Exit hesi
A client with acute pancreatitis is admitted with severe , piercing abdominal pain and an elevated serum amylase . Which additional information is the client most likely to report to the nurse? A Abdominal pain decreases when lying supine . B Pain lasts an hour and leaves the abdomen tender . C Right upper quadrant pain refers to right scapula . D Drinks alcohol until intoxicated at least twice weekly .
A Abdominal pain decreases when lying supine .
The nurse is caring for a group of clients with the help of a practical nurse ( PN ) Which nursing actions should the nurse assign to the PN ( select all that apply ) A Administer a dose of insulin per siding scale for a client with type 2 diabetes melitus ( DM ) b Start the second blood transfusion for a client twelve hours following a below knee amputation no C Initate patient controlled analgesia ( PCA ) pumps for two clients immediately postoperatively D Perform daily surgical dressing change for a client who had an abdominal hysterectomy E Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
A Administer a dose of insulin per siding scale for a client with type 2 diabetes melitus ( DM ) D Perform daily surgical dressing change for a client who had an abdominal hysterectomy E Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty
A client who gave birth 48 hours ago has decided to bottle feed the infant . During the assessment , the nurse observes that both breasts are swollen , warm , and tender on palpation . Which instruction should the nurse provide ? A Apple ice to the breasts for comfort . B Wear a loose - fitting bra during the day to prevent nipple irritation . C Run warm water over breasts . D Express small amounts of milk from the breasts to relieve pressure .
A Apple ice to the breasts for comfort .
A client presses the call bell and requests pain medication for a severe headache . To assess the quality of the client's pain , which approach should the nurse Select use ? A Ask the client to describe the pain . B Observe body language and movement . C Identify effective pain relief measures . D Provide a numeric pain scale
A Ask the client to describe the pain .
The nurse identifies an electrolyte imbalance , a weight gain of 4.4 lbs ( 2 kg ) in 24 hours and an elevated central venous pressure for a client with full thickness burns . Which intervention should the nurse implement ? A Auscultate for regular heart rate B Review arterial blood gases results C Measure ankle circumference D Document abdominal girth
A Auscultate for regular heart rate
A pediatric client is taking the beta - adrenergic blocking agent propranolol . In developing a teaching plan , the nurse should teach the parents to report which sign of overdose? A Bradycardia . B Tachypnea . C Hypertension D Coughing .
A Bradycardia .
A male client with cirrhosis has jaundice and pruritus . He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort . Which action should the nurse take ? A Encourage the client to use cooler water and apply calamine lotion after soaking . B Obtain a PRN prescription for an analgesic that the client can use for symptom relief . C Suggest that the client take brief showers and apply oil - based lotion after showering . D Explain that the symptoms are caused by liver damage and cannot be relieved .
A Encourage the client to use cooler water and apply calamine lotion after soaking .
The nurse is taking the blood pressure measurement of a client with Parkinson's disease . Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading ? ( Select all that apply . ) A Frequent syncope . B Occasional nocturia . C Flat affect . D Blurred vision E Frequent drooling .
A Frequent syncope . C Flat affect . D Blurred vision
A child newly diagnosed with sickle cell anemia ( SCA ) is being discharged from the hospital . Which information is most important for the nurse to provide the parents prior to discharge ? A Instructions about how much fluid the child should drink daily . B Signs of addiction to opioid pain medications . C Information about non - pharmaceutical pain relief measures . D Referral for social services for the child and family .
A Instructions about how much fluid the child should drink daily
A client who is admitted for primary hypothyroidism has early signs of myxedema coma . In assessing the client , in which sequence should the nurse complete these actions ? ( Rank the first action at the top with the remainder in descending order . ) A Observe breathing patterns . B Assess blood pressure . C Measure body temperature . D Palpate for pedal edema .
A Observe breathing patterns . B Assess blood pressure . C Measure body temperature . D Palpate for pedal edema .
Following a cardiac catheterization and placement of a stent in the right coronary artery , the nurse administers prasugrel , a platelet inhibitor , to the client . To monitor for adverse effects from the medication , which assessment is most important for the nurse to include in this clients plan of care ? A Observe color of urine . B Measure body temperature . C Assess skin turgor . D Check for pedal edema .
A Observe color of urine .
