HESI Chronic
A client with sickle cell anemia is admitted with severe abdominal pain and the diagnosis is sickle cell crisis. Which is the most important nursing action to implement?
Evaluate the effectiveness of narcotic analgesics. Pain management is the priority for a client during sickle cell crisis. Continuous narcotic analgesics are the mainstay of pain control, which should be evaluated frequently to determine if the client's pain is adequately controlled.
The nurse is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the nurse instruct the client to report immediately?
Fever related to infection. Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections should be reported immediately.
A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider?
Fingerstick glucose of 300 mg/dL. Elevated fingerstick glucose levels need to be reported to the healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also, elevated glucose levels spill into the urine and provide a medium for bacterial growth.
A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. Which assessment finding is most important for the nurse to identify?
Flushed skin and headache. The most common type of reaction is a febrile, nonhemolytic blood transfusion reaction related to leukocyte incompatibility, which causes chills, fever, headache, and flushing.
A client with osteoarthritis receives a prescription for Naproxen. Which potential side effect should the nurse provide to the client about this medication?
Gastrointestinal disturbance. Prostaglandin synthesis inhibitors such as naproxen can have gastrointestinal side effects such as nausea and gastric burning. It is recommended that this drug be taken with food to avoid gastrointestinal upset.
The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately?
Increased abdominal pain with rebound tenderness. Positive rebound tenderness following a colonoscopy may be an indication of perforation and the development of peritonitis and requires follow-up immediately.
A client with rheumatoid arthritis is prescribed piroxicam, a nonsteroidal antiinflammatory drug (NSAID). Which effect is characteristic of NSAIDs used for treating rheumatoid arthritis?
Inflammation is reduced by inhibiting prostaglandin synthesis. Nonsteroidal antiinflammatory drugs (NSAIDs) are used for treating rheumatoid arthritis by inhibiting the synthesis of prostaglandins and providing relief from the associated pain.
The nurse is preparing an adult client for an upper gastrointestinal (UGI) series. Which information should the nurse include in the teaching plan?
Nothing by mouth is allowed for 6 to 8 hours before the study. The client should be NPO, including smoking or chewing gum for at least 6 hours before the UGI study.
A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardial infarction?
Oral contraceptives. Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or stroke.
The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome?
Prevent the formation of effusion fluid. Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a pleural effusion by causing the pleural spaces to be sealed together, thereby preventing the accumulation of pleural fluid.
The nurse is providing postoperative instructions for a female client after a mastectomy. Which information should the nurse include in the teaching plan? (Select all that apply.)
Report inflammation of the incision site or the affected arm. Avoid lifting more than 4.5 kg (10 pounds) or reaching above her head. Part of a client's s/p mastectomy teaching plan should include reporting evidence of inflammation at the incision site or the affected arm, and avoiding lifting or reaching above their head.
Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing?
Respiratory effort. Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition progresses, the nurse must ensure that the client is able to breathe effectively.
The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.)
Vagal stimulation. Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells. Hypersecretion of gastric juices and an increased number of parietal cells that stimulate secretion are most often the causes of ulceration. Vagal stimulation and decreased duodenal inhibition also increase the secretion of caustic fluids.
A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. Which response is best for the nurse to provide?
"Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." Anger is a common emotional reaction when confronted with the diagnosis of an STI, and often lay blame and project this anger at the sexual partner. Although HPV is not a reportable disease in many states, all contacts should be informed of the infection, treatment, transmission, and precautions to minimize infecting others.
A couple trying to cope with an infertility problem wants to know what can be done to preserve emotional equilibrium. Which is the best response for the nurse to provide?
"Get involved with a support group. I will give you some names." A support group provides a safe haven for the couple to share their feelings and experience and gain insight from others dealing with the same experience and let's them know they are not alone in their situation.
A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed?
"I know I will miss having sexual intercourse with my husband." Further teaching is needed in response to the client's misunderstanding of not being able to have sexual intercourse after a hysterectomy.
The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his postoperative care and prognosis?
"I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. The client's understanding is reflected in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may indicate early cancer.
Which client is at highest risk for compromised psychological adjustment after a hysterectomy?
A 29-year-old woman whose uterus ruptured after giving birth to her first child. The client who is a primipara and is still in her childbearing years and is at the highest risk for unresolved conflicts about the end of her childbearing opportunities.
Which client should the nurse assess first?
