hesi 656+
A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet?
Demonstrates willingness to adhere to the diet consistently
During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide
Dialysis would need to be resumed if chronic rejection becomes a reality
The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?
Direct the UAP to measure the emesis while the nurse irrigates the NGT
A-12-years old boy has a body mass index (BMI) of 28, a systolic pressure and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicated that his mother understands the management of his diet?
One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice.
A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?
a bone marrow transplant
An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. Which action should the nurse take?
notify the provider of the refusal of meds
The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?
pt with viral meningitis with temp change from 101 f to 102 f
A 17-year -old male is brought to the emergency department by his parents because he has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first?
putting a mask on the client
A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply).
A full pitcher of water is on the bedside table (will contribute to fluid overload) The client is lying in a supine position in bed (leads to orthopnea)
During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy?
3 year hx of OC
The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?
A client with congestive heart failure who reports a 3 pound weight gain in the last two days
To reduce the risk of being named in malpractice lawsuit, which action is most important for the nurse to take?
Adhere consistently to standards of care.
The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse?
An 11-year-old with a headache, nausea, and projectile vomiting
An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first? A. Call respiratory therapy. B. Begin manual ventilation immediately. C. Monitor oxygen saturation levels q5 minutes. D. Silence the alarm and call the technician.
Answer B. Begin manual ventilation immediately. RationaleThe first action that must be taken is to begin manual ventilation. Remember the ABC's — airway, breathing and circulation! The nurse's highest priority is to ensure that the client is receiving oxygen. Also, remember Maslow — safety is a primary human need and breathing is fundamental to safety. (A, C, and D) do not have the priority of initiating manual ventilation.
A mother calls the nurse to report that at 0900 she administered a PO dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine, what instruction should the nurse provide to this mother? A. Give another dose. B. Withhold this dose. C. Administer a half dose now. D. Mix the next dose with food.
Answer B. Withhold this dose. RationaleThis dose should be withheld (B) because the amount absorbed by the infant is unknown. (A and C) pose safety concerns due to the unknown absorption. (D) is not recommended because all of the mixture (food and medicine) may not be eaten.
When checking a third grader's height and weight, the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement? A. Report findings to the parents. B. Document findings in the child's school file. C. Refer child to the family healthcare provider. D. Encourage child to get more sleep.
Answer C. Refer child to the family healthcare provider. RationaleADHD is most commonly managed with methylphenidate, which causes insomnia due to CNS stimulation and growth suppression secondary to appetite suppression. The child should be referred to the healthcare provider (C) because a change in the administration schedule of methylphenidate or discontinuing the drug is indicated until the child's growth increases. (A and B) may not ensure referral for a valuation of the medication's impact on the child's growth pattern. (D) is ineffective.
A male client who was admitted with an acute myocardial infarction receives a cardiac diet with sodium restriction and complains that his hamburger is flavorless. Which condiment should the nurse offer? A. Pickle relish. B. Steak sauce. C. Fresh horseradish. D. Tomato ketchup.
AnswerC. Fresh horseradish. RationaleA cardiac diet restrict sodium intake. Horseradish (C) should be recommended because it is low in sodium. (A, B, and D) are high in salt content and should not be offered.
While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? A. "I think I am qualified to teach this group. "B. "How old do you think I am? "C. "Do you think you can teach it any better? "D. "We need to stay focused on the topic."
AnswerD. "We need to stay focused on the topic. "Rationale(D) is the best response since the nurse should keep the students focused and avoid entering into an argument with them. (A) is defensive; there is no need for the nurse to defend her/his position. (B) is irrelevant; it does not matter how old the student thinks the nurse is. (C) is sarcastic; the nurse should avoid this kind of exchange and remain professional.
Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider?
Avoid administration of oxygen at high levels for extended periods. (oxygen toxicity)
A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? a. discontinue the magnesium sulfate immediately b. Decrease the client's iv rate to 50 ml per hour c. Continue with the plan of care for this client d. Change the client's to NPO status
C Rationale: continue with the plan. Diuresis in 24 to 48h after birth is a sign of improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs, kidney perfusion increases. With improvement perfusion, fluid is drawn into the intravascular bed from the interstitial tissue and then cleared by the kidneys
Close car windows and use air conditionerAvoid sudden changes in temperatureKeep away from pets with long hairStay indoors when grass is being cut The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply)
Close car windows and use air conditionerAvoid sudden changes in temperatureKeep away from pets with long hairStay indoors when grass is being cut
The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply)
Ease the client to the floor Loosen restrictive clothing Note the duration of the seizure
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?
Encourage the client to obtain a complete physical exam since these symptoms are consistent with an ulcer
A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elev ated blood pressure. Which intervention should the nurse implement first?
Ensure client takes a diuretic q AM
The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take? a- Explain that memory loss and confusion are common with vitamin B12 deficiency. b- Ask if the client is experiencing any changes in bowel habits c- Determine if the client is taking iron and folic acid supplements d- Encourage the husband to bring the client to the clinic for a complete blood count.
