HESI

An adult male reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mmHg. Which risk factors should the nurse explore further with the client? (Choose all that apply.) History of hypertension. Homosexual lifestyle. Vegetarian diet. Excessive aerobic exercise. Family health history.

(selected incorrect answer)

A client presents to the clinic with concerns regarding her left breast. Which assessment finding is most important for the nurse to report to the healthcare provider? Bloody discharge from the nipple. A fixed nodular mass with dimpling of skin. A slight asymmetry of the breasts. Multiple firm, round, freely moveable masses.

A fixed nodular mass with dimpling of skin. A fixed nodular mass with dimpling of the overlying skin is a common finding during late stages of breast cancer and should be reported. Although other findings may be included in the report, a bloody discharge may indicate a benign condition, such as intraductal papilloma.

A nurse who usually works on a step-down unit is moved to work a 12-hour shift in the critical care unit. Which client is best for the charge nurse to assign to this nurse?

A ventilator dependent client with chronic obstructive pulmonary disease (COPD). stop changing answers LEAST CRITICAL are given to those who float A ventilator dependent client with chronic obstructive pulmonary disease (COPD) is the best choice to assign to a nurse who is moved to work in a more complex level of care than usually assigned. Clients with more acute or complex needs should be assigned to critical care staff.

A client with Myasthenia Gravis is admitted with bradycardia caused by an overdose of pyridostigmine. Which action should the nurse take first?

Administer a PRN dose of atropine 1 mg IV. An overdose of pyridostigmine, a cholinesterase inhibitor drug, can precipitate a cholinergic crisis causing cholinergic-induced bradycardia. Atropine should be given to increase the heart rate and blood pressure.

A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his "right foot is aching." The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement?

Administer a prescription for gabapentin, a neuroleptic agent. Neuropathic pain commonly occurs after nerves are severed during amputation, and the client should be reassured that he is "not crazy" because the missing limb hurts. These occurrences of pain of the amputated limb are often referred to as "phantom pains". The exact cause is not known, but it is believed to have something to with the severed peripheral nerves and their circuitry with the spinal cord and the brain. Adjuvant medications, such as a neuroleptic agent, are often helpful in reducing this type of pain.

A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement?

Administer prescribed dose of levothyroxine. Rationale: In the negative feedback mechanism of hypothyroidism, a low level of thyroid hormone stimulates TSH production by the hypothalamus and results in an elevated TSH level, but the thyroid gland does not respond with adequate production of thyroid hormones (T3 and T4) to regulate basal metabolic rate. These serum hormone levels indicate the need to administer supplemental thyroid hormone, such as levothyroxine, as soon as possible to avert possible myxedema coma.

The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, which assessment should the nurse obtain? Onset of any bleeding. Appearance of wound. Bilateral pedal pulse force. Degree of skin elasticity.

Appearance of wound. An elevation of the white blood cell count (WBC) and erythrocyte sedimentation rate (ESR) reflect the presence of infection and inflammation. The wound should be assessed for erythema, edema, tenderness or increased pain, local heat or fever, and purulent exudate, so the wound's appearance can be described when the laboratory results are reported to the healthcare provider.

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting this illness and is only continuing treatments because his family wants him to live. Which action should the nurse take?

Arrange a meeting with the family, physician, and client. For the client with a terminal illness who is tired of fighting, the nurse should advocate for the client and arrange a meeting with the client, family and healthcare team to discuss the client's wishes.

The nurse is arranging home care for an older client who has a new colostomy following a large bowel resection three days ago. The client plans to live with a family member. Which actions should the nurse implement? (Select all that apply.) Assess the client for self care ability. Provide pain medication instructions. Call home care agency to set up oxygen. Request a home safety inspection. Teach care of ostomy to care provider.

Assess the client for self care ability. Provide pain medication instructions. Teach care of ostomy to care provider. For the client with a new colostomy returning to home care, the nurse must assess the client's ability to care for self in order to make home care arrangements prior to discharge. Pain medication instructions, both verbal and written, should be provided prior to discharge. Teaching ostomy care to the care provider is essential, especially when the client is older and possibly confused.

The client provides three positive responses to items on the CAGE (Cut down, Annoyed, Guilty, Eye-opener) questionnaire. Which interpretation should the nurse provide the client?

At least two positive responses are strongly suggestive of alcohol dependence. The CAGE (Cut down, Annoyed, Guilty, Eye-opener) questionnaire assess alcohol addiction. The client should be confronted with results of the CAGE screening tool which indicates that any two positive responses to the four "yes/no" questions are strongly suggestive of alcohol dependence.