A 55-year-old newly admitted client troubled by jaw pain and indigestion. The 55-year-old client should be assessed first to rule out cardiac involvement because jaw pain and indigestion are common descriptors of myocardial injury.
A client with acute appendicitis is experiencing anxiety and loss of sleep about missing the final examination week at college. Which outcome is most important for the nurse to include in the plan of care?
Achieve a sense of control. The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is the overall outcome of this client's nursing care plan.
The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)?
Administer medications for pain relief, shortness of breath, and nausea. Hospice care provides symptom management and pain control during the dying process and enhances the quality of life for a client who is terminally ill. Administering medication and monitoring for therapeutic and adverse effects is within the scope of practice for the PN. Scope of practice guidelines vary by state and country and should be consulted when delegating.
A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is 70 beats per minute, respirations are 18 breaths per minute and blood pressure is 125/75 mmHg. Which action should the nurse implement next?
Administer the medication. Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be administered since the client is not demonstrating any signs of toxicity.
A male client with chronic atrial fibrillation and slow ventricular response is scheduled for surgical placement of a permanent pacemaker. The client asks the nurse how this device will help him. How should the nurse explain the action of a synchronous pacemaker?
An electrical stimulus is discharged when no ventricular response is sensed. The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as symptomatic dysrhythmias like atrial fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated on demand or as needed according to the patient's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium stimulating it to contract when no ventricular depolarization is sensed.
The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information?
An image that describes metastatic sites of cancer. PET scans provide information regarding certain diseases of the heart (determination of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors and their metastasis.
A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. The client complains of feeling distended and has sharp, cramping gas pains. Which nursing intervention should be implemented?
Assist the client to ambulate in the hall. Postoperative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated, flatus passed and distention minimized by implementing early and frequent ambulation.
Based on an analysis of the client's rhythm, atrial fibrillation, the nurse should prepare the client for which treatment protocol?
Anticoagulation therapy. The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria.
The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs of a client who returns to the unit after having a mastectomy for cancer. Which information should the nurse provide the UAP?
Apply the blood pressure cuff to the arm on the non-operative side. The nurse gives the UAP the following instructions when providing care to a post-op mastectomy client. Blood pressure readings should be obtained from the arm on the nonoperative side to reduce the risk of injury to the extremity that may have compromised lymphatic drainage postoperatively. The arm on the operative side of the mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage.
A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure?
Assess for signs of bleeding and hypovolemia. Assessment for signs of bleeding should be implemented because internal bleeding is the greatest risk following a liver biopsy.
The nurse is caring for a client receiving tamoxifen for the treatment of breast cancer. Which action should the nurse include in the client's plan of care?
Assist the client in coping with hot flashes. Tamoxifen, an estrogen receptor blocking agent, can cause hot flashes, so client education regarding menopausal-like symptoms should be included in the plan of care.
A client arrives at the emergency department for treatment of injuries sustained in a motor vehicle collision. The nurse notes the asymmetrical expansion of the chest wall during respiration. Which action should the nurse implement next?
Auscultate the lungs bilaterally. Chest trauma may result in the development of pneumothorax. After noting the asymmetric expansion of the chest wall, the nurse should auscultate the lungs to determine if the client can move air through all of the lung fields.
The nurse completes a visual inspection of a client's abdomen. Which technique should the nurse perform next in the abdominal examination?
Auscultation Auscultation of the client's abdomen is performed next because manual manipulation of the abdomen can stimulate peristalsis and create an inaccurate assessment of bowel sounds heard during auscultation.
The nurse is preparing a teaching plan for a client with newly diagnosed glaucoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies?
Avoid allergy medications that contain pseudoephedrine or phenylephrine. OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications.
A female client is recently diagnosed with Sarcoidosis. The client tells the nurse that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the nurse should include that sarcoidosis most commonly occurs in which ethnic group of women?
Black women. Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs, has shown familial tendency due to multiple genes that together increase the susceptibility of developing the disease. In the United States, sarcoidosis more commonly affects Black Americans than white Americans and is twice as common in Black-American women as in Black-American men.
A client is admitted after a blunt abdominal injury. Which assessment finding requires immediate action by the nurse?
Bluish periumbilical skin discoloration. Immediate action is indicated for intraperitoneal hemorrhage which causes periumbilical discoloration and indicates the presence of a splenic rupture, a life-threatening complication of blunt abdominal injury.
Which instruction should the nurse include in the discharge teaching for a client who needs to perform the self-catheterization technique at home?
