HESI #1 EAQ'S
Steroid therapy is prescribed for a client with an exacerbation of ulcerative colitis. The nurse evaluates that teaching is effective when the client makes which statement?
"I should take this medicine in the early morning with food."
The licensed practical nurse is discussing the various record-keeping forms with a nursing student. Which statement made by the nursing student indicates a need for further teaching? 1 "I should use the Rand system to consolidate the client's orders." 2 "I should mention that I filed an incident report in the client's nursing notes." 3 "I should use the acuity charting system to rate each client by the severity of the illness." 4 "I should use a 24-hour record-keeping system to avoid unnecessary record-keeping forms."
2 "I should mention that I filed an incident report in the client's nursing notes."
Which statement is true regarding the measurement of rectal temperature? 1 The thermometer probe is inserted about 3.5 inches into the rectum. 2 The thermometer probe is lubricated before inserting into the rectum. 3 The rectal route of measuring temperature is preferred in clients with traction. 4 The client is placed in the side-lying position while measuring rectal temperature.
2 The thermometer probe is lubricated before inserting into the rectum.
Which statement about palliative care needs correction? 1 Palliative care can be started earlier in the dying process. 2 Palliative care is aimed at improving comfort and prolonging life at all costs. 3 Palliative care can serve as a bridge between curative care and hospice care. 4 Palliative care is aimed at providing psychological, social, and spiritual assistance.
2 Palliative care is aimed at improving comfort and prolonging life at all costs.
The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment? 1 Determining the level of mobility 2 Removing the clothes of the client 3 placing the client in recumbent position 4 Cleaning the wounds with antiseptic solution
2 Removing the clothes of the client
Which nursing intervention would be beneficial to a client with human immunodeficiency virus (HIV) infection who is experiencing fatigue? 1 Recommending high-fiber foods 2 Scheduling ample periods of rest 3 Recommending dry and salty foods 4 Encouraging fluid intake of more than 2,500 mL/day
2 Scheduling ample periods of rest
what is 38 celsius to fahrenheit?
100.4 F
While assessing the body temperature of a client, the nurse finds subnormal temperature. Which intervention is beneficial for the client? 1 Administering acetaminophen 2 Covering the client with blankets 3 Assessing for a headache, thirst, and chills 4 Assessing for a possible site of localized infection
2 Covering the client with blankets
A client arrives at a health clinic reporting hematuria, frequency, urgency, and pain on urination. What does the nurse suspect is the cause of these signs and symptoms? 1 Chronic glomerulonephritis 2 Cystitis 3 Nephrotic syndrome 4 Pyelonephritis
2 Cystitis
What is the result of increased dental caries in an older adult? 1 Decreased digestion 2 Decreased nutritional status 3 Increased incidence of pyrosis 4 Increased incidence of choking
2 Decreased nutritional status
Which is a clinical manifestation of a panic attack?
A sensation of choking
A nurse is caring for a client with chronic inflammation of the bowel. What is the most serious complication associated with this condition?
Perforation
A registered nurse is educating a licensed practical nurse (LPN) about promoting rest and sleep in sleep-deprived clients. Which statement made by the LPN indicates a need for further teaching? 1 "I won't allow visitors in the client's room." 2 "I'll carry out all procedures within a given time frame." 3 "I'll limit interruptions for vital sign checks during the night." 4 "I'll make sure that the client's room is kept at a comfortable temperature."
1 "I won't allow visitors in the client's room."
While caring for a client with urinary tract infection, the nurse manager delegated the work of administering oral medications. Which delegatee would be appropriate for this task? Select all that apply. 1 Certified nursing assistant (CNA) 2 Patient care associate (PCA) 3 Licensed practical nurse (LPN) 4 Licensed vocational nurse (LVN) 5 Unlicensed assistive personnel (UAP)
3 Licensed practical nurse (LPN) 4 Licensed vocational nurse (LVN)
Which strategy may provide the least accurate reading while measuring the tympanic temperature in a client? 1 The client has been placed in supine position. 2 The lens and the probe cover are clean and intact. 3 The plastic probe covers the tip of the thermometer. 4 The client has been outdoors for more than 10 minutes.
