Hesi B
150. 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
Answer 83 • Rationale: 1000 ml-----12hr. • Xml ---------1hr. • 1000/12 = 83.33 = 83.
112. At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?
Anxiety
128. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take?
Ask the client what he is thinking about at his time.
119. An older male comes to the clinic with a family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first?
Assess the surroundings for noise and distractions
163. Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)?
Aural migraine headaches.
104. The nurse should teach the client to observe which precaution while taking dronedarone?
Avoid grapefruits and its juice
124. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan?
Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
200. A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? a. Explain that it may take several weeks for the medication to be effective b. Confirm the desired effect of the medication has been achieved c. Notify the healthcare provider that a change may be needed. d. evaluate when and how the medication is being administered to the cient
B. Confirm the desired effect of the medication has been achieved. Rationale: Trazodone o Desyrel, an atypical antidepressant is prescribed for client with AD improve mood and sleep.
159. An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions?
Be alert for possible cross-sensitivity to cephalosporin agents.
148. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?
Bowel patterns Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation.
106. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection?
Confirm the necessity for continued use of the CVC.
149. While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?
Contact the medical records department supervisor.
175. The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?
Convey to the client that birth is imminent.
135. A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?
Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider
136. After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first?
Determine client's pulse, blood pressure, and respirations
108. A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take?
Determine if she can ask for support from family, friend, or the baby's father.
187. A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first?
Determine the client's vital sign.
111. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding?
Document the ongoing wound healing.
113. The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately?
Elevate the presenting part off the cord.
147. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement
Encourage the client to eat finger foods.
134. After administering an antipyretic medication. Which intervention should the nurse implement?
Encouraging liberal fluid intake
110. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care?
Ensure proper alignment of the leg in traction.
181. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement?
Ensure that no dependent loops are present in the tubing.
144. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first?
Establish a structured routine for the client to follow.
101. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?
Explain that the client may be placed in five positions
171. An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement?
Explain the reason for using only non-narcotics.
177. Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include?
Fall prevention measures.
155. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement?
Hold oral intake until swallow evaluation is done.
102. A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke?
Inability to close the affected eye, raise brow, or smile
146. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?
Instruct the mother to change the child's diaper more often.
156. The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)
Interacts with a flat affect. Avoids eye contact. Has a disheveled appearance
103. The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching?
Keeps the irrigating container less than 18 inches above the stoma
120. The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need?
Large amounts of fluid and electrolyte replacement
188. A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?
No wheezing upon auscultation of the chest.
152. 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?
Palpate at the radial pulse site with the pads of two or three fingers.
133. The rapid response team's detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement?
Perform bilateral chest auscultation.
168. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention
Postmenopausal women need an intake of at least 1,500 mg of calcium daily
186. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care?
Provide daily care of tong insertion sites using saline and antibiotic ointment
138. A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement?
Raise the head of the bed to a Fowler's position and support his arms with a pillow
114. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider?
Reassess readiness for SNF transfer.
115. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.)
Recognize signs and symptoms of hypoglycemia. • Report persist polyuria to the healthcare provider. • Take Glucophage with the morning and evening meal
143. An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement?
Reinforce the importance of annual papanicolaou (Pap) smears.
176. To evaluate the effectiveness of male client's new prescription for ezetimibe, which action should the clinic nurse implement
Remind the client to keep his appointments to have his cholesterol level checked.
122. Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement?
Remove cigarettes for the client's room
107. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?
Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).
162. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?
Report weight gain of 2 pounds (0.9kg) in 24 hours
193. A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer?
Simethicone (Mylicon)
109. A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first?
Stop the normal saline infusion.
127. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?
Supervise a newly hired graduate nurse during an admission assessment
167. 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?
Teach family proper range of motion exercises.
117. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location)
The apical heart rate is best auscultated on the adult chest at the PMI, which lies at the 4th or 5th intercostal left midclavicular line, commonly found at or just below the left nipple
160. 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?
The client's need for pain medication should be determined
158. In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
-Place personal religious artifacts on the body. • Attach identifying name tags to the body. • Follow cultural beliefs in preparing the body.
125. A nurse with 10 years experience working in the emergency room is reassigned to the perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse?
A mother with an infected episiotomy
129. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)
Administer PRN nebulizer treatment. • Obtain 12 lead electrocardiogram. • Monitor continuous oxygen saturation.
130. The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?
Administer a prescribed analgesia for pain.
139. A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next?
Administer the analgesic as requested Rationale: Chronic pain may be difficult to describe but should be treated with analgesics as indicated.
192. The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement?
Administer the medication via the oral route as prescribed
157. A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement?
Transfer the client to the surgical floor.
131. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child?
Use sunblock or protective clothing when outdoors.
145. A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?
Ventricular arrhythmias. • Rationale: adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretions that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias are life threatening and required immediate intervention to correct critical potassium levels.
170. The nurse is auscultating a client's lung sounds. Which description should the nurse use to document this sound? a. High pitched or fine crackles. b. Rhonchi c. High pitched wheeze d. Stridor
a. High pitched or fine crackles.
199. The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose? a. Jaundice b. Nausea c. Fever d. Fatigue
a. Jaundice
161. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.) a. Monitor abdominal girth. b. Increase oral fluid intake to 1500 ml daily. c. Report serum albumin and globulin levels. d. Provide diet low in phosphorous. e. Note signs of swelling and edema.
a. Monitor abdominal girth. c. Report serum albumin and globulin levels. e. Note signs of swelling and edema. • Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated in end stage liver disease.