Catheterize every 4 to 6 hours. The average interval between catheterizations for adults is every 4 to 6 hours. Although the sterile technique is indicated in healthcare facilities, the clean technique is often followed by the client when performing self-catheterization at home.
The nurse is caring for a client with non-Hodgkin's lymphoma who is receiving chemotherapy. Laboratory results reveal a platelet count of 10,000/mL. Which action should the nurse implement?
Check stools for occult blood. Platelet counts less than 100,000/mm3 are indicative of thrombocytopenia, a common side effect of chemotherapy. A client with thrombocytopenia should be assessed frequently for occult bleeding in the emesis, sputum, feces, urine, nasogastric secretions, or wounds.
Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire?
Cherry red color to the mucous membranes. The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules, and the subsequent vasodilation-induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning.
A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse?
Chest x-ray indicating a mediastinal shift. Immediate action is required for findings of a mediastinal shift, which can precipitate life-threatening cardiovascular collapse as the great cardiac vessels become kinked and compressed due to the tension pneumothorax.
A female client admitted with abdominal pain is diagnosed with cholelithiasis. The client asks the nurse what she should expect as a common treatment. Which recommended plan of care should the nurse provide the client?
Cholecystectomy via laparoscopy. The nurse should explain to the client that gall bladder surgical removal is most often recommended via laparoscopic excision.
A male client comes into the clinic with a history of penile discharge with painful, burning urination. Which action should the nurse implement?
Collect a culture of the penile discharge. Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment.
Which assessment finding is of greatest concern to the nurse who is caring for a client with stomatitis?
Cough brought on by swallowing. A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a client with stomatitis. Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcare provider immediately.
Which is the primary nursing problem for a client with asymptomatic primary syphilis?
Deficient knowledge. An asymptomatic client with primary syphilis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing problem is deficient knowledge of the disease pathophysiology.
A client who has just tested positive for human immunodeficiency virus (HIV) does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection?
Discuss retesting to verify the results, which will ensure continuing contact. Encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although post-test counseling should include education, retesting encourages the client to maintain medical follow-up and management.
A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. Which action should the nurse implement?
Document the finding as the only action. Coronary artery bypass surgery graft (CABG) places a client at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy, so the serum potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. Documentation of the normal finding is indicated at this time.
The unlicensed assistive personnel (UAP) reports that an 87-year-old female client who is sitting in a chair at the bedside has an oral temperature of 97.2 °F (36.2 °C). Which intervention should the nurse implement?
Document the temperature reading on the vital sign graphic sheet. A subnormal temperature of 97.2 °F (36.2 °C) (orally) is a common finding in older clients, so the nurse should document the findings and continue with the plan of care.
Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy?
Drinks a six-pack of beer every day. Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a client with diabetic nephropathy. The usual can of beer is 12 ounces (360 mL). Clients with diabetes are recommended to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthy fluctuations in blood glucose and promote poor glucose control. Nephropathy is exacerbated by poor blood glucose control.
When teaching a client with breast cancer about the prescribed radiation therapy for treatment, which information is important to include?
Dry, itchy skin changes may occur. Side effects from radiation to the breast most often include temporary skin changes such as dryness, tenderness, redness, swelling, and pruritus.
The nurse is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the nurse to report to the healthcare provider?
Dyspnea. A client with a large bone fracture is at risk for intramedullary fat leaking into the bloodstream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately.
After a liver biopsy is performed at the bedside, the nurse is assigned to care for the client. Which nursing intervention is most important for the nurse to implement?
Evaluate vital signs every 15 minutes x 2, then every 30 minutes x 4, then hourly x 4. Vital signs should be checked every 15 minutes to assess for bleeding after a biopsy of the liver, which is highly vascular. The client should be positioned on the right side with a pillow or sandbag under the costal margin and supporting the biopsy site. The client should be maintained on bed rest for several hours to decrease the risk of bleeding from the biopsy site.
A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make?
Exposure to cold environmental temperatures. TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Prolonged exposure to cold environmental temperatures stimulates the hypothalamus to secrete a thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH.
The nurse is caring for a client with end-stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, which position should the nurse ask the client to demonstrate?
Extend the arm, dorsiflex the wrist, and extend the fingers. Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist causing rapid, non-rhythmic extension and flexion of the wrist while attempting to hold position.
The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul-smelling fecal-like material. Which action should the nurse implement?
Give IV fluids with electrolytes. When the bowel is obstructed, electrolytes and fluids are not absorbed, so parenteral fluids with sodium chloride, bicarbonate, and potassium should be administered to prevent electrolyte imbalance and dehydration.
A client who returns to the unit after having a percutaneous coronary intervention (PCI) with balloon angioplasty, complains of acute chest pain. Which action should the nurse implement next?
Give a sublingual nitroglycerin tablet. After a percutaneous coronary intervention (PCI) with balloon angioplasty, a client who experiences acute chest pain may be experiencing cardiac ischemia related to re-stenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin to dilate the coronary arteries and increase myocardial oxygenation.
The nurse is giving discharge instructions to a client with chronic prostatitis. Which instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract?
Have intercourse or masturbate at least twice a week. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases the number of microorganisms present and reduces the risk of further infection from stored contaminated seminal fluids.
A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the nurse identify in the client's history?
Heart failure (HF). Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload associated with heart failure which causes pulmonary edema.
Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer?
Human papillomavirus. According to the CDC (2017), it is estimated at least 80% of all women who are sexually active will contract the Human papillomavirus (HPV) in their lifetime. Certain types of HPV have been suspected to cause cervical cancer and HPV strain 16 and 18 have been identified to cause 70% of cervical cancers.
A client with primary dysmenorrhea has several medications at home. She calls the clinic to ask the nurse which medication should she use for her pain. Which option should the nurse recommend as the first choice in the management of this client's pain?
Ibuprofen. Ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID) provides the most effective relief for primary dysmenorrhea because it has antiprostaglandin properties.
An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. Which is the priority nursing problem for this client?
Impaired comfort. In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, which supports the primary nursing problem, "Impaired comfort".
A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first?
Instill the first dose of nystatin vaginally per applicator. Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a "cottage-cheese" appearance, and vaginal nystatin should be implemented first to initiate treatment to provide relief of symptoms.
The nurse is caring for a client after transurethral resection of the prostate (TURP) and determines the client's urinary catheter is not draining. What should the nurse implement?
Irrigate the catheter. Obstruction of urinary flow after a TURP is most often due to blood clots, and sterile irrigation should be implemented to remove the clots that are blocking the catheter.
A nurse is preparing to insert an IV catheter after applying a eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. Which action should the nurse take to maximize its therapeutic effect?
Leave the cream on the skin for 1 to 2 hours before the procedure. Topical anesthetic creams, such as EMLA, should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter.
In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning?
Left lateral, supine, brief periods on the right side, and prone. After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side, which can impair circulation and cause pain, and includes the prone position to help prevent flexion contractures of the hips, prepares the client for optimal functioning and ambulation.
A client's prostate-specific antigen (PSA) exam result showed a PSA density of 0.13 ng/mL. Which conclusion regarding this lab data is accurate?
Low risk for prostate cancer. Clients with a PSA density of less than 0.15 ng/mL are considered at low risk for prostate cancer.
A client with osteoarthritis requests information from the nurse about which type of exercise regimen would be most beneficial for him. The nurse should communicate which information?
Low-impact exercise, walking, swimming, and water aerobics. Low-impact exercises such as walking or swimming, that do not put additional pressure and strain or cause further harm to damaged joints, are most beneficial to clients with osteoarthritis. Strength-building exercises, circuit training, and high-impact aerobics may cause too much stress on the joint areas and subsequently increase inflammation and damage.
The nurse is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm3 and a platelet count of 160,000/mm3. Which intervention is the primary focus in the client's plan of care for the nurse to implement?
Maintain strict protective precautions. The client should be under strict protective transmission precautions because the WBC values are low and normal WBC levels are 4,000-10,000/mm3, so the client is at an increasingly high risk for infection.
The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique?
Maintains correct spinal alignment to protect the surgical area. Log-rolling technique maintains the spine in a straight superior-inferior plane that aligns the spine without movement while protecting the surgical area, which is especially important when the procedure involves bone grafts that may take several weeks for the bone to fuse.
An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete?
Measure the blood pressure. Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure should be measured.
Which preexisting diagnosis places a client at the greatest risk of developing superior vena cava syndrome?
Metastatic cancer. Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return of blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava.
The nurse is caring for a client scheduled to undergo the insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different?
Method of insertion. The best explanation of how a PEG tube differs from a GT is by the method of insertion. GT insertion involves making an incision in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is more commonly used due to the fact it does not require general anesthesia and is less invasive due to being inserted with endoscopic visualization through the esophagus into the stomach and then pulled through a small incision in the abdominal wall and held in place by a tiny plastic device called a "bumper" that holds the tube in place inside the stomach and a small water-filled balloon which keeps the stomach in place against the abdominal wall.
While caring for a client who has esophageal varices, which nursing intervention is most important for the nurse to implement?
Monitor infusing IV fluids and any replacement blood products. Maintaining hemodynamic stability in a client with esophageal varices can precipitate a life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products.
A client is admitted for complaints of chest pain and aching for the past 4 days. The results for serum creatine kinase-MB (CK-MB) and troponin levels are obtained. Which rationale should the nurse use to evaluate the laboratory findings?
Myocardial damage that occurred several days earlier is best validated by serum troponin levels. An elevated serum troponin has become the cardiac marker of choice for diagnosing an acute MI, according to the American College of Cardiology (ACC) guidelines (2017) for NSTEMI. An elevated troponin will become evident within 2 to 3 hours of an MI in comparison to the CK-MB and other cardiac enzymes that can take up to 6 to 9 hours after the MI occurrence.
Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis?
New onset of coughing. A pneumothorax (partial or complete lung collapse) is the potential complication of a thoracentesis. Manifestations of a pneumothorax include the new onset of a nagging cough, tachycardia, and an increased shallow respiration rate.
A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. Which action should the nurse implement first?
Notify the client's healthcare provider. Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells clogging the microcirculation in the penis, causing a reduction of blood flow and oxygenation to the penis, so the healthcare provider should be first notified immediately. The prescribed therapy may consist of noninvasive measures such as applying ice to the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa, and giving pain medications. If noninvasive measures do not work, then needle aspiration of the corpora cavernosa is implemented by the healthcare provider.
A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. Which action should the nurse implement?
Notify the healthcare provider. Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a client with a myocardial infarction indicate impending cardiogenic shock related to heart failure, a common complication of MI. The healthcare provider should be notified immediately for emergency interventions for this life-threatening complication.
During the assessment of a client who is 24 hours posthemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. Which action should the nurse implement?
Notify the surgeon. The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or dark red or purple, the stoma is ischemic, and the surgeon should be notified immediately.
The nurse is assessing a client with a cuffed tracheostomy tube in place who is breathing spontaneously. To evaluate if the client can tolerate cuff deflation to promote speaking and swallowing, which action should the nurse implement?
Observe the client for coughing colored sputum after drinking a small amount of colored water. To evaluate the risk for aspiration after the cuff is deflated, the client should be instructed to swallow a small amount of colored water, then observed for coughing up colored sputum, or the tracheostomy should be suctioned for the presence of colored water.
Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)?
Obtain a prescription for an adjusted dose of insulin. Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin.
A client with a recent history of blood in his stools is scheduled for a proctoscopy/sigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.)
Obtain consent for the procedure. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure. The usual preoperative preparation for proctoscopy/sigmoidoscopy entails obtaining the client's consent to the procedure, a clear liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure.
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate?
Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. Treatment of acute osteomyelitis requires the administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks.
The nurse obtains a client's history that includes a right mastectomy and radiation therapy for cancer of the breast 10 years ago. Which current health problem potentially could be a consequence of radiation therapy?
Pathologic fracture of two ribs on the right chest. The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurrence of two right-sided ribs with pathological fractures resulting without evidence of trauma is related to radiation damage.
The nurse is caring for a client who has a closed head injury from a motor vehicle collision. Which assessment finding could potentially indicate diabetes insipidus (DI)?
Polydipsia. A characteristic finding of Diabetes Insipidus (DI) is the excretion of large quantities of urine (5 to 20L/day), and most clients compensate for the fluid loss by drinking large amounts of water (polydipsia). DI can occur when there has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor, or an illness such as meningitis. This damage interrupts the ADH production, storage, and release causing excessive urination and thirst.
The nurse is teaching a client who is newly diagnosed with emphysema on how to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing?
Promotes CO2 elimination. Pursed lip breathing helps eliminate CO2 by increasing positive pressure within the alveoli increasing the surface area of the alveoli making it easier for the O2 and CO2 gas exchange to occur. PLB prolongs exhalation, which prevents bronchiolar collapse and air trapping.
The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)?
Pulse change from 85 to 160 beats/minute lasting more than 10 minutes. The RRT should be called to intervene for a client with an acute life-threatening change, such as a pulse change resulting in tachycardia for a prolonged time in a post-operative client.