While assessing a client who is admitted with heart failure and pulmonary edema , the nurse identifies dependent peripheral edema , an irregular heart rate , and a persistent cough that produces pink blood - tinged sputum . After initiating continuous telemetry and positioning the client , which intervention should the nurse implement ? A Obtain sputum sample . B Document degree of edema . C Initiate hourly urine output measurement . D Administer intravenous diuretics .
A Obtain sputum sample .
The nurse is managing the care of a client with Cushing's syndrome . Which interventions should the nurse delegate to the unlicensed assistive personnel ( UAP ) ? ( Select all that apply . ) A Report any client complaint of pain or discomfort . B Evaluate the client for sleep disturbances . C Assess the client for weakness and fatigue . D Weigh the client and report any weight gain . E Note and report the client's food and liquid intake during meals and snacks .
A Report any client complaint of pain or discomfort . D Weigh the client and report any weight gain . E Note and report the client's food and liquid intake during meals and snacks .
A toddler presenting with a history of intermittent skin rashes , hives , abdominal pain , and vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the parents . Which type of testing should the nurse provide education to the toddler's family about ? A Serum Immunoglobulin E ( IgE ) . B Intradermal test . C Atopy patch test . D Placebo - controlled food challenge
A Serum Immunoglobulin E ( IgE ) .
Prior to obtaining a trapeze bar for a client with limited mobility , which client assessment is most important for the nurse to obtain ? A Upper body muscle strength . B Balance and posture . C Risk for disuse syndrome . D Pressure sore risk .
A Upper body muscle strength .
A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure . In preparing the client for the procedure , which Intervention has the highest priority ? A Allow client to gargle with warm salt water . B Administer a sedative to alleviate anxiety . C Instruct client to write down the questions . D Deny client's request for a midnight snack .
B Administer a sedative to alleviate anxiety .
After administering a proton pump inhibitor ( PPI ) , which action should the nurse take to evaluate the effectiveness of the medication? A Auscultate for bowel sounds in all quadrants . B Ask the client about gastrointestinal pain . D Measure the client's fluid intake and output . C Monitor the client's serum electrolyte levels .
B Ask the client about gastrointestinal pain .
A preschool - aged boy is admitted to the pediatric unit following successful resuscitation from a near - drowning incident . While providing care to the child , the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation . The nurse notices the older boy becomes withdrawn when asked about what happened . Which action should the nurse take ? A Develop a water safety teaching plan for the family . B Ask the older brother how he felt during the incident . C Tell the older brother that he seems depressed . D Commend the older brother for his heroic actions .
B Ask the older brother how he felt during the incident .
Anurse receives report on a client who is four hours post - total abdominal hysterectomy . The previous nurse reports that it was necessary to change the client's perineal pad hourly and that it is again saturated . The previous nurse also reports that the client's urinary output has decreased . Which action should the nurse implement first ? A Evaluate the skin turgor B Assess for weakness or dizziness . C Change the perineal pad . D Measure the urinary output .
B Assess for weakness or dizziness .
Which self care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus ? A Self - injection techniques . B Blood glucose monitoring . C Diabetic diet meal planning . D A realistic exercise plan .
B Blood glucose monitoring .
The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction . What instruction should the nurse provide the unlicensed assistive personnel ( UAP ) who is working with the nurse ? A Notify the nurse when transfusion has finished , so further client assessment can be done . B Continue measure the client's vital signs every thirty minutes until the transfusion is complete . C Monitor the client carefully for the next three hours and report the onset of a reaction immediately D Since a reaction did not occur , the priority is to maintain client comfort during the transfusion .
B Continue measure the client's vital signs every thirty minutes until the transfusion is complete .
While caring for a client's postoperative dressing , the nurse observes purulent drainage at the wound . Before reporting this finding to the healthcare provider , the nurse should review which of the client's laboratory values A Serum albumin . B Culture for sensitive organisms . C Serum blood glucose ( BG ) level . D Creatinine level .
B Culture for sensitive organisms .
A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations . Which finding should the nurse identify may indicate an emerging situation ? Potassium 3.5 mEq / L ( 3.5 mmol ) . OB Fingertips feel numb . Oc Sodium 135 mEq / L ( 135 mmol / L ) . D Cervical spine stiffness .
B Fingertips feel numb .
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia ( BPH ) . Which information should the nurse provide ? A Consume a high protein diet . B Increase physical activity . C Take vitamin supplements . D Obtain a prostate - specific antigen blood level test .