4 The client has been outdoors for more than 10 minutes.
Which eye finding can be attributed to the age-related change in older adults? 1 Regular shape of the iris 2 increased luster of bulbar conjunctiva 3 Faster constriction response of the pupil 4 Formation of gray ring around the cornea
4 Formation of gray ring around the cornea
Which site of temperature measurement is least preferred if the client has diaphoresis? 1 Oral 2 Rectal 3 Axillary 4 Temporal
4 Temporal
A nurse is caring for a client who just had major abdominal surgery. What client responses indicate the possibility of developing a superficial venous thrombosis? Select all that apply 1 Pitting edema of the ankle 2 Reddened area at the ankle 3 Pruritus on the side of the calf 4 Tender area in the posterior lower leg 5 Warmth along the course of the involved vessel
4 Tender area in the posterior lower leg 5 Warmth along the course of the involved vessel
While assessing a client with suspected increased intracranial pressure, the nurse documents anisocoria in the medical reports of the client. Which condition in the client supports the nurse's documentation? 1 Fixed pupils 2 Double vision 3 Dilated pupils 4 Unequal pupils
4 Unequal pupils
A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing? 1 Vitamin C aids in the process of epithelialization. 2 Vitamin C helps in the synthesis of immune factors. 3 Vitamin C increases the metabolic energy required for inflammation. 4 Vitamin C is required for collagen production by fibroblasts
4 Vitamin C is required for collagen production by fibroblasts
A nurse is providing colostomy care to a client with a nosocomial infection caused by methicillin-resistant Staphylococcus aureus (MRSA). Which personal protective equipment (PPE) should the nurse use? Select all that apply. 1 Gloves 2 Gown 3 Mask 4 Goggles 5 Shoe covers 6 Hair bonnet
1 Gloves 2 Gown 4 Goggles
A client with a terminal illness creates a legal document that requests that he not be given intravenous nutrition and hydration if he becomes permanently unconscious. What is this document known as? 1 Living will 2 "Tail" agreement 3 Informed consent 4 Durable power of attorney
1 Living will
The registered nurse is discussing with a licensed practical nurse (LPN) how to communicate with a client with hearing loss. Which statement made by the LPN indicates a need for further discussion? 1 "I will face the client with my mouth visible to the client." 2 "I will provide a sign language interpreter to communicate." 3 "I will rephrase the sentence if the client misunderstands it." 4 "I will reduce any environmental noise while communicating."
2 "I will provide a sign language interpreter to communicate."
Which intervention will help a client prevent dental plaque and caries? 1 Performing hand hygiene 2 Drinking fluoridated water 3 Avoiding hot, cold, and spicy foods 4 Eating four to six small meals daily
2 Drinking fluoridated water
Which predisposing condition may be present in a client with pitting edema? 1 Shock 2 Kidney disease 3 Hypothyroidism 4 Severe dehydration
2 Kidney disease
A client has a diagnosis of hemorrhoids. Which signs and symptoms does the nurse expect the client to report? Select all that apply. 1. flatulence 2. Anal itching 3. Blood in stool 4. Rectal bulging/pressure 5. Pain when defecating
2. Anal itching 3. Blood in stool 4. Rectal bulging/pressure 5. Pain when defecating
While reporting the laboratory results of a client to a health-care provider, the nurse states, "The client's laboratory reports are within the normal limits." Which part of SBAR technique does the nurse refer to? 1 Situation 2 Read back 3 Background 4 Recommendation
3 Background
The registered nurse is explaining basic rules for documentation to a licensed practical nurse (LPN). Which statements made by the LPN indicate effective learning? Select all that apply. 1 "I will use generalized empty phrases." 2 "I will fill the chart at the end of my shift." 3 "I will leave few empty lines in the chart." 4 "I will document the details when observed." 5 "I will record in the chart using black ink pen."
4 "I will document the details when observed." 5 "I will record in the chart using black ink pen."
A nurse is educating the parents of toddlers about how to promote healthy sleep patterns in their children. Which statement made by a parent indicates a need for further teaching? 1 "I'll use quiet time activities before sleep." 2 "I'll reassure my child that she is not alone." 3 "I'll allow my child to have a favorite bedtime toy." 4 "I'll keep telling stories to my child until she falls asleep."
4 "I'll keep telling stories to my child until she falls asleep."
Which team member of the hospice interdisciplinary team helps the clients and their families handle grief issues?