196. An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? a. Multiple organ dysfunction syndrome (MODS) b. Disseminated intravascular coagulation (DIC) c. Chronic obstructive disease. d. Acquired immunodeficiency syndrome (AIDS)
a. Multiple organ dysfunction syndrome (MODS) • Rational: MODS are a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has evidence of several organ systems that require intervention, such as blood pressure, hemoglobin, WBC, and respiratory rate. DIC may develop as a result of MODS. The other options are not correct.
191. The nurse is auscultating is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio file to select the option that applies.) a. Murmur b. s1 s2 c. pericardial friction rub d. s1 s2 s3
a. Murmur
142. A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? a. Observe aspiration site. b. Assess body temperature c, Monitor skin elasticity d. Measure urinary output
a. Observe aspiration site.
182. The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? a. Yogurt and/or buttermilk. b. Avocados and cheese c. Green leafy vegetables d. Fresh fruits
a. Yogurt and/or buttermilk.
116. 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 Rationale: During the aging process older clients often experience sensory or cognitive changes, such as decreased visual or hearing acuity, slower thought or reasoning processes, and shorter attention span. Materials for this age group should include at least of terms, such as a medical terminology that incline may not know and use common words that expresses information clearly and simply. Simple, attractive pictures help hold the learner's attention. The reading level of material should be at the 4th to 5th grade level. Materials should be printed using large font (18-point or higher), not the standard 12-point font.
164. When implementing a disaster intervention plan, which intervention should the nurse implement first? a. Initiate the discharge of stable clients from hospital units b. Identify a command center where activities are coordinated c. Assess community safety needs impacted by the disaster d. Instruct all essential off-duty personnel to report to the facility
b. Identify a command center where activities are coordinated
198. A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? a. Administer naloxone (Narcan) per PNR protocol b. Initiate seizure precautions c. Obtain a serum drug screen d. Instruct the family about withdrawal symptoms.
b. Initiate seizure precautions • Rationale: Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client.
183. The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? a. An adult female who has been depress for the past several month and denies suicidal ideations. b. A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium. c. A young male with schizophrenia who said voices is telling him to kill his psychiatric. d. An elderly male who tell the staff and other client that he is superman and he can fly
c. A young male with schizophrenia who said voices is telling him to kill his psychiatric. Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk.
105. A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? a. Increased Glasgow coma scale score. b. Nuchal rigidity and papilledema. c. Confusion and papilledema d. Periorbital ecchymosis.
c. Confusion and papilledema Rationale: papilledema is always an indicator of increased ICP, and confusion is usually the first sign of increased ICP. Other options do not necessarily reflect increased ICP.
140. A client with a chronic health problem has difficulty ambulating short distance due to generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client? a. Crutches with 2 point gait. b. Crutches with 3 point gait. c. Crutches with 4 point gait. d. A quad cane
c. Crutches with 4 point gait.
195. When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? a. Arrange to transport the client to the hospital b. Instruct the client to keep a food journal, including portions size. c. Review the client's use of over the counter (OTC) medications. d. Reinforce the importance of keeping the feet elevated.
c. Review the client's use of over the counter (OTC) medications. • Rationale: Sodium is used in several types of OTC medications. Including antacids, which the client may be using to treat his GERD. Further evaluation is need it to determine the need for hospitalization (A) A food journal (B) may help over, but dietary modifications are needed now since edema is present. (C) May relieve dependent edema, but not treat the underlying etiology.
194. The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? a. Case management and screening for clients with HIV. b. Regional relocation center for earthquake victims c. Vitamin supplements for high-risk pregnant women. d. Lead screening for children in low-income housing.
c. Vitamin supplements for high-risk pregnant women. • Rational: Primary prevention activities focus on health promotions and disease preventions, so vitamin for high-risk pregnant women provide adequate vitamin and mineral for fetal developmental.
179. A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? a. Infection b. Increase intracranial pressure c. Shock d. Head Injury.
c. shock
123. A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)
• A client must be willing to accept palliative care, not curative care. • The healthcare provider must project that the client has 6 months or less to live.
141. The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.)
• Answer: 12160 Rationale: 4ml x 76kg x 40 (bsa) =12,160 ml
185. In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?
• Anxiety related to fear of suffocation.
154. A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to 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. What action should the nurse take?
• Ask the older brother how he felt during the incident.
169. When evaluating a client's rectal bleeding, which findings should the nurse document?
• Color characteristics of each stool.
174. An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries?
• Decrease prevalence of glaucoma in the population.
126. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?
• Digoxin.
189. The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?
• During acute illness
165. The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis, "high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis?
• Fever and dysuria.
179. An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first?
• Identify pills in the bag.
166. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement?
• Maintain both lower extremities elevated on pillows.
184. 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?
• Maternal pulse rate of 162 beats per min
173. Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client's plan of care?
• Medicate as needed for pain and anxiety
121. Which intervention should the nurse include in the plan of care for a child with tetanus?
• Minimize the amount of stimuli in the room
180. A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider?
• New onset of purple skin lesions.
132. Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? (Select all that apply)
• Notify the food services department of the allergy. • Enter the allergy information in the client's record. • Add egg allergy to the client's allergy arm band.
118. An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.)
• Notify the healthcare provider of the client's change in mental status. • Include q2 hour's reorientation in the client's plan of care.
197. A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take?
• Provide the man and his mother with a copy of the Patient's Bill of Rights
153. A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement?
• Reposition the client with the head of the bed elevated
151. While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first?
• Submit a referral for an evaluation by a physical therapist.
137. The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)
• Take postoperative vital signs for a client who has an epidual following knee arthroplasty • Collect a sputum specimen for a client with a fever of unknown origin • Ambulate a client who had a femoral-popliteal bypass graft yesterday
190. A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs?
• Tell all their assigned clients to stay in their rooms.
172. 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)
• Weigh the client and report any weight gain. • Report any client complaint of pain or discomfort. • Note and report the client's food and liquid intake during meals and snacks.