B Increase physical activity .
Which intervention should the nurse include in the plan of care for a child with tetanus? A Encourage coughing and deep breathing. B Minimize the amount of stimuli in the room. C Reposition from side to side every hour D Open window shades to provide natural light.
B Minimize the amount of stimuli in the room.
The nurse is reviewing the diagnostic tests prescribed for a client with a positive skin test . Which subjective findings reported by the client supports the diagnosis of tuberculosis ? A Barking cough and vomiting . B Mucopurulent cough and night sweats . C Dry cough and chest tightness . D Chronic cough and fatty stools .
B Mucopurulent cough and night sweats .
When assessing an IV site that is used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site . Which additional assessment finding warrants Immediate intervention by the nurse ? A Client uses the arm cautiously . B Red streak tracking the vein . C A sluggish blood return . D Spot of dried blood at insertion site .
B Red streak tracking the vein .
An older client with a long history of coronary artery disease ( CAD ) , hypertension ( HTN ) , and heart failure ( HF ) arrives in the Emergency Department ( ED ) in respiratory distress . The healthcare provider prescribes furosemide IV . Which therapeutic response to furosemide should the nurse expected in the client with acute HF ? A Increased cardiac contractility B Reduced preload C Relaxed vascular tone . D Decreased afterload .
B Reduced preload
A client with Type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin ( A1C ) of 10 % . Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart every 6h are prescribed . What actions should the nurse include in this client's plan of care ? ( Select all that apply . ) A Do not contaminate the insulin aspart so that it is available for IV use . B Review with the client proper foot care and prevention of injury . C Teach subcutaneous injection technique , site rotation , and insulin management . D Coordinate carbohydrate controlled meals at consistent times and intervals . E Fingerstick glucose assessments every 6h with meals . F Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose .
B Review with the client proper foot care and prevention of injury . C Teach subcutaneous injection technique , site rotation , and insulin management . D Coordinate carbohydrate controlled meals at consistent times and intervals . F Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose .
The nurse is completing the admission assessment of a 3 - year - old who is admitted with bacterial meningitis and hydrocephalus Which assessment finding evidence that the child is experience increased intracranial pressure ( ICP ) ? A Tachycardia and tachypnea B Sluggish and unequal pupillary responses . C Increased head circumference and bulging fontanels D Blood pressure fluctuations and syncope .
B Sluggish and unequal pupillary responses .
A young adult visits the clinic reporting symptoms associated with gastritis . Which information in the client's history is most important for the nurse to address in the teaching? A Consumes 10 of more drinks of alcohol every weekend . B Snacks on foods with very high salt content on a daily basis . C Exercises vigorously every evening right before going to bed . D Recently became a vegetarian and eats a lot of high fiber foods .
B Snacks on foods with very high salt content on a daily basis .
The nurse preparing a client who had a below - the - knee ( BKA ) amputation for discharge to home . Which recommendations should the nursie provide this client ? ( Select all that apply . ) A Avoid range of motion exercises B Use a residual limb shrinker . C Apply alcohol to the stump after bathing D Inspect skin for redness E Wash the stump with soap and water .
B Use a residual limb shrinker . D Inspect skin for redness E Wash the stump with soap and water .
In assessing a client with type 1 diabetes mellitus , the nurse notes that the client's respirations have changed from 16 breaths / minute with a normal depth to 32 breaths / minute and deep and the client has become lethargic . Which assessment data should the nurse obtain next ? a Temperature . B Breath sounds . C Blood glucose . D White blood cell count .
C Blood glucose .
An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 , is admitted to the hospital in diabetic ketoacidosis Which occurrence is the most likely cause of the ketoacidosis ? A Ate an extra peanut butter sandwich before gym class . B Incorrectly administered too much insulin OC C Had a cold and ear infection for the past two days . D Skipped eating lunch ,
C Had a cold and ear infection for the past two days .
A client at 12 - weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum , Which action is most important for the nurse to implement ? A Obtain the client's 24 - hour dietary recall . B Document mucosal membrane status . C Initiate prescribed intravenous fluids . D Schedule a consult with a nutritionist .
C Initiate prescribed intravenous fluids .