The nurse is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the nurse report to the healthcare provider?
Rebound abdominal tenderness over the right lower quadrant. Right lower quadrant (RLQ) rebound abdominal tenderness may be related to acute appendicitis and should be reported to the healthcare provider.
The nurse is caring for a client with human immunodeficiency virus (HIV) infection who develops Mycobacterium avium complex (MAC). Which is the most significant desired outcome for this client?
Return to pre-illness weight. MAC is an opportunistic infection that presents as a tuberculosis-like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight using oral, enteral, or parenteral supplementation as needed.
The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. Which is the priority nursing problem that should guide the discharge instruction plan?
Risk for infection. A wound healing by secondary intention is an open wound that is at risk for infection and the location of the wound near the anal area increases the risk for infection even more so.
A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further?
Serosanguineous nasal drainage. Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis.
A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the nurse anticipate to be elevated if the client experienced myocardial damage?
Serum troponin. Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB.
Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine, but his wife moved into the spare bedroom to sleep when he returned home. He states, "I guess we will never have sex again after this." Which response is best for the nurse to provide?
Sexual activity is similar in cardiac workload and energy expenditure as climbing two flights of stairs and may be resumed like other activities. Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no more energy expenditure or cardiac stress than walking briskly up two flights of stairs, so if you do not experience shortness of breath or chest discomfort doing the stairs then you should be okay to resume sexual activity.
Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn?
Slow capillary refill in the digits with absent distal pulse points. A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy.
A client asks the nurse which possible treatments might be used for their tumor. How should the nurse reply?
The three hallmark treatments include surgery, radiation, and chemotherapy. Varying factors determine what measures will be used for cancer tumors/treatments. Surgery, radiation, and chemotherapy are the three standard treatment regimes.
The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client?
There is a radical change in appearance as a result of this surgery. Radical neck dissection is the removal of lymphatic drainage channels and nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. The overall outcome of this type of surgery causes the neck to be disfigured, so the radical change in appearance, "Alteration in body image" will be a priority in the care of this client.
A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement?
Turn off the television and darken the room. To decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or rotational movements, such as sudden head movements or position changes, should be minimized. To effectively manage the client's symptoms, turn off the television, darken the room by minimizing fluorescent lights, flickering television lights, and distracting sounds.
The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess?
Upper chest subcutaneous emphysema. Subcutaneous emphysema is a complication and indicates air is leaking beneath the skin surrounding the chest tube.
The nurse is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the nurse that the client is stabilizing?
Urine output of 40 mL/hour. A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, no less than 30 mL/hour, the client's kidneys are perfusing adequately which indicates the client's status is stabilizing.
Which intervention should the nurse implement that best confirms the placement of an endotracheal tube (ETT)?
Use an end-tidal CO2 detector. The end-tidal carbon dioxide detector indicates the presence of CO2 tidal by a color change or a number indicated on the detector, which is supporting evidence that the ETT is in the trachea, not the esophagus.
Which method elicits the most accurate information during a physical assessment of an older client?
Use reliable assessment tools for older adults. Specific assessment tools designed for an older adult, such as Older Adult Resource Services Center Instrument (OARS), mini-mental assessment, fall risk, depression (Geriatric Depression Scale), or skin breakdown risk (Braden Scale), consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information.
A client in the preoperative holding area receives a prescription for midazolam IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement?
Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. Midazolam, a benzodiazepine sedative, is commonly used for conscious sedation intraoperatively and interferes with the client's cognition and level of consciousness, so the consent form should be signed before the drug is administered.
The nurse is completing the health assessment of a 79-year-old male client who denies any significant health problems. Which finding requires the most immediate follow-up assessment?
Yellowish discoloration of the sclerae. In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a normal finding and may indicate liver damage and requires further assessment.
Which findings are within the expected parameters of a normal urinalysis for an older adult? (Select all that apply.)
pH 6. Sugar negative. Bilirubin negative. Specific gravity 1.015. A pH of 6.0 is within the normal pH range for urine. Glucosuria and bilirubinuria are abnormal and should be negative upon urinalysis. Normal changes associated with aging include decreased creatinine clearance and decreased concentrating and diluting abilities which influence the normal range of urine specific gravity, 1.001 to 1.035. Although common health problems associated with aging include renal insufficiency, urinary incontinence, urinary tract infection, and enlarged prostate, these are indicative of pathology which should be treated.