A male client with multiple myeloma is admitted with pneumonia and pancytopenia. The nurse reviews the complete blood cell count findings and identifies a platelet count of 20,000 cells/mm3 (20 x 109/L). Which intervention should the nurse include in the client's plan of care?

Avoid intramuscular injections. Multiple myeloma is a malignant proliferation of plasma B cells that infiltrate the bone marrow and inhibit hemopoiesis, so the nurse should implement thrombocytopenia precautions and avoid injections, which can result in intramuscular hematoma formation.

A mother brings her 2-month-old infant to the clinic for a well-baby appointment. The nurse obtains a history and conducts a physical assessment. Which finding requires the most immediate intervention?

Bilateral retinal hemorrhages. Bilateral retinal hemorrhages with no reported trauma or injury to an infant are usually evidence of shaken baby syndrome. Shaken baby syndrome occurs with forcefully shaking an infant or a toddler causing shearing of the brain which causes permanent brain damage and can lead to death.

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? Muscle weakness. Apical heart rate 72 beats/minute. Hypertension. Blood pressure 90/76 mm Hg.

Blood pressure 90/76 mm Hg. Clonidine, an alpha adrenergic blocking agent used to treat hypertension, is also administered for symptoms related to opiate withdrawal. If a client's systolic blood pressure is less than 90 mm Hg, the medication should not be given.

A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500 mg PO every 12 hours. When the client requests an afternoon snack, which dietary choice should the nurse provide Vanilla-flavored yogurt. Low-fat chocolate milk. Calcium-fortified juice. Cinnamon applesauce.

Cinnamon applesauce. Dairy products and calcium-fortified dairy products decrease the absorption of ciprofloxacin. Cinnamon applesauce contains no calcium, so this is the best snack selection.

When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?

Client has elevated BP SBP >140 or DBP >90 =sign of preeclampsia (protein in urine and edema of hands & feet are also a key features)

A client with gestational diabetes is being induced for labor. Which assessment is most important for the nurse to perform prior to increasing the oxytocin rate? Vaginal exam. Blood pressure. Contraction pattern. Fingerstick glucose.

Contraction pattern. Before increasing the rate of the oxytocin infusion, it is most important for the nurse to determine the frequency and pattern of uterine contractions.

A client is admitted reporting an acute onset of right flank pain and urinary urgency. Which assessment is most important for the nurse to obtain? Current body temperature. Numerical rated pain intensity. Amount of daily caffeine intake. Fluid intake for past 24 hours.

Current body temperature. KEY WORD URINARY URGENCY someone w/ pyelonephritis (kidney infection UTI) For a client who is exhibiting signs of pyelonephritis, a temperature elevation would help to confirm this diagnosis. The nurse should also assess the client's perception of pain using a pain scale, especially related to kidney disease, but pain intensity assessment does not have the priority of body temperature.

The healthcare provider prescribed furosemide for a 4-year-old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? Daily weight decrease of 2 pounds (0.9 kg). Blood urea nitrogen (BUN) increase from 8 to 12 mg/dL (2.9 to 4.3 mmol/L). Urine specific gravity change from 1.021 to 1.031. Urinary output decrease of 5 mL/hour.

Daily weight decrease of 2 pounds (0.9 kg). Furosemide is a loop diuretic. Assessment of weight is usually an effective, non-invasive measure for evaluating fluid volume status. This client's weight loss indicates that the furosemide is removing excess fluid.

To prevent infection by autocontamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?

Dress each wound separately. Each wound should be dressed separately using a new pair of sterile gloves to avoid autocontamination (the transfer of microorganisms from one infected wound to a non-infected wound).

A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to the client? Cheddar cheese and crackers. Carrot and celery sticks. Beef bologna sausage slices. Dry roasted almonds.

Dry roasted almonds. Foods rich in magnesium include green leafy vegetables and nuts and seeds.

A middle-aged male client, admitted to a critical care unit several weeks ago because of serious injuries sustained in a motor vehicle accident, is currently in stable condition. Based on this client's age and recent life-threatening crisis, which intervention is should the nurse implement? Provide a routine schedule of activities to facilitate trust. Encourage the client to reflect on personal goals and priorities. Discuss the cause of the accident with the client and his family. Allow long periods of uninterrupted rest in order to reduce fatigue.

Encourage the client to reflect on personal goals and priorities. Critical illness often prompts a re-examination of one's life priorities. The individual faces mortality, perhaps for the first time. Based on Erikson's developmental theory, middle-aged individuals are at the stage of Generativity vs. Stagnation. Generativity involves reflection on one's accomplishments and a personal evaluation of success in meeting life goals.