The father of a 4 - year - old has been battling metastatic lung cancer for the past 2 years . After discussing the remaining options with his healthcare provider , the client requests that all treatment stop and that no heroic measures be taken to save his life . When the client is transferred to the palliative care unit , which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care ? A Reassure the client that his child will be allowed to visit . B Provide the client written information about end - of - life care . C Obtain a detailed report from the nurse transferring the client . D Mark the chart with client's request for no heroic measures .
C Obtain a detailed report from the nurse transferring the client .
A client with a prescription for " do not resuscitate " ( DNR ) begins to manifest signs of impending death . After notifying the family of the client's status , what priority action should the nurse implement A The impending signs of death should be documented . B The client's status should be conveyed to the chaplain . C The client's need for pain medication should be determined . D The nurse manager should be updated on the client's status .
C The client's need for pain medication should be determined .
The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? A Core strengthening B Aerobic exercise C Weight-Bearing exercise D Muscle stretching and toning .
C Weight-Bearing exercise
An older client brought to the emergency department ( ED ) with a sudden onset of confusion that occured after after experiencing a fall at home . The client's daughter who has power of attorney, has broguht the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR? A Currently prescribed medication B Client's healthcare power of attorney C increasing confusion of the client D Fall at home an reason for admission
C increasing confusion of the client
The psychiatric nurse is caring for clients on an adolescent unit . Which client requires the nurse's immediate attention ? A A 14 - year - old client with anorexia nervosa who is refusing to eat the evening snack . B A 16 - year - old client diagnosed with major depression who refuses to participate in group . C A 17 - year - old client diagnosed with bipolar disorder who is pacing around the lobby . D An 18 - year - old client with antisocial behavior who is being yelled at by other clients .
D An 18 - year - old client with antisocial behavior who is being yelled at by other clients .
A client presents to the labor and delivery unit with a report of leaking fluid that is greenish - brown vaginal discharge . Which action should the nurse take first ? A Start an intravenous infusion . B Administer oxygen via facemask C Perform a vaginal exam . D Begin continuous fetal monitoring .
D Begin continuous fetal monitoring .
A 3 - year - old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall . His parents are very concerned that child has regressed in his toileting behaviors . Which information should the nurse provide to the parents ? A A retraining program will need to be initiated when the child returns home . B Diapering will be provided since hospitalization is stressful to preschoolers . C A potty chair should be brought from home so he can maintain his toileting skills . D Children usually resume their toileting behaviors when they leave the hospital .
D Children usually resume their toileting behaviors when they leave the hospital .
The healthcare provider prescribes a sepsis protocol for a client with mutli - organ failure caused by a ruptured appendix . Which intervention is most important for the nurse to include in the plan of care ? A Assess warmth of extremities . B Keep head of bed raised 45 degrees . C Monitor blood glucose level . D Maintain strict intake and output .
D Maintain strict intake and output .
A teenager presents to the emergency department with palpitations after vaping at a party . The client is anxious , fearful , and hyperventilating . The nurse anticipates the client developing which acid base imbalance ? A Respiratory acidosis . B Metabolic alkalosis . C Metabolic acidosis . D Respiratory alkalosis .
D Respiratory alkalosis .
When assessing a recently delivered , multigravida client , the nurse finds that her vaginal bleeding is more than expected . Which factor in this client's history is related to this finding ? A The second stage of labor lasted 10 minutes . B She received butorphanol 2 mg IVP during labor . C She is over 35 years of age . D She is a gravida 6 , para 5 .
D She is a gravida 6 , para 5 .
A client is scheduled for a spiral computed tomography ( CT ) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires followup by the nurse? A CT scan that was performed six months earlier B Metal hip prosthesis was placed twenty years ago C Report of clients sobriety for the last five years D Takes metformin for type 2 diabetes mellitus
D Takes metformin for type 2 diabetes mellitus
A client fell in the bathroom when left unattended by the unlicensed assistive personnel ( UAP ) . Which information should the nurse include in the client's health record ? A The UAP left the client to assist another client . B The last time client was assisted to the bathroom . C The unit was understaffed when the client fell . D The client fell sustaining a fracture to the left hip .
D The client fell sustaining a fracture to the left hip .
After receiving report on an inpatient acute care unit , which client should the nurse assess first ? A The client with an obstruction of the large intestine who is experiencing abdominal distention . B The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds C The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid . D The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity .
D The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity .
