, as does consuming frozen liquids. Hard candy can produce moisture in the mouth.

The nurse is evaluating measures implemented for the non-responsive client. Which findings indicate the effectiveness of the care delivered? (Select all that apply.) A. Footboard at the end of the bed B. Heals without redness bilaterally C. Skin intact on the back D. Sheepskin booties in place E. Elbow joint fully flexes and extends. F. Ankle joint rotates 360 degrees freely.

correct answer: B,C,E,F rationale: The footboard helps prevent foot drop, but does not measure the effectiveness of the treatment. The sheepskin booties are in place to protect the heal, but they do not demonstrate the effectiveness. The remaining are assessments that demonstrate the interventions are effective.

The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When viewing the consent form, the nurse notes the surgeon's signature, but not the client's signature. What steps must the nurse take? (Select all that apply.) A.Call the surgeon. B. Ask the client, "Did your surgeon explain the procedure to you?" C. Have the client's spouse sign the form. D. Ask the client, "Do you have any questions?" E. Witness the signature. F. Obtain the consent.

correct answer: B,D,E rationale: It is the surgeon's responsibility to review the procedure with the client until the client has no further questions. The nurse can verify the review by the surgeon and ask if the client has any further questions. If the client has questions, the nurse must call in the surgeon. When the nurse signs the consent form, the nurse is witnessing the signature only.

One week after being told that she has terminal cancer with a life expectancy of 3 weeks, the client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family."

correct answer: C rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party. Option B puts words in the client's mouth that may not be accurate. The nurse should support the client's goals rather than telling the client how to spend her time.

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? A. Increased serum albumin level B. Decreased serum creatinine C. Decreased serum ammonia level D. Increased liver function test results

correct answer: C 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.

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client safely administered the injections. What is the nurse's best response? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C."When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home."

correct answer: C rationale: The nurse needs to focus on the client's positive behaviors, so focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. Option A does not focus on the specific behaviors related to giving the injection and could be interpreted as punitive. Option B uses reflective dialogue to assess the client's feelings, but telling the client that he is nervous may serve as a negative reinforcement of this behavior. Option D reinforces the client's dependence on the nurse.

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.) A. Place 4 sugar cubes under the tongue. B. Place 1 tablespoon of honey in the client's cheek. C. Start an IV of Normal Saline. D. Obtain a 50% dextrose solution. E. Administer glucagon as per the standing order. F. Turn the client to the side.

correct answer: C,D,E,F 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.

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? A. Azotemia B. Oliguria C. Hyperkalemia D. Nephron obstruction

correct answer: D 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.

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? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline.

correct answer: D 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 is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up? A. Urine specific gravity of 1.03 B. Frothy, tea-colored urine C. Clay-colored stools D. Elevated serum amylase and lipase levels

correct answer: D 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 assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection

correct answer: D 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.

The nurse is making an initial daily assessment at 0715 and notes 550 mL of LR running at 75 mL an hour. At what time, in military time, will the nurse hang the next bag of IV fluid? _____

correct answer: 1435 rationale: 550mL/75 mL = 7.33 hr 60 X 0.33333 = 19.99 min = 20 min 7 hr 20 min + 0715= 1435

The nurse is working at a community-based clinic. Which client's spiritual well-being concerns the nurse the most? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement

correct answer: A rationale: In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement.

A nurse is working in an occupational health clinic when an employee walks in and states, "I was walking outside and I believe I was just struck by lightning." The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury

correct answer: A rationale: Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation.

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult."

correct answer: A rationale: Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement.

The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and 8:00 pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan on drawing the test? A. 7:00 am B. 9:00 am C. 12:00 noon D. 2:00 pm

correct answer: A rationale: The aPTT test should be drawn 1 hour before the scheduled dose.

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention.

correct answer: A rationale: The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output, but no additional action is needed.

The nurse is concerned the client will develop a nosocomial infection. Which nursing action is best for the nurse to take when providing care for an incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers.

correct answer: A rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection.

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? A. Prepare the client for a pericardial tap. B. Administer intravenous furosemide. C. Assist the client to cough and breathe deeply. D. Instruct the client to restrict oral fluid intake.

correct answer: A 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 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? A. Around the waist B. At the inner aspect of the left stump C. At the outer aspect of the left stump D. At the left groin area

correct answer: A rationale: The waist is the anchor point for the bandage for an above the knee amputation.

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 health care provider before the chest tube is removed? A. Tidaling of water in water seal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101°F D. Absence of chest tube drainage for 2 days

correct answer: A rationale: Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care 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.