Social worker
A client who visited the hospital reports sneezing, excessive nasal secretions, and itching eyes. On assessment, the condition is diagnosed as anaphylactic hypersensitivity. Which cells act against this reaction?
b-cells
A client is in the last stage of chronic pulmonary disease and does not have an option to receive care at home. Which type of health-care facility or organization would be most appropriate?
long term care facility
A nurse notices a firm, edematous, irregularly shaped skin lesion on a client who reports an insect bite. Which skin lesion is this?
wheal
Which predisposing condition may be present in a client with pitting edema?
Kidney disease
A nurse in the postanesthesia care unit (PACU) is providing care to a client who had an abdominal cholecystectomy and observes serosanguineous drainage on the abdominal dressing. What is the next nursing action? 1 Change the dressing. 2 Reinforce the dressing. 3 Replace the tape with Montgomery ties. 4 Support the incision with an abdominal binder.
2 Reinforce the dressing.
Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult? 1 The nurse should minimize the use of tape on the skin. 2 The nurse should keep the client adequately hydrated. 3 The nurse should change the dressings as soon as they get wet. 4 The nurse should provide rest for the client throughout the day.
2 The nurse should keep the client adequately hydrated.
A hospice-care facility is providing care to a client in the terminal stage of renal disease. The primary health-care provider is explaining to a client how a hospice facility works. Which statement made by the client's caregiver indicates the need for correction? 1 "A hospice facility provides care to terminally ill clients." 2 "With admission to hospice facility, we should realize that death is a natural part of life." 3 "The objective of hospice facility is to provide care to clients with terminal illness and a poor prognosis." 4 "The goal of hospice-care facility is to maximize the quality of life and keep the client as comfortable as possible."
1 "A hospice facility provides care to terminally ill clients."
A newly hired nurse is approached by a surveyor from the department of health. The surveyor asks the nurse about the best way to prevent the spread of infection. What is the most appropriate nursing response? 1 "Let me get my preceptor." 2 "Wash your hands before and after any client care." 3 "Clean all instruments and work surfaces with an approved disinfectant." 4 "Ensure proper disposal of all items contaminated with blood or body fluids."
2 "Wash your hands before and after any client care."
While taking a client's temporal artery temperature, the nurse places the probe flush on the client's forehead. What is the rationale behind this intervention? 1 To maintain standard precautions 2 To scan continuously for the highest temperature 3 To prevent the nurse from measuring ambient temperature 4 To decrease the chance of moisture interfering with the measurement
3 To prevent the nurse from measuring ambient temperature
Which temperature measurement site is least accurate?
Axillary
The nurse is caring for a client with ureteral colic. To prevent the development of renal calculi in the future, what should the client's plan of care include? 1 Interventions to decrease the serum creatinine level 2 Excluding milk products from the diet 3 Instructing the client to drink 8 to 10 glasses of water daily 4 A goal of 2000 mL/24 hours urinary output
Instructing the client to drink 8 to 10 glasses of water daily
The health care professional is recording the client's initial admission nursing history. Which member of the health care team is held responsible for this documentation?
RN
After measuring the body temperature, the nurse documents a core temperature reading of 99 °F, but the actual oral route reading is 98 °F. Which route was used by the nurse for temperature measurement?
Rectal
After a basal cell carcinoma is removed by fulguration, a client is given a topical steroid to apply to the surgical site. The nurse evaluates that the teaching regarding steroids and skin lesions is effective when the client states that the primary purpose of the medication is to do what?
Reduce inflammation at the surgical site
Acetylsalicylic acid is prescribed for a client with rheumatoid arthritis. The nurse understands what is the major rationale for this treatment?
Reduction of joint inflammation
A nurse is teaching the basic principles of good sleep hygiene to a client with fibromyalgia syndrome. Which statements made by the client indicate that teaching has been effective? Select all that apply. 1 "I'll avoid long naps." 2 "I'll take a cold bath within two hours of bedtime." 3 "I'll avoid large meals four hours before bedtime." 4 "I'll go to bed and wake up at the same time each day." 5 "I'll keep the sleep environment dark, quiet, and comfortable."
1 "I'll avoid long naps." 4 "I'll go to bed and wake up at the same time each day." 5 "I'll keep the sleep environment dark, quiet, and comfortable."
During a physical examination, a client reports difficulty falling asleep. Which instructions should the nurse provide to the client to promote sleep? Select all that apply. 1 "Include meat in your diet." 2 "Drink milk before going to sleep." 3 "Avoid including cheese in your diet." 4 "Regularly change your daily routine." 5 "Perform moderate exercise two hours before bedtime."