The nurse is collecting a heel stick blood specimen for a neonatal screen, which includes thyroxine (T4) and thyroid stimulating hormone (TSH) levels, prior to the discharge of a 2-day-old newborn. When the parents ask why these tests are being conducted, which explanation should the nurse provide? This technique is used for early detection of mental retardation. Dosages for thyroid replacement therapy will be determined by this test. This is a routine blood test required by law to screen for metabolic deficiencies. These lab values will provide data to anticipate delays in growth and development.

This is a routine blood test required by law to screen for metabolic deficiencies. The nurse should explain that the blood test is routine and is mandated by state law. The newborn screening tests are mandatory in most of the 50 states and help to detect inherited disorders of metabolism that can lead to mental retardation if not treated, such as congenital hypothyroidism, phenylketonuria and galactosemia.

A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 mL/hour. Normal saline is infusing at 125 mL/hour with a secondary infusion of dopamine at 4 mcg/kg/minute per infusion pump. Which intervention should the nurse implement?

Titrate the dopamine infusion to raise the BP. EG-good thinking

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL™ chest drainage unit becomes increasingly anxious and complains of difficulty breathing. The nurse determines the client is tachypneic with absent breath sounds in the client's right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? Continuous bubbling in the water-seal chamber. Decreased bright red bloody drainage. Tachypnea with difficulty breathing. Tracheal deviation toward the left lung.

Tracheal deviation toward the unaffected left lung with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax. Tachypnea with difficulty breathing are early signs of respiratory distress, which can result from a variety of causes, including a pneumothorax.

The nurse is providing intermittent gavage feedings for a 33-week gestational age newborn. The nurse positions the newborn in a right side-lying position with the head slightly elevated and passes the feeding tube through the mouth. Prior to administering the bolus feeding, it is most important for the nurse to obtain which assessment?

Volume of gastric residual. To avoid over-distending the stomach and create feeding intolerance, a common practice for premature infants is to deduct the amount of the residual gastric volume from the total prescribed bolus feeding. Before instilling the bolus feeding, the nurse should aspirate the stomach contents, measure it, return it, and deduct that amount from the next feeding.

A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response? a) no one will hurt you b) you seem quite frightened rn

b) you seem quite frightened A client with delusions firmly holds false beliefs to be true, and it is best to acknowledge feelings related to the delusion. Reassuring statements such as, "You will be alright" are not effective for such clients.

An antacid is prescribed for a client with gastroesophageal reflux (GERD). The client asks the nurse, "How does this help my GERD?" Which is the best response by the nurse? a)antacids decrease prod of gastric secretions b)antacids will neutralize the acid in stomach

b)antacids will neutralize the acid in stomach Antacids neutralize hydrochloric acid in the stomach reducing the heartburn associated with gastroesophageal reflux disease (GERD).

While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take? Determine if the drainage has an unpleasant odor. Cleanse the wound with a sterile saline solution. Monitor the client's white blood cell count (WBC). Request a culture and sensitivity of the wound.

bruh Request a culture and sensitivity of the wound. duh A client who has a postoperative dressing with purulent drainage may have an infected wound and the most important action for the nurse to take is request a wound culture and sensitivity.

A client with bleeding esophageal varices receives vasopressin IV. Which should the nurse monitor for during the IV infusion of this medication?

chest pain & dysrhythmia In large doses, vasopressin may produce increased blood pressure, coronary insufficiency, myocardial ischemia or infarction, and dysrhythmia. -vasopressin constricts blood vessels= HTN adverse effect

The nurse is assessing a client with a closed head injury sustained in a motor vehicle collision. Which finding indicates the lowest level of neurologic functioning?

decerebrate posturing during position changes -The lowest level of neurological functioning is characterized by decerebrate posturing (abnormal extension). Posturing (decorticate or decerebrate) is not considered a purposeful response to pain. -As neurological functioning deteriorates, the client will progress from localization of a tactile stimulus to withdrawal from painful stimuli, followed by decorticate posturing in response to the stimuli, before finally exhibiting decerebrate posturing.

When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply.) Canned fruit cocktail. Creamy peanut butter. Correct answercheck_circleVegetable juice. Correct answercheck_circleVanilla frozen yogurt. Correct answercheck_circleClear beef broth.

key words FULL liquid diet A full liquid diet includes all liquids that are not clear, such as vegetable juice and frozen yogurt, as well as clear liquids.