Explain that memory loss and confusion are common with vitamin B12 deficiency Rationale: Pernicious anemia is related to the absence of intricic factor in gastric secretions, leading to malabsorption of vit B12, and commonly causes memory loss, confusion and cognitive problems, and GI manifestations. The nurse should reassure the husband that the client's signs are consistent with the primary disease. Although B, C and D provide additional information about the client's compliance and response to therapy, a quick and dramatic response can occur after 72 hrs. of B12 injections.
The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?
FHR of 200 bpm baby can go into HF because the beats are shallow and not deep enough
The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history
Frequency of laxative use for chronic constipation
the nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, what actions should the nurse take before inserting the catheter?(Select all that apply)
Gently palpate the client's bladder for distention. Hold the catheter 3 - 4 inches (7.5 - 10 cm) from its tip. Secure the urinary drainage bag to the bed frame.
An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client's compliance with self-care? a- Speak clearly and face the clients for lip reading b- Provide written instructions for eyes drop administration c- Ensure that someone will stay with the client for 24 hours. d- Have the client vocalize the instructions provided.
Have the client vocalize the instructions provided.
A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first?pH 7.50; PaCo2 42; HCO3 33; pO2 92
Infuse 0.9 % sodium chloride 500 ml bolus
A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results
Institute coughing and deep breathing protocols it will help remove CO2 which will lower the levels
During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate...through the sheath to dissolve an occluded artery. Which interventions should the nurse implement?
Instruct the client to keep the left leg straight Observe the insertion site for a hematoma Circle first noted drainage on the dressing
One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?
Observe for unilateral swelling (DVT)
The father of 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. Obtain a detailed report from the nurse transferring the client. c. Mark the chart with client's request for no heroic measure d. Provide the client whitening information about end-of-life care
Obtain a detailed report from the nurse transferring the client. Rationale: To maintain continuity of care, it is important for the nurse working on the palliative care unit to obtain a detailed "situation, background, assessment, recommendation (SBAR) report, which provide clinical and no clinical information, as well as further information about the client may need. A, C and D are important intervention but not have priority at this time.
A client with multiple sclerosis is receiving beta-1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply)
RBC count WBC count platelet count
An unlicensed assistive personnel (UAP) informs the nurse who is giving medications that a female client is crying. The client was just informed that she has a malignant tumor. What action should the nurse implement first? A. Provide the client with a PRN antianxiety medication and allow privacy for her to grieve. B. Instruct the UAP to notify the client's spiritual advisor of her need for counseling. C. Ask another nurse to finish giving medications and attend to the client immediately. D. Tell the client that the nurse will be back to talk to her after medications are given.
RationaleThe nurse should first acknowledge the client's grief and arrange with the client a time to provide support, then complete the administration of medications (D). During that time, the nurse should assess the client to determine what intervention is best to offer the grieving client (A). The nurse, not the UAP (B), should talk with the client to determine if the client needs her spiritual advisor's counsel and support. The client's grief is not an emergency situation, so after acknowledging it and informing her that the nurse will return to talk with her, the nurse should finish administering the medications (C) and then spend time supporting the grieving client.
To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply).
Space activities to allow for rest periods Take warm baths before starting exercise
A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement?
Suggest the use of alternative sources of protein such as dairy products and nuts
A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan?
Take on an empty stomach with a full glass of water
The nurse is caring for a 17-year-old male who fell 20 feet 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?
Talk directly to the adolescent while providing care
An older client is admitted for repair of a broken hip. To reduce the risk for infection in the postoperative period, which nursing care interventions should the nurse include in the client's plan of care? (Select all that apply)
Teach client to use incentive spirometer q2 hours while awake. Remove urinary catheter as soon as possible and encourage voiding.
After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life- threatening condition?
Widening QRS complexes and flat waves
The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion? a- Increase the oxygen flow via nasal cannula if dyspnea is present. b- Place in a Trendelenburg position to increase cerebral blood flow c- Monitor capillary glucose measurements hourly during transfusion. d- Encourage increased intake of oral fluid to improve skin turgor.
a- Increase the oxygen flow via nasal cannula if dyspnea is present.
Which class of drugs is the only source of a cure for septic shock?
antiinfectives
The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy the client's serum blood potassium is elevated, which finding requires immediate action by the nurse?
anuria for 12 hours
A male client with ulcerative colitis received a prescription for a corticosteroid last month, but because of the side effect he stopped taking the medication 6 year ago. Which finding warrants immediate intervention by the nurse?
anxiety and restlessness (steroid withdrawal)
After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?
ask the client about gastro pain
A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?
assess for contraindications against thrombolytic therapy
A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, an exhibiting signs of restlessness. Which action should the nurse take fist?
auscultate breath sounds
A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?
avoid large crowds
When conducting diet teaching for a client who was diagnosed with hypoparathyroidism, which foods should the nurse encourage the client to eat? a- Nuts b- Yogurt. c- Fresh turkey d- Fresh chicken e- Processed cheese.