Which steps should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back.

correct answer: A,B rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

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.) A. Frequent oral care every 2 hours while awake. B. Use incentive spirometer every 2 hours. C. Empty contents from NG tube every 8 hours. D. Ambulate within 1 hour of return from the PACU. E. Limit visitors until postoperative day 2.

correct answer: A,B,C 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 post operatively, 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 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.) A. "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."

correct answer: A,B,C 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.

The nurse is performing an intake interview for a newly admitted client to the rehabilitation unit. Which questions will the nurse include in the interview? (Select all that apply.) A. "When do you usually go to bed? And, when do you usually wake up?" B. "Do you usually bathe/shower in the morning or in the evening?" C. "Do you have any intolerance to food that we need to know about?" D. "How long do you think you will be here on the rehabilitation unit?" E. "Do you urinate every hour, on the hour, when you are awake?"

correct answer: A,B,C,D rationale: The goal of the intake interview is to understand the client's daily routines so those routines can be observed and upheld while residing on the rehabilitation unit. Asking about how long the client will be on the rehabilitation unit helps the nurse to understand the client's expectations of the duration of the stay. Urinary and bowel patterns are important to understand, but the issue with this assessment is the frequency of urination. The better question is, "How often do you urinate when you are awake?"

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.) A. Nausea and vomiting B. Loss of appetite C. Abdominal cramping D. Guarding with abdominal palpation E. Low urine output F. Cool, clammy skin

correct answer: A,B,C,D 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 health care provider must be notified immediately.

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.) A. Assess lung sounds. B. Look for equal and bilateral expansion of the chest. C. Monitor skin color. D. Evaluate the need for suctioning. E. Tell the family the client is expected to fully recover. F. Make sure the ventilator alarms are set.

correct answer: A,B,C,D,F 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.

The postoperative client states to the nurse, "When I had surgery last year I got constipated. It was miserable. What can I do to avoid constipation after this surgery this time?" (Select all that apply.) A. "Drink approximately 3000 mL of non-caffeinated fluid per day." B. "I will make sure that you get out of bed an walk for 10 minutes, six times per day." C. "I will administer your pain medication even if you do not have any pain." D. "I will ask your healthcare provider for a prescription of docusate." E. "When you are on a regular diet, make sure you order plenty of fruits and vegetables." F. "When you are resting in bed, make sure you are flat on your back."

correct answer: A,B,D,E rationale: Pain medication can be constipating, and should only be taken when needed. When in bed, use gravity to help move the contents of the bowel by sitting upright. The remaining selections are correct. When postoperative, it may take up to 48 hours after a general diet is started to have a bowel movement.

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.) A. Frequent vital signs. B. Determine if the client is allergic to aspirin. C. Assist out of bed 2 hours after return from the procedure. D.Offer fluids of choice. E.Assess distal pulses on the side of the procedure. F. Monitor infusion of IV nitroglycerine.

correct answer: A,B,D,F rationale: The client's incisional leg needs to stay straight for 6 to 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.

A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of respiratory compromise for this client. What will the nurse include in this client's plan of care? (Select all that apply.) A. Raise the head of the bed to no less than a 45 degrees angle. B. Have the client use an incentive spirometer 10 times every hour while awake. C. Limit total fluid intake to no more than 1000 mL/day. D. Have the client sit on the side of the bed instead of getting up and walking. E. Ask the client to take deep breaths and cough five times every hour while awake.

correct answer: A,B,E rationale: As long as the client is not on a fluid restriction, offer no less than 2000 mL of fluid to keep the body well hydrated and keep respiratory secretions loose. Ambulation is key for this client. Sitting at the side of the bed is not a replacement for ambulating. Having the client sit up helps expand the lungs. Taking deep breaths, through coughing or incentive spirometry, helps expand the lungs and decrease atelectasis.

Which foods will the nurse recommend for the client with tuberculosis being discharged to home? (Select all that apply.) A. Bean soup B. Spinach C. Apples D. Bananas E. Dark chocolate F. Shellfish

correct answer: A,B,E,F 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.