A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? (Select all that apply.) Monitor stools for presence of blood. Auscultate bowel sounds in all quadrants. Review last partial thromboplastin time results. Prepare to administer warfarin. Assess characteristics of pain.

key words abdominal pain- auscultate for bowel sounds too(missed this) Monitor stools for presence of blood. Auscultate bowel sounds in all quadrants. Review last partial thromboplastin time results. Assess characteristics of pain.

constant alarm & low o2 from ventilator indicates?

malfunction. First action is to begin manual ventilation immediately

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) Teach client how to use guided imagery. Encourage family to visit frequently. Record the client's desire to live. Instruct client and family to reconsider end of life choices. Encourage family to bring the client old photographs.

missed one Teach client how to use guided imagery. Encourage family to visit frequently. Encourage family to bring the client old photographs. this helps reduce anxiety and enhance coping

The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. Which information about the most commonly prescribed medication, mebendazole, should be included?

second dose of med should be given in 2 weeks Teaching about mebendazole, the drug of choice for pinworm infestation, should include a reminder that a second dose should be given in two weeks in order to prevent reinfestation.

The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first? Change the client's position. Irrigate the dialysis catheter. Check the client's blood pressure and serum bicarbonate. Continue to monitor intake and output with next exchange.

stop changing answer ;*( Change the client's position. Rationale: To facilitate drainage, for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD), the client's position should be changed to move the dialysate solution toward the catheter if the output flow is less than the input flow.

The wife of a client diagnosed with Parkinson's disease tells the nurse that her husband is having trouble swallowing and she is afraid he is going to choke. Which intervention should the nurse implement?

teach wife to thicken all liquids & serve semi-solid foods Dysphagia is usually a chronic problem for the client with Parkinson's disease. A semi-solid diet with thick liquids is easier to swallow than solid foods.

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

tuna sandwich w chips & ice cream In a high protein diet, a lunch with fish and dairy contains the highest amount of protein. For instance, four ounces of tuna contains 11 grams of protein, and ice cream 5 grams of protein per cup.

What instruction should the nurse provide the parents of a 3-year-old boy with a BMI-for-age at the 97th percentile?

yo child is overweight for his age & size-help him select healthy foods Children with a BMI-for-age at or above the 95th percentile are considered overweight, and at risk for obesity and all the associated health problems. The nurse should offer recommendations for healthy eating and exercise.

An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problems should the nurse include in this client's plan of care? (Select all that apply.) Fatigue. Fluid volume excess. Fluid volume deficit. Decreased cardiac output. Altered peripheral tissue perfusion.

Fatigue. Fluid volume excess. Decreased cardiac output. Altered peripheral tissue perfusion. Fatigue, fluid excess, decreased cardiac output, and altered tissue perfusion are concerns for this client. *HF is characterized by a decreased cardiac output, which causes compensatory fluid retention resulting in an excess fluid volume. The ineffectiveness of the heart's pumping action in those with HF results in altered peripheral tissue perfusion and fatigue. missed one

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

Focus on small achievable tasks, not taxing problems. The client is manifesting maladaptive behaviors that prevent healthy adjustment and personal growth. Coping with life events can often feel overwhelming. The plan of care should include effective coping strategies that assist the client to focus on small achievable tasks, not taxing problems.

Which self care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus? Diabetic diet meal planning. Blood glucose monitoring. A realistic exercise plan. Self-injection techniques.

GIRL how Blood glucose monitoring.

The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? Cloudy opacity of the crystalline lens. Gradual onset of continuous eye pain and blurred vision. Recent change in the ability to read and drive after dark. Gray-white circle around the iris of both eyes.

Gradual onset of continuous eye pain and blurred vision. The onset of eye pain and blurred vision may indicate closed-angle glaucoma, which requires immediate medical intervention.

An adult woman with type 2 diabetes mellitus (DM2) is to be admitted within the next hour to the medical unit from the Emergency Department. The client's laboratory findings indicate that her serum glucose is 175 mg/dL (or 9.63 mmol/L - SI) and her A1c is 9%. When requesting a dinner tray for the client, which menu should the nurse select? -Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie. -Grilled fish with whole-grain brown rice, steamed broccoli, and pear poached in red wine. -Lean hamburger with cheese, tomato, and lettuce on whole-wheat bun, and angel food cake. -Vegetarian lasagna with cheese and spinach, tossed green salad with ranch dressing, and fresh fruit.

Grilled fish with whole-grain brown rice, steamed broccoli, and pear poached in red wine. The best diet choice is one which has a low fat protein (grilled fish), whole-grains (brown rice), fresh vegetable (steamed broccoli), and fruit for dessert.

The nurse is developing the plan of care for a hospitalized child with von Willebrand's disease. What priority nursing intervention should be included in this child's plan of care? Reduce exposure to infection. Eliminate contact with cold drafts. Guard against bleeding injuries. Reduce contact with other children.