1 "Include meat in your diet." 2 "Drink milk before going to sleep." 5 "Perform moderate exercise two hours before bedtime."
Which action may cause lipohypertrophy in a client who is receiving insulin injections? 1 Injecting insulin subcutaneously 2 Storing insulin in the refrigerator 3 Using buffered regular insulin injections 4 Administering insulin into the same site each time
4 Administering insulin into the same site each time
A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What increased risk does the nurse consider when assessing this client? 1 Weight loss 2 Hypoglycemia 3 Decreased blood pressure 4 Inadequate wound healing
4 Inadequate wound healing
The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? 1 Primary 2 Secondary 3 Superinfection 4 Nosocomial
4 Nosocomial
Which client-made, legally enforceable document contains the instructions of the client regarding his or her refusal to receive cardiopulmonary resuscitation upon admission to a hospital for surgery? 1 Informed consent 2 Occurrence basis policy 3 Resident Assessment Instrument (RAI) 4 Physician Orders for Life-Sustaining Treatment (POLST)
4 Physician Orders for Life-Sustaining Treatment (POLST)
The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected outcome for the client? 1 All nursing functions will be completed by discharge. 2 All invasive intravenous lines will remain patent. 3 The client will remain awake, alert, and oriented at all times. 4 The client will be free of signs and symptoms of infection by discharge.
4 The client will be free of signs and symptoms of infection by discharge.
Which statement is true about do-not-resuscitate (DNR) orders? 1 The nurse is not legally bound to follow a DNR order. 2 The client is always involved directly at the time a DNR order is executed. 3 The charge nurse is responsible for following the applicable policies for writing DNR orders. 4 The physician includes the DNR order in the medical record after consulting with the client and his or her family.
4 The physician includes the DNR order in the medical record after consulting with the client and his or her family.
A client with diabetes was taught to self-administer insulin. Which site should the client choose for fast absorption? 1 Arms 2 Thighs 3 Buttocks 4 Abdomen
4 Abdomen
The practical nurse is discussing the filling out of an incident report with a group of nursing students. Which statement made by a nursing student indicates a need for further discussion? 1 "I should give objective information." 2 "I should avoid giving unnecessary details." 3 "I should include the name of the registered nurse in the incident report." 4 "I should avoid mentioning the incident report in the client's nursing note."
3 "I should include the name of the registered nurse in the incident report."
A client is discharged home the same day as a hernia repair. Where did the operation likely take place? 1 Long-term care center 2 Hospice service center 3 Ambulatory surgery center 4 Specialty home care service center
3 Ambulatory surgery center
A client is diagnosed with AIDS. When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? 1 Cytomegalovirus 2 Histoplasmosis 3 Candida albicans 4 Human papillomavirus
3 Candida albicans
The nurse caring for a client with a systemic infection is aware that which assessment finding is most indicative of a systemic infection? 1 White blood cell (WBC) count of 8200/mm3 2 Bilateral 3+ pitting pedal edema 3 Oral temperature of 101.3° F 4 Pale skin and nail beds
3 Oral temperature of 101.3° F
Which nursing intervention would benefit a client with hyperthermia? 1 Providing a blanket 2 Reducing the oral fluid intake 3 Removing any external covering 4 Encouraging that the client conduct physical activity
3 Removing any external covering
A client who has been taking ibuprofen for rheumatoid arthritis asks the nurse if acetaminophen can be substituted instead. What is the appropriate nursing response?
"Ibuprofen has anti inflammatory properties and acetaminophen does not."
The registered nurse is explaining about personal health records to a licensed practical nurse. Which statement made by the licensed practical nurse indicates need for further discussion? 1 It may contain only the information submitted by the client. 2 It is managed by various institutions such as private vendors. 3 Vendors may or may not charge a fee for storage of the information. 4 It allows clients to input their own information into an electronic database.
1 It may contain only the information submitted by the client
Which statement regarding the Health Insurance Portability and Accountability Act is true? 1 It protects the confidentiality of all health information. 2 It emphasizes the client's right to accept or refuse treatment. 3 It maintains written policies and procedures regarding advance directives. 4 It emphasizes the right of the client to participate fully in health-care-related decisions.
1 It protects the confidentiality of all health information.
Which musculoskeletal condition occurs in part as a result of deficiencies in vitamin D and calcium? 1 Osteoporosis 2 Osteoarthritis 3 Ankylosing spondylitis 4 Fibromyalgia syndrome
1 Osteoporosis
Which statement is true regarding the reconstruction phase of wound healing? 1 Wound dehiscence mostly occurs in the reconstruction phase. 2 The reconstruction phase begins on the second day and lasts for 2 to 3 days. 3 Collagen formation increases rapidly between postoperative days 1 and 5. 4 During the reconstruction phase, the wound takes the form of a light pink, matured scar.
1 Wound dehiscence mostly occurs in the reconstruction phase.
The nurse is teaching a client with diabetes about foot care. Which statements made by the client indicates the client understands which activities would be beneficial to prevent infection? Select all that apply. 1 "I will apply lotion to my feet daily." 2 "I will clean my feet with hot water." 3 "I will cut my nails close to the nail bed." 4 "I will soak my feet in water for at least 10 minutes before doing nail care." 5 "I will assess the skin on my feet for redness, abrasions, and open areas daily."
1 "I will apply lotion to my feet daily." 5 "I will assess the skin on my feet for redness, abrasions, and open areas daily."
Among the following clients, which is at the highest risk for hepatitis infection? 1 A gay man 2 A bisexual man 3 A lesbian woman 4 A heterosexual woman
1 A gay man
Which action should be the nurse's first priority for a client with major burns? 1 Assessing airway patency 2 Checking the client from head to toe 3 Administering oxygen as needed 4 Elevating the extremities if no fractures are noticed
1 Assessing airway patency
Which action performed by the client with diabetes would increase the risk of sepsis during foot care? 1 Cleansing cuts with iodine 2 Trimming the nails after shower 3 Wearing leather shoes while walking 4 Cutting toenails even with a rounded contour
1 Cleansing cuts with iodine
While recovering from abdominal surgery a client develops thrombophlebitis. Which clinical indicators of this complication should the nurse expect to identify when assessing the client? Select all that apply. 1 Pain in the calf 2 Intermittent claudication 3 Redness in the affected area 4 Pitting edema of the lower leg 5 Ecchymotic areas around the ankle 6 Localized warmth in the lower extremity
1 Pain in the calf 3 Redness in the affected area 6 Localized warmth in the lower extremity
Which key feature does the nurse associate with a stage 2 pressure ulcer? 1 Presence of nonintact skin 2 Development of sinus tracts 3 Damage to the subcutaneous tissues 4 Appearance of a reddened area over a bony prominence
1 Presence of nonintact skin
Which statement regarding rheumatoid arthritis is true? 1 it is a systemic condition. 2 It affects the hips and knees. 3 It involves bone spur formation. 4 It affects males and females equally.
1 it is a systemic condition.
A registered nurse is teaching a nursing student about interventions for a client with nocturia who complains of fatigue. Which statement indicates the nursing student needs further learning? 1 "I'll advise the client to limit fluids at night." 2 "I'll advise the client to perform pelvic floor exercises." 3 "I'll advise the client to take diuretic medications in the morning." 4 "I'll advise the client to remove rugs and furniture from walkways."
2 "I'll advise the client to perform pelvic floor exercises."
A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers a developing hematoma and edema. The client reports tenderness when the ankle is palpated. The nurse anticipates that the plan of care will include the application of what? 1 Binder 2 Ice pack 3 Elastic bandage 4 Warm compress
2 Ice pack
A licensed practical nurse (LPN) assigns the task of measuring temporal artery temperature to an unlicensed assistive personnel (UAP). Which action of the UAP indicates the need for the LPN to intervene during the measurement? 1 Ensuring that the client's forehead is dry 2 Placing the probe flush on the client's forehead 3 Wiping the probe with water and disposing of the probe cover 4 Sweeping the probe across the forehead and continuing behind the earlobe
3 Wiping the probe with water and disposing of the probe cover
A registered nurse teaches a client and the caregiver about pressure ulcer care. Which statement made by the caregiver indicates the need for further teaching? 1 "I should inspect the client's skin daily." 2 "I should manage the client's incontinence as quickly as possible." 3 "I should properly dispose of the client's contaminated dressings." 4 "I should not worry about what the client eats."
4 "I should not worry about what the client eats."
A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. What would be the best response from the nurse? 1 "I don't know. I will ask the health care provider for a prescription." 2 "Antibiotics are used to treat viruses, and you have a bacterial infection." 3 "Antibiotics are ineffective for treating the bacteria that cause upper respiratory infections." 4 "Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics."
4 "Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics."
The nurse is teaching nutritional management to reduce fatigue in a client with human immunodeficiency virus (HIV) infection. Which instruction from the nurse will be most beneficial to the client? 1 "You should avoid dairy products and red meat." 2 "You should increase your intake of foods high in potassium." 3 "You should use a straw and tilt your head back and forth when drinking." 4 "You should cook in large quantities and freeze meal-sized portions in packets."
4 "You should cook in large quantities and freeze meal-sized portions in packets."
The rehabilitation team members on a hospice unit are caring for a client. One of the team members provides spiritual guidance to the client. Which team member plays this role?
Chaplain
Which laboratory test result will be elevated in a client with inflammatory arthritis?
Erythrocyte sedimentation rate (ESR)
A nurse is caring for a client who had a kidney transplant. What sign indicates that the client may be rejecting the transplanted kidney?
Fever
Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers?
Incontinence and inability to move independently.
A registered nurse teaches a licensed practical nurse about the roles of a team leader. Which of these statements made by the licensed practical nurse indicate effective learning? Select all that apply. 1 "I will conduct routine staff evaluations." 2 "I will receive reports on assigned clients." 3 "I will assist in administering medications." 4 "I will submit staffing schedules for the unit." 5 "I will make assignments for team members."
2 "I will receive reports on assigned clients." 3 "I will assist in administering medications." 5 "I will make assignments for team members."
Which action is appropriate while assessing the body temperature in a client who is suspected of having hypothermia? 1 Measuring oral temperature with a glass thermometer 2 Measuring rectal temperature with an electronic thermometer 3 Measuring axillary temperature with an electronic thermometer 4 Measuring tympanic temperature with a tympanic thermometer
2 Measuring rectal temperature with an electronic thermometer
Which statement is true regarding wound healing? 1 Fibrin in the clot breaks the wound apart. 2 Leukocytes begin to engulf bacteria, fungi, and virus. 3 If an infection is present, the number of leukocytes decreases. 4 During the inflammatory phase, there is an initial decrease in the flow of blood elements.
2 Leukocytes begin to engulf bacteria, fungi, and virus.
What are the desired outcomes that the nurse expects when administering a nonsteroidal antiinflammatory drug (NSAID)? Select all that apply. 1 Diuresis 2 Pain relief 3 Antipyresis 4 Bronchodilation 5 Anticoagulation 6 Reduced inflammation
2 Pain relief 3 Antipyresis 6 Reduced inflammation
Which nursing action is useful when a telephone order is confusing and unclear?
asking a peer nurse to listen to the conversation
A registered nurse is teaching a licensed practical nurse (LPN) about protecting client confidentiality. Which statement by the LPN indicates effective learning? 1 "I'll shred notes after use." 2 "I'll always keep client statistics." 3 "I'll personally keep client information." 4 "I'll discuss client information in the cafeteria."
1 "I'll shred notes after use."
What is the score in the Glasgow Coma Scale when the client has no eye response after a head injury? 1 2 3 4
1
A client with a 20-year history of excessive alcohol use is admitted to the hospital with jaundice and ascites. What is the priority nursing action during the first 48 hours after the client's admission? 1 Monitor the client's vital signs. 2 Increase the client's fluid intake. 3 Improve the client's nutritional status. 4 Determine the client's reasons for drinking.
1 Monitor the client's vital signs.
What assessment findings indicate that a client is experiencing an allergic reaction to antibiotic therapy? Select all that apply. 1 Pruritus 2 Confusion 3 Wheezing 4 Muscle aches 5 Bronchospasm
1 Pruritus 3 Wheezing 5 Bronchospasm
Which fungal infection in a client is commonly referred to as athlete's foot? 1 Tinea pedis 2 Tinea cruris 3 Tinea corporis 4 Tinea unguium
1 Tinea pedis
A nurse is interviewing a client who was diagnosed with systemic lupus erythematosus (SLE). Which common responses to this disease can the nurse expect the client to exhibit? (Select all that apply.) 1 butterfly facial rash 2 firm skin fixed to tissue 3 inflammation of the joints 4 muscle mass degeneration 5 inflammation of small arteries
1 butterfly facial rash 3 inflammation of the joints
The nurse is preparing discharge instructions for a client that acquired a nosocomial infection, Clostridium difficile. What should the nurse include in the instructions? 1 Anticipate that nausea and vomiting will continue until the infection is no longer present. 2 The infection causes diarrhea accompanied by flatus and abdominal discomfort. 3 Consume a diet that is high in fiber and low in fat. 4 Other than routine handwashing, it is not necessary to perform special disinfection procedures.
