HESI EXIT STUDY
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? A) Talk directly to the adolescent while providing care. B) Initiate open communication with the teens parents.• C) Monitor vital signs and neuro status every 2 hours.• D) Inquire about food allergies and food likes and dislikes.
A Talk directly to the adolescent while providing care.
The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining. Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain at a level 2 on a 0 to 10 pain scale. The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report?• A) History of vomiting at home for 3 days prior to surgery. B) Peripheral pulses present with full range of motion of both legs. C) Soft abdomen, absent bowel sounds, no bleeding on dressing. D) Declining to take ice chips for
A) History of vomiting at home for 3 days prior to surgery.
The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was effective? A) Absence of fine crackles. B) Increase in breath sounds. C) Absence of coarse crackles. D Increase in respiratory rate.
A) Absence of fine crackles.
Which client is best to assign to the practical nurse (P) who is assisting the registered nurse (RN) with the care of a group of clients? A) An older adult who is scheduled for foot amputation due to diabetes complications.• B) An adult with alcoholism, cirrhosis, and hepatic encephalopathy. C) An older client who is one day postoperative with a colostomy for colon cancer.• D) An adult who is one day postoperative for a laparoscopic cholecystectomy.
A) An older adult who is scheduled for foot amputation due to diabetes complications.
A young adult is brought to the Emergency Department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.) A) Auscultate for presence of bilateral breath sounds. B) Obtain a portable chest x-ray to verify ETT location.• C) Assess for symmetrical chest movement. D) Check for capillary refill of 3 seconds or less. E) Monitor ETT markings between 22 and 26 cm at teeth line.
A) Auscultate for presence of bilateral breath sounds. C) Assess for symmetrical chest movement.
A client presents to the emergency department (ED) with complaints of abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client? A) Begin with questions that are less sensitive in nature. B) Ask questions in a vague, non-specific format. C) Get the most difficult questions over with first. D) Share personal values to put the client at ease.
A) Begin with questions that are less sensitive in nature.
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next? A) Continue with the blood pressure assessment. B) Reposition the stethoscope over the brachial artery. C) Reinflate the cuff to a higher number. D) Note the presence of an auscultatory gap.
A) Continue with the blood pressure assessment.
A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid.She has an appointment with her healthcare provider in two weeks. What action should the nurse take? A) Explain that this normal secretion can be assessed at the next visit. B) Recommend that the client start wearing a supportive brassiere. C) Tell the client to begin nipple stimulation to prepare for breast feeding. D) Reschedule the client's prenatal appointment for the following day.
A) Explain that this normal secretion can be assessed at the next visit.
A clinical trial is recommended for a female client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? A) Explore the client's decision to refuse treatment and offer support. B)Discuss success of clinical trials and ask the client to consider participating for one month. C) Explain to the family that they must accept their mother's decision. D) Ask the client with her children present if she fully understands the decision she has made.
A) Explore the client's decision to refuse treatment and offer support.
The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge instructions? A) Notify your healthcare provider if you start having abdominal pain. B) There are no precautions about taking exenatide with other medications. C) Exenatide acts in the same way as insulin in lowering blood glucose. D) Inject exenatide within 30 minutes before or after a meal.
A) Notify your healthcare provider if you start having abdominal pain.
An adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? A) Onset of mild confusion. B) Weak palpable distal pulses. C) Pale, diaphoretic skin. D) Pain score 8 out of 10.
A) Onset of mild confusion.
A nurse is caring for a client who has a diagnosis of renal calculi and reports severe flank pain which of the following is a priority nursing action? A) Relieve the client's pain B) Encourage the client to increase fluid intake C) Monitor the client's I and O D) Strain the clients urine
A) Relieve the client's pain The nurse should apply the urgent versus non-urgent priority-setting framework when caring for the client. Using this framework, the nurse should consider urgent needs to be the priority because they pose a greater threat to the client.
The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? Select all that apply: A) Restlessness B) Clenched Fist C) Increased pulse rate D) Increased respiratory rate. E) Increased temperature F) Peripheral pallor of the skin
A) Restlessness B) Clenched Fist C) Increased pulse rate D) Increased respiratory rate. Pyloromyotomy is surgery to widen your baby's pylorus. The pylorus is the opening between your baby's stomach and intestine. He or she may have trouble eating if the opening is too narrow (a condition called stenosis).