Guard against bleeding injuries. Von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of factor VIII (a defective serum protein called von Willebrand's factor) that results in a prolonged bleeding time because platelets fail to adhere to the walls of a ruptured vessel to form a platelet plug. The priority intervention to include in the plan of care is guarding against any injury that might result in bleeding from injection sites.

The nurse is ready to insert an indwelling urinary catheter as seen in the picture. At this point in the procedure, which actions should the nurse take before inserting the catheter? (Select all that apply)

Hold the catheter 3 to 4 inches (7.5 to 10 cm) from its tip. Ask the client to bear down as if voiding to relax the sphincter. Prior to inserting a urinary catheter, the nurse should grasp the catheter 3 to 4 inches (7.5 to 10 cm) from the catheter tip with the dominant hand and ask the client to bear down.

The nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and a fever of 103.6 oF (39.7 oC). Laboratory findings indicate that the child has a serum sodium concentration of 156 mEq/L (156 mmol/L). Which physiologic mechanism contributes to this finding?

Insensible loss of body fluids contributes to the hemoconcentration of serum solutes. Fever causes insensible fluid loss, which contributes to fluid volume deficit and results in hemoconcentration of sodium (serum sodium greater than 150 mEq/L or mmol/L). Dehydration, which is manifested by dry, sticky mucous membranes, and flushed skin, is often managed by replacing lost fluids and electrolytes with IV fluids that contain varying concentrations of sodium chloride.

The nurse is assessing a client with pulmonary edema who is reporting two pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies crackles in all lung fields and use of accessory muscles. Which action should the nurse include in the client's plan of care? Administer the prescribed amiodarone immediately. Institute a daily fluid restriction while the client is in the hospital. Arrange a prescribed electrophysiology study (EPS) for the client. Assess the client's commitment to their daily exercise regimen.

Institute a daily fluid restriction while the client is in the hospital. key words "crackles in all lung fields" Rationale: In pulmonary edema, pulmonary capillary congestion, usually due to left-sided heart failure, causes fluid accumulation in the alveoli that compromises gaseous exchange between lungs and blood. This is manifested by orthopnea, frothy pink sputum, crackles, paroxysmal nocturnal dyspnea, and pulsus alternans. The nurse should institute a daily fluid restriction while the client is in the hospital.

A client with scleroderma (systemic sclerosis), an auto-immune collagen disease, experiences frequent severe pain caused by Raynaud's phenomenon. To help manage this problem, which instruction should the home health nurse provide the client and family

Keep the home environment warm to reduce episodes. Severe pain caused by Raynaud's phenomenon is a common problem associated with scleroderma and occurs when exposure to cold or stress causes arteriolar constriction and resultant decreased blood flow to the digits. Maintaining a warm environment may help decrease episodes.

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? Pain scale rating of a "9" on a 0 to10 scale. Last menstrual period was 7 weeks ago. Reports white, curdy vaginal discharge. History of irritable bowel syndrome (IBS).

Last menstrual period was 7 weeks ago Acute lower abdominal pain in a young adult female can be indicative of an ectopic pregnancy, which can be life-threatening. Since the client's last menstrual period was 7 weeks ago, a pregnancy test should be obtained to rule out ectopic pregnancy, which can result in intra-abdominal hemorrhage caused by a ruptured fallopian tube.

A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately? Red edematous stomal appearance. Mucous strings floating in the drainage. Stomal output of 40 mL in last hour. Liquid brown drainage from stoma.

Liquid brown drainage from stoma. The ureteroileostomy or ileal conduit is surgical created by implanting the ureters into an isolated segment of ileum that drains urine through an abdominal stoma. Brown drainage may be feces, which should not be coming out of the stoma and could indicate that the bowel was cut during the surgery, thereby putting the client at risk for sepsis.

The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis?

Long distance runner since high school. Osteoarthritis is a degenerative joint disease often caused by traumatic injury or repetitive stress to weight-bearing joints, such as high impact sports like running.

The nurse administers morphine sulfate IV to a client with pancreatitis, who is experiencing extreme periumbilical pain and abdominal distention. Which additional intervention should the nurse implement? Apply heat to the abdomen. Initiate contact isolation. Provide a clear liquid diet. Maintain IV at 125 ml/hour.

Maintain IV at 125 ml/hour. The client with pancreatitis should be kept NPO to rest the gastrointestinal tract, so hydration must be maintained with IV fluids, and IV access provides the most efficient route for medication administration.

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care? Encourage intake of high potassium foods. Provide perineal skin barrier cream. Initiate toileting schedule. Monitor for signs of anemia.

Monitor for signs of anemia Erythropoiesis is impaired in clients with chronic renal failure due to impaired production of erythropoietin, a hormone produced by the kidney that simulates bone marrow production of red blood cells and platelets. Monitoring for signs of anemia should be included in the plan of care.

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with chronic kidney disease. What intervention should the nurse include in the plan of care?

Monitor serum electrolytes daily. Rationale: Chronic kidney disease (CKD) is a progressive, irreversible loss of kidney function, decreasing glomerular filtration rate (GFR), and the kidney's inability to excrete metabolic waste products and water, resulting in fluid overload, electrolyte imbalance, elevated pulse rate, and weight gain. The plan of care should include monitor serum electrolytes daily to evaluate serum potassium and calcium that can predispose to fatal cardiac dysrhythmias.

Two weeks post-burn, a male client with 40% deep partial-thickness injury continues to have open wounds and is now developing diarrhea. His blood pressure is 80/40 mmHg and his temperature is 96o F (35.6o C). Which action is most important for the nurse to take? Continue to monitor vital signs. Increase the room temperature. Assess the oxygen saturation. Notify the rapid response team.

Notify the rapid response team. bro is in shock...call rapid Hypotension, hypothermia, and diarrhea are findings associated with systemic gram-negative sepsis, so the rapid response team or emergency team should be notified.

Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form?

OB explained a procedure that a neurologist will perform The individual who is ultimately responsible for the procedure should provide the information necessary for informed consent, so when an obstetrician explains the procedure scheduled to be performed by a neurologist this should be explored further by the nurse before witnessing the client's signature.

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this clients plan of care? Observe color of urine. Check for pedal edema. Assess skin turgor. Measure body temperature.

Observe color of urine. Prasugrel, a platelet inhibitor, can cause hemorrhage, so it is critical to monitor for signs and symptoms of bleeding, such as pink-tinged urine. don't change ur answer

A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply.) Observe for evidence of hypokalemia. Encourage oral fluid intake of 3,000 mL/day. Weigh the client daily, in the morning. Teach the client how to restrict dietary sodium. Monitor PTT, PT, and INR lab values.

Observe for evidence of hypokalemia. Weigh the client daily, in the morning. Teach the client how to restrict dietary sodium. read carefully this pt has fluid vol excess For a client with heart failure and fluid volume overload, the goal is to decrease workload on the heart. Fluid volume excess is managed with diuretics to help eliminate the excess fluid load. Since many diuretics cause potassium excretion, the plan of care should include observing for hypokalemia and teaching the client how to restrict dietary sodium, which reduces fluid retention related to sodium intake. Fluid balance is best assessed by changes in daily weight.

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter? Assess perineal area. Measure abdominal girth. Palpate flank area. Observe insertion site.

Observe insertion site. Rationale: A suprapubic catheter is inserted into the bladder through an incision, placing the client at risk for infection. The nurse should observe the insertion site during home visits for any signs of inflammation.

A client is admitted to the hospital after experiencing a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding? Abnormal responses for cranial nerves I and II. Unilateral facial drooping. Persistent coughing while drinking. Inappropriate or exaggerated mood swings.

Persistent coughing while drinking. After a stroke, clients may experience dysphagia and an impaired gag reflex that is evaluated by a speech pathology team. Coughing while drinking results from impaired swallowing and gag reflex, so a referral to a speech therapist is indicated to evaluate the coordination of oral movements associated with speech and deglutition (swallowing).

An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which interventions should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.)

Place a bedside commode next to bed. -safety bc pt just had stroke Measure neurological vital signs every 4 hours. Encourage family to participate in the client's care. For the client recovering from a cerebral vascular accident (CVA), a bedside commode promotes safety. To evaluate the client's continued convalescence and rehabilitation, monitoring neurological status guides care, monitors client's progress, and identifies early signs of complications. Encouraging the family to participate in the client's care helps prepare for home care and demonstrates the value of family members providing participative care for the client.

At 40-weeks gestation, a client who is in active labor is lying in a supine position and tells the nurse that she has finally found a comfortable position. What action should the nurse take?

Place a wedge under the client's right hip hypotension from pressure on the vena cava due to the weight of the fetus-puts full term client at risk -Placing this way will displace the fetus and relieve pressure on the vena cava

An older adult resident of an extended care facility receives a prescription for diphenhydramine 25 mg PO to treat generalized pruritus. Two hours after administration of the drug, the client continues to experience itching, is confused, and has an unsteady gait. Which action should the nurse implement first? Give a second dose of diphenhydramine. Lubricate the skin with an emollient. Place the client on fall precautions. Apply soft limb restraints to extremities.