2 The infection causes diarrhea accompanied by flatus and abdominal discomfort
A client with diabetes is self-administering insulin. Which action performed by the client indicates a need for correction? 1 Inspecting the vial for crystals 2 Washing the hands with hot water 3 Inspecting the barrel for air bubbles 4 Bringing the insulin to room temperature
2 Washing the hands with hot water
A nurse instructs a client who avoids bathing to take a bath or shower each day as a means of maintaining hygiene and preventing infection. Which of these reactions should the nurse expect if the client is in the action stage? Select all that apply. 1 "I only take a bath once a week, but I don't see any infections on my skin." 2 "I try to take a shower every day, but I skip it sometimes because of my tight work schedule." 3 "I understand that bathing regularly is a good habit, but my bathroom is very cold in the mornings." 4 "Please tell me how to get into the habit of taking a bath daily so I can keep myself clean and healthy." 5 "I want to take a bath regularly, but I don't have time because I need to look after my kids and my parents."
2 "I try to take a shower every day, but I skip it sometimes because of my tight work schedule." 3 "I understand that bathing regularly is a good habit, but my bathroom is very cold in the mornings." 5 "I want to take a bath regularly, but I don't have time because I need to look after my kids and my parents."
What effect of povidone-iodine does a nurse consider when using it on the client's skin before obtaining a specimen for a blood culture? 1 Avoids drying the skin 2 Makes the skin more supple 3 Eliminates surface bacteria that may contaminate the culture 4 Provides a cooling agent to diminish the feeling from the puncture wound
3 Eliminates surface bacteria that may contaminate the culture
The nurse is providing discharge instructions to a client who is recovering from an acute case of viral hepatitis. Which statement by the client indicates a need for further education? 1 "I will avoid alcohol." 2 "I will eat small frequent meals." 3 "I will take acetaminophen for pain rather than aspirin." 4 "I will eat foods high in carbohydrates, moderate in fats, and moderate in proteins."
3 "I will take acetaminophen for pain rather than aspirin."
A nurse is interviewing a female client with a tentative diagnosis of cystitis pending laboratory results. The nurse anticipates that the causative agent of the cystitis is Escherichia coli. Why does the nurse anticipate this microorganism? 1 It thrives in the kidneys. 2 It is a virulent bacteria. 3 It inhabits the intestinal tract. 4 It competes with fungi for host sites.
3 It inhabits the intestinal tract.
A client with arthritis, "Can I take Tylenol instead of aspirin? Aspirin irritates my stomach." The nurse explains what about acetaminophen (Tylenol)? 1 It lacks anticoagulant action 2 It has the same action as aspirin 3 It lacks an anti-inflammatory action 4 It has more severe side effects than aspirin
3 It lacks an anti-inflammatory action
While caring for a child, a nurse finds that the child is often hospitalized with injuries and infections. On further assessment, the nurse notes that the child is malnourished. What could be the reason for the child's condition? 1 Severe illness 2 Improper growth 3 Physical neglect 4 Emotional maltreatment
3 Physical neglect
Five days after a client has abdominal surgery a nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? 1 Increased bowel sounds 2 Loosening of the sutures 3 Serosanguineous drainage 4 Purplish color of the incision
3 Serosanguineous drainage
Five days after a client has abdominal surgery a nurse assesses the client's incision site for signs of dehiscence. Which clinical finding supports the nurse's conclusion that the client is experiencing wound dehiscence? 1 Increased bowel sounds 2 Loosening of the sutures 3 serosanguineous drainage 4 Purplish color of the incision
3 serosanguineous drainage
A woman arrives at the women's health clinic complaining of frequency and burning pain when voiding. The diagnosis is a urinary tract infection. What is important for the nurse to encourage the client to do? 1 Void every 2 hours. 2 Record fluid intake and urinary output. 3 Pour warm water over the vulva after voiding. 4 Wash the hands thoroughly after urinating and defecating.
4 Wash the hands thoroughly after urinating and defecating.