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.) A.Yell, "Call 911." B.Ask the mother if she has the child's bronchodilator. C.Start cardiopulmonary respirations. D.Ask the mother if the child is allergic to bee stings. E.Stay with the child and mother until the ambulance arrives. F.Sit the child straight up in Fowler's position.

correct answer: A,B,E,F 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 nurse is preparing to administer a bolus tube feeding. What steps must the nurse include prior to administering the feeding? (Select all that apply.) A. Aspirate the stomach contents. B. Assess bowel sounds. C. Position the client in semi-Fowler's position. D. Irrigate the lumen after the contents are replaced. E. Warm the feeding to room temperature. F. Assess the pH of the stomach contents.

correct answer: A,B,E,F rationale: The client needs to be in high Fowler's position to decrease the risk of aspiration. Irrigation of the lumen is only necessary if there is an obstruction. The contents were replaced, so there is no suspicion of obstruction. The remaining steps are correct.

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.) A. Apply heat packs to your knees as needed for pain. B. Support your knees while you are in bed with a pillow or a rolled towel. C. Take 1000 mg of acetaminophen every 4 hours, as needed for pain. D. Walk no less than 3 miles every day. E. Get 7 to 8 hours of sleep every night. F. Eat a balanced diet, including fish with Omega-3 fatty acids.

correct answer: A,B,E,F 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 nurse is providing care to a client immediately after a total right mastectomy. What steps will the nurse include when positioning the client? (Select all that apply.) A. Raise the head of the bed 30 to 45 degrees. B. Roll the client to her right side and place a pillow behind her back. C. Elevate her right arm under two pillows. D. Require the client to stay in bed for 72 hours post procedure. E. Place a sandbag on the incision.

correct answer: A,C rationale: The client must stay on her back or on the unaffected side, not on the operative side. Mobility as tolerated; there is no need to remain immobile. A sandbag is used when there is risk of bleeding from the wound. There is no mention of that risk in the stem. Sitting up and elevating the arm will help lymph drainage.

The spouse is at the bedside of the client who just died. The hospice nurse states to the spouse, "I know your children want to come over and say goodbye before we call the funeral home. Just let me know when you are ready for me to prepare the body." What steps will the nurse include in the postmortem care? (Select all that apply.) A. Remove the existing Foley catheter. B. Wash the genitalia only. C. Close the client's eyes. D. Remove soiled padding under the client. E. Place a dressing over the abdominal scar.

correct answer: A,C,D rationale: Postmortem care includes making the client ready for the family to view prior to the client's transfer to the mortuary. The nurse need to make sure the client's body is completely washed, and all dressings and all tubes, i.e. Foley, NG, IV, are removed. As the client may excrete contents from the bowel and the bladder during the dying process, remove all soiled pads and bedding from under the client and replace with fresh items. Make sure the client's eyes are closed.

The nurse is providing care to a client with a central venous catheter. The health care provider orders multiple labs. Using the discard method, what steps will the nurse use to draw the blood samples? (Select all that apply.) A. Prepare the catheter hub with an antiseptic solution according to facility protocol. B. Attach a syringe to the hub containing 2 mL of normal saline and flush the line. C. Attach the vacutainer sleeve or 20 mL syringe to the catheter hub. D. Withdraw waste blood and discard it in an appropriate container. E. Draw the amount of blood needed for the laboratory samples. F. Flush the line with no more than 2 mL of normal saline to flush the line.

correct answer: A,C,D,E 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.

The nurse evaluates the insertion site of an IV catheter and suspects the IV is infiltrated. Which findings support the evaluation? (Select all that apply.) A. The area around the insertion site is swollen. B. There is bruising 1 inch below the insertion site. C. The insertion site is cool to the touch. D. The client complains of a burning pain at the site. E. Redness is noted in the area of the insertion site. F. Blood is noted in the IV tubing when the IV bag is lowered.

correct answer: A,C,D,E rationale: Bruising is an accumulation of blood under the skin, most likely from oozing with the insertion of the IV. When blood is noted in the IV tubing when the IV bag is lowered, that is a sign of patency. The remaining signs are related to infiltration.

The client reports to the clinic nurse, "I sleep for about 2 hours and then I have to get up to use the bathroom. I repeat that pattern about three to four times per night." What questions will the nurse include in this client's assessment? (Select all that apply.) A. "How much fluid do you drink after 8:00 in the evening? B. "Does your spouse wake up with you, and use the bathroom after you?" C. "What time of day do you take your water pill?" D. "Do you drink any alcoholic beverages in the evening?" E. "When did this pattern of urination start?" F. "Do you have any itching or burning when you urinate?"

correct answer: A,C,D,E,F rationale: Asking if the spouse also gets up at night does not relate to the clients' pattern of frequency of urination at night. The goal of the assessment is to try and understand the client's urinary usual patterns and to determine if there are any modifiable factors that can decrease the frequency of urinating at night. Urinary frequency is also a sign of a urinary tract infection.

The nurse is preparing an IV solution containing 10 mEq of potassium in 100 mL of normal saline. Which findings would concern the nurse? (Select all that apply.) A. A red and swollen peripheral IV site B. An order to infuse the solution at 50 mL/hr C. Starting the infusion without an infusion device D. Inverting the potassium solution every 30 minutes while infusing E.The solution is a lemon-yellow color

correct answer: A,C,E rationale: Potassium can cause phlebitis. The red swollen IV site is showing signs infection. The IV site would need to be changed before starting the solution. Potassium solutions must infuse with an infusion devise to avoid an accidental bolus infusion. Potassium solution should be clear, and not lemon yellow. The remaining selections are not concerning to the nurse.

The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the nurse consider when administering PN? (Select all that apply.) A. Remove the PN from the refrigerator 30 minutes before infusing. B. Have a second nurse double check the PN before connecting the solution. C. Have a second IV line in place for administering IV medications. D. Assure the infusion time for the PN does not exceed 24 hours. E. Tell the client a feeling of being full should occur with PN. F. Return amber and cloudy solutions of PN to the pharmacy.

correct answer: A,D,F rationale: There are no issues with antibody incompatibility with PN, so there is no need to double check the PN, or start a second IV line. PN is administered through the venous system and does not satiate the client. The remaining selections are true about the administration of PN.

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.) A. Oral care B. Bathing C. Foot care D. Catheter care E. Enteral feeding

correct answer: A,E 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.

The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the nurse bring to the attention of the healthcare provider? A. Temperature: 97.5°F/36.4°C B. Pulse: 80 beats/min C. Respirations: 26 breaths/min D. Blood pressure: 90/53 mm Hg

correct answer: B rationale: A normal pulse rate for a 1-year-old is 90 to 130. This child's heart beat is below the normal range. The remaining vital signs are within the normal limits for a 1-year-old.

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? A. Measure the client's calf circumference. B.Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure.

correct answer: B 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.

The nurse is reviewing routine medications taken by a client with chronic angle-closure glaucoma. Which medication prescription should the nurse question? A. Antianginal with a therapeutic effect of vasodilation B. Anticholinergic with a side effect of pupillary dilation C. Antihistamine with a side effect of sedation D. Corticosteroid with a side effect of hyperglycemia

correct answer: B 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.

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? A.Bilateral jugular venous distention B. Oral temperature of 102°F C. Intermittent focal motor seizures D. Intractable pain in the cervical region

correct answer: B 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 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? A. Hypophosphatemia B. Hypocalcemia C. Hyponatremia D. Hypokalemia

correct answer: B 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.

Which condition should the nurse anticipate as a potential problem in a female client with a neurogenic bladder? A. Stress incontinence B. Infection C. Painless gross hematuria D. Peritonitis

correct answer: B 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.

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? A. The vaccine is given annually before the flu season to those older than 50 years. B. The immunization is administered once to older adults or those at risk for illness. C. The vaccine is for all ages and is given primarily to those persons traveling overseas to areas of infection. D. The vaccine will prevent the occurrence of pneumococcal pneumonia for up to 5 years.

correct answer: B 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.

Which change in laboratory values indicates to the nurse that a client with rheumatoid arthritis may be experiencing an adverse effect of methotrexate therapy? A. Increase in rheumatoid factor B. Decrease in hemoglobin level C. Increase in blood glucose level D. Decrease in erythrocyte sedimentation rate (ESR; sed rate)

correct answer: B 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.

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? A.Turns on the continuous wall suction to 190 mm Hg B.Inserts the catheter until resistance or coughing occurs C.Withdraws the catheter while maintaining suctioning D.Reclears the tracheostomy after suctioning the mouth

correct answer: B 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 to 2 cm at a time with intermittent, not continuous, suction. Option D introduces pathogens unnecessarily into the tracheobronchial tree.

The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts were made prior to obtaining the sample with the tourniquet in place for nearly 5 minutes. Which laboratory finding would the nurse suspect is inaccurate related to the prolonged tourniquet placement? A.Na 148 mEq/L B. K 5.3 mEq/L C. Cl 102 mEq/L D. Ca 9.3 mg/dL

correct answer: B rationale: Prolonged tourniquet placement can cause accumulation of potassium, skewing the result upward. The sodium level is also high, but that is not related to the blood draw. The chloride and calcium levels are normal.