Place the client on fall precautions. READ KEY WORDS: UNSTEADY GAIT The client's confusion and unsteady gait pose a safety risk, so fall precautions should be implemented. Diphenhydramine is probably the cause of the client's neurological changes, and a second dose is likely to intensify these symptoms. SAFETY FIRST

A client who underwent an uncomplicated gastric bypass surgery is having difficulty with diet management. Which dietary instruction is most important for the nurse to explain to the client?

Plan volume-controlled, evenly-spaced meals throughout the day. Eating volume-controlled and evenly-spaced meals throughout the day allows the client to feel full, avoid binging, and eliminate the possibility of eating too much at one time.

The nurse finds a client at 33-weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement?

Position a firm wedge to support pelvis and thorax at 30 degree tilt. For the pregnant woman in cardiac arrest, it is important to relieve aortocaval compression caused by the gravid uterus. Left lateral uterine displacement (LUD) should be maximized using a firm wedge to support the pelvis and thorax at a 30° tilt to optimize maternal hemodynamics during CPR. Maternal modifications should include ventilation with 100% oxygen. Pregnant adults should be resuscitated using a compression-ventilation ratio of 30:2, without interruption of continuous compressions. Effective chest compressions should be forceful rhythmic applications of pressure ("fast and hard") at 100 compressions/minute at the depth of 2 inches (5 cm) to generate myocardial and cerebral blood flow.

While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value?

Potassium. As insulin lowers the blood glucose of a client with diabetic ketoacidosis, the serum potassium level also decreases as potassium returns to the cell. This can cause potentially fatal hypokalemia, so it is essential for the nurse to monitor the client's serum potassium.

A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continuous positive airway pressure (CPAP). His vital signs are: temperature 98.8 oF (37.1 oC), heart rate 118 beats/minute, respirations 46 breaths/minute, blood pressure 176/92 mmHg. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement?

Prepare for rapid sequence intubation. The vital signs and pulmonary assessment indicate that the CPAP is not improving the client's respiratory condition and his respiratory distress is worsening. A more secure airway via rapid sequence intubation is indicated and should be implemented immediately. Increasing the oxygen may worsen the COPD.

The nurse is discussing mitigation at a disaster preparedness committee meeting. Which activity should the nurse suggest to enhance mitigation?

Provide a community disaster preparedness meeting. Mitigation is implementing actions or measures that can reduce the severity of a disaster's effects such as awareness and education. Ensuring safety in the community is an example of mitigation.

An older client with a history of pernicious anemia has developed ataxia and paresthesia. In planning care, which nursing intervention has the highest priority? Provide assistance with ambulation. Keep the head of the bed elevated. Instruct about healthy diet choices. Offer a PRN sleep aid at night

Provide assistance with ambulation. Pernicious anemia, due to a vitamin B12 deficiency, may result in neurological deficits, such as confusion, paresthesias in the extremities, and ataxia, which places the client at risk for falls. The highest priority is to ensure that the client is assisted with ambulation.

The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication? Dilute the Dextrose in one liter of 0.9% Normal Saline solution. Mix the Dextrose in a 50 mL piggyback for a total volume of 100 mL. Push the undiluted Dextrose slowly through the currently infusing IV. Ask the pharmacist to add the Dextrose to a TPN solution.

Push the undiluted Dextrose slowly through the currently infusing IV. INSULIN SHOCK so To reverse life-threatening insulin shock, the nurse should administer the 50% Dextrose as a slow IV bolus through the currently infusing IV.

An older adult client is diagnosed with severe shingles and starts a new prescription for acyclovir, an antiviral medication. Which action should the nurse include during client teaching prior to discharge? Demonstrate how to apply sterile gauze dressings over the infected site. Explain the increased risk for postherpetic neuralgia during treatment. Encourage increased oral fluid intake while taking the medication. Schedule an appointment for medication peak and trough levels.

Rationale: Acyclovir is often used to treat shingles. The medication acyclovir can precipitate in the renal tubules, so increased fluid intake is beneficial while taking the medication.

A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which of this client's serum laboratory values requires intervention by the nurse? Total calcium 9 mg/dL (2.25 mmol/L SI) Correct answercheck_circleCreatinine 4 mg/dL (354 micromol/L SI) Phosphate 4 mg/dL (1.293 mmol/L SI) Fasting glucose 95 mg/dL (5.3 mmol/L SI)

Rationale: The client's creatinine level is elevated (normal is 0.6 to 1.2 mg/L [53 to 106 micromol/L SI]), indicating kidney impaired kidney function, which requires further evaluation to decrease the possibility of permanent kidney damage related to calcium supplements

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement?