b&D yogurt and processed cheese
A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? a. Olanzapine b. Divalproex. c. Lorazepam d. Fluoxetine
b) divalproex
The nurse is preparing to administer an infusion of amino acid-dextrose total parenteral nutrition (TPN) through a central venous catheter (CVC) line. Which action should the nurse implement first? a- Attached de IV tubing to the central line. b- Check the TPN solution for cloudiness c- Set the infusion PUMP at the prescribed rate. d- Prime the IV tubbing with the TPN solution.
b- check the TPN solution for cloudiness
The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics? Select all that apply a. Written at a twelfth-grade reading level b. Contains a list with definitions of unfamiliar terms c. Uses common words with few Syllables d. Printed using a 12-point type font e. Uses pictures to help illustrate complex ideas
b. Contains a list with definitions of unfamiliar terms c. Uses common words with few Syllables e. Uses pictures to help illustrate complex ideas
An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? a. Observe neck for jugular vein distention b. Notify healthcare provider to prepare for pericardiocentesis c. Asses for paradoxical blood pressure d. Monitor oxygen saturation (Sp02) via continuous pulse oximetry
b. notify the HCP to prepare for pericardiocentesis
A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care? a. Elevate lower extremities while out of bed b. Teach family proper range of motion exercises. c. Maintain proper body alignment when in bed d. Encourage diaphragmatic breathing exercises.
b. teach family proper range of motion exercises
A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?
blood pressure of 90/76
a client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation... is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip what? a- The mother perceives and marks at least four fetal movements b- Fetal movements must be elicited with vibroacoustic stimulator c- Two FHR accelerations of 15 beats/minute x 15 seconds are recorded. d- No FHR late deceleration occur in response to fetal movement
c) Two FHR accelerations of 15 beats/minute x 15 seconds are recorded.
During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement? a- Notify the pediatrician immediately. b- Teach the parents about congenital heart defects .c- Document the finding in the infant's record .d- Apply oxygen per nasal cannula at 3 L/min.
c. document the finding in the infants record
A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication?
chest pain and dysrythmia vasopressin can cause vasoconstriction in the vessels, including the heart
Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning
cold sensitivity
A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client?
come to the clinic to be seen by the healthcare provider
A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement? a. Elevate the client's upper extremity before counting the pulse rate b. Auscultate directly below the IV site with a Doppler stethoscope c. Turn off the intravenous fluids that are infusing while counting the pulse. d. Palpate at the radial pulse site with the pads of two or three fingers.
d. Palpate at the radial pulse site with the pads of two or three fingers.
Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity?
distal pulse intensity
In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement?
document the extent of bruising in the patients chart
A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement?
elevate the HOB to 60 to 90 degrees
A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care?
evaluate their daily blood clotting factors
An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? a. Report the finding to the police department b. Discuss treatment options for abusive partners c. Determine the frequency and type of client's abuse d. Explore client's readiness to discuss the situation
explore the clients readiness to discuss the situation
A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?
explore the clients reasoning for wanting to be discharged
A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first?
furosemide pt is in overload and removal of some fluid need to be done
The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement?
give antiemetic S/e of drug causes nausea/vomiting
A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse she is. What information for the nurse to obtain?
history of alcohol use
A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications?
hydrocortisone pt is in addisonian crisis and needs steroid replacement to improve symptoms
A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? a- Hypernatremia b- Excessive thirst c- Elevated heart rate d- Poor skin turgor
hypernatremia
A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?
ineffective coping related to denial
A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention
maintain contact precaution
A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding should the nurse withhold the next dose of this drug? a. Maternal blood pressure of 90/60 b. Fetal heart rate of 170 beats per minute for 15 mints c. Maternal pulse rate of 162 beats per min d. Serum potassium of 2.3 mg/dl
maternal pulse rate of 162
A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care?
monitor for secondary infection
A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus?
o2 sat
A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide?
oatmeal cookies
A client presents to the labor and delivery unit, screaming "THE BABY IS COMING" which action should the nurse implement first.
observe the perineum
A client who has a suspected brain tumor is schedules for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement?
obtain the clients food allergy list (contrast)
During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (Select all that apply
plain air popped popcorn natural whole almonds
An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?
playing boardgames and talking about stressors
The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats / minute. Which action should the nurse take?
postpone the feeding until the infants vitals are stable
A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply)
postural hypotension irregular heat beat diaphoresis and pallor HA and tremors
Which instruction is most important for the nurse to provide a client who receives a new plan of care to treat osteoporosis? a. Begin a weight-bearing exercise plan b. Increase intake of foods rich in calcium c. Schedule a bone density tests every year. d. Remain upright after taking the medication.
remain upright after taking the medication
A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority?
signs a no self harm contract
An infant is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant's heart rate drops to 80 beats / minute. What action should the nurse take
slow the feeding and monitor the infants response
During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 f. which intervention should the nurse implement?
stop infusion and start saline
For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action?
tented skin
A client admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor, which important finding places the client at greatest risk? a. Blood pressure of 100/60 b. Incontinent with blood in urine c. Unresponsive to painful stimuli d. Presence of hematemesis
unresponsive to painful stimuli
A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity?
vomiting
The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next
wait 1 minute and palpate the systolic pressure before auscultating
In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?
watery diarrhea
An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?
weak palpable distal pulses