Redress the abdominal incision. pt is picking at it... An abdominal incision should be redressed using aseptic technique when it is no longer occlusive after a client has been picking at it. The IV site should be assessed to ensure that it has not been dislodged due to the client picking at the tape and a dressing reapplied, if needed.

During a return demonstration of teaching provided by the nurse, the daughter of a client administers her mother's eye drops by resting her dominant hand on her mother's forehead and dropping the medication into the conjunctival sac. Which action should the nurse take in response to this demonstration?

Remind the client to gently close her eyes after the eye drops are instilled. To instill eye drops correctly, the dominant hand should be rested on the forehead, and the eye drops directed toward the conjunctival sac. The daughter placed her hand correctly and correctly directed the eye drops toward the conjunctival sac; she should then instruct her mother to gently close her eyes to help distribute the medication evenly.

At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client's medical record. Based on data contained in the record, what action should the nurse take before assisting the client with ambulation? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)

Remove sequential compression devices. couldn't access pic) Sequential compression devices should be removed prior to ambulation and there is no indication that this action is contraindicated. An oxygen saturation that has stabilized is not a contraindication. Ambulation will help the client breath deeper and possibly prevent atelectasis which may evident by the low grade temperature.  A dressing should be reinforce when the integrity is compromised.  Otherwise reinforcing the dressing is unnecessary prior to ambulation.

A 6-month-old infant is admitted to the hospital with diarrhea. The mother is feeding the infant a bottle of tap water and tells the nurse that the baby has taken three 8-ounce bottles of water in the last 4 hours. Which laboratory finding is most important for the nurse to monitor? Creatinine clearance. White blood cell count. Serum potassium levels. Serum sodium levels.

Serum potassium levels. Serum sodium levels should be monitored because the recent water intake places this infant at risk for water intoxication and hyponatremia.

A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. Which defense mechanism is the client using? Sublimation. Regression. Compensation. Suppression.

Sublimation. The client is channeling his socially unacceptable feelings of anger and impulsivity into socially acceptable activities (pounding leatherwork), which is called sublimation.

The nurse is caring for an adolescent who fell 20 feet (6.1 meters) 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. Monitor vital signs and neuro status every 2 hours. Inquire about food allergies and food likes and dislikes. Initiate open communication with the teen's parents.

Talk directly to the adolescent while providing care. Talking directly to the client who is in a sustained vegetative state provides environmental stimulation and includes him in an interpersonal relationship because he may still be able to hear and process verbal communication. Open communication that is compassionate and honest provides support to the family, but verbal stimulation is an important aspect of caring for comatose clients and offers hope for the possibility of a response.

When should the nurse conduct an Allen's test?

The Allen's test should be performed prior to puncturing the radial artery to obtain a blood gas specimen to determine patency of the ulnar artery in the selected extremity. To perform an Allen's test: 1) The client's hand is formed into a fist while the nurse compresses the ulnar artery. 2) Compression continues while the fist is opened. 3) If blood perfusion through the radial artery is adequate, the hand should flush and resume its normal pinkish coloration.

Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have had a pulmonary embolus. What action should the nurse take first? Notify the healthcare provider. Bring the emergency crash cart to the bedside. Provide supplemental oxygen. Prepare a continuous heparin infusion per protocol.

The client's chest pain and dyspnea occurring several days after orthopedic surgery suggest a pulmonary embolus. Oxygen is administered immediately to relieve hypoxemia which could lead to a deterioration in the client's condition.

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome should the nurse include in the plan of care for this client?

The client's daily blood pressure will be less than 140/80 mmHg this month. Rationale: A client who is reporting blurred vision is likely experiencing complications related to type 2 diabetes, such as retinopathy or cardiovascular changes. The client's daily blood pressure will be less than 140/80 mmHg this month is an outcome statement in the plan of care that is client-centered, measurable, and has a time frame.

A client is receiving intravenous (IV) fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first ?

The nurse should first observe the drip chamber to determine the flow rate and slow the rate if indicated. A client receiving intravenous fluids by gravity is at risk for fluid volume overload because it it difficult to continuously regulate the volume of infusing fluids. -The IV site and tubing ports do not provide useful information about the flow rate of the IV solution.

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide? This hernia is a normal variation that resolves without treatment. Restrictive clothing will be adequate to help the hernia go away. Incorrect answercancelAn abdominal binder can be worn daily to reduce the protrusion. The quarter should be secured with an elastic bandage wrap.

This hernia is a normal variation that resolves without treatment. An umbilical hernia is a normal variation in infants that occurs due to an incomplete fusion of the abdominal musculature through the umbilical ring that usually resolves spontaneously as the child learns to walk.