A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her? A) The diaphragm must be refitted after childbirth. B) The diaphragm should be inserted 2 to 4 hours before intercourse. C) Vaseline lubricant can be used when inserting the diaphragm. D) The most effective form of contraception is a diaphragm.
A) The diaphragm must be refitted after childbirth.
The nurse is preparing to administer a formula feeding by nasogastric tube to a 2-month-old. Which intervention should the nurse implement? A) Use the syringe plunger to push formula at a rate of 5 mL/minute. B)Measure and discard residual gastric contents before feeding C) Hold the infant with head and shoulders slightly elevated D)Microwave refrigerated formula to room temperature.
A) Use the syringe plunger to push formula at a rate of 5 mL/minute.
The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics)? (Select all that apply.) A) Uses common words with few syllables. B) Written at a twelfth-grade reading level. C) Printed using a 12-point type font. D) Contains a list with definitions of unfamiliar terms. E) Uses pictures to help illustrate complex ideas.
A) Uses common words with few syllables. D) Contains a list with definitions of unfamiliar terms. E) Uses pictures to help illustrate complex ideas.
A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (IN) is 1. Which protocol prescription should t90-[] ]he nurse implement? A) Withhold the heparin and continue the same dose of warfarin. B) Increase the heparin dose and decrease the warfarin dose.• C) Decrease the heparin dose. D) Increase the warfarin dose.
A) Withhold the heparin and continue the same dose of warfarin.
The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? A. Opening the package. B. Picking up the second glove. C. Picking up the first glove. D. Positioning of the table.
Answer B. Picking up the second glove. RationaleBy picking up the upper end of the second glove (C), the PN risks contamination of the sterile gloved hand. Instead, the PN should carefully slide the first gloved hand under the cuff of the second glove. (A, B, and D) are correctly performed by the PN.
A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply). A. A peripheral IV is saline-locked. B. The client is lying supine in bed. C. Oxygen is flowing at 5 L/minute via mask. D. A prescribed diet that is low in sodium. E. A pitcher of water is on the bedside table. F. A bedside commode is located near the bed.
Answer B. The client is lying supine in bed. C. Oxygen is flowing at 5 L/minute via mask. E. A pitcher of water is on the bedside table. Rationale(B, C, and D) are the correct answers and represent hazards to this client. The client's head of the bed should be elevated to promote lung expansion, not supine (B). Oxygen flow rate (C) is too high for a client with COPD, whose respirations are dependent upon a hypoxic drive due to pCO2 levels. The pitcher of water (E) should not be readily assessable to the client with intravascular volume overload associated with an exacerbation of HF. (A, D, and F) are expected interventions in observations that provide for the client's safety during the treatment of HF and COPD.
A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. What is the most likely source of contamination that the nurse should consider when interviewing the client about exposure? A Close living quarters at evacuation centers.• B Drinking water contaminated by sewage.• C Food contamination from flood waters. D Nosocomial transmission in the medical area
B Drinking water contaminated by sewage.•
The nurse caring for a 3-month-old infant who is one day after a pyloromyotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing both knees to the chest. Which action should the nurse take? A)Increase IV infusion rate for rehydration.• B) Administer a prescribed analgesic for pain. C) Feed one ounce of formula to correct hypoglycemia. D) Provide additional blankets to increase body temperature.
B) Administer a prescribed analgesic for pain.
An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first? A) Continue to provide life support until a thorough search for a guardian is completed. B) Carry on with surgical preparation of the client without a signed informed consent. C) Notify the unit manager that an emergency court order is needed to allow surgery. D) Ask the man's friend to sign the informed consent since the client is unresponsive.
B) Carry on with surgical preparation of the client without a signed informed consent.
The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide? A) Clarify that all STIs are transmitted through sexual intercourse. B) Emphasize that using safe sex practices removes the risk of STIs. C) Explain that reinfections occur from sex with untreated partners. D) Provide counseling that most contraceptives protect against infection.
B) Emphasize that using safe sex practices removes the risk of STIs.
The nurse notes that a client with depression has been more withdrawn and non- communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? A) Encourage the client to participate in group activities. B) Engage the client in non-threatening conversations. C) Schedule a daily conference with the social worker. D) Encourage the client's family to visit more often.
B) Engage the client in non-threatening conversations.
The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client? A) Tenderness. B) Musical and drumlike. C) Absent sounds. D) Pain.
B) Musical and drumlike.
After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (P)? A) Evaluate and update plans of care for clients. B) Receive a postoperative client and conduct the assessment. C) Use bladder ultrasound to detect urinary retention. D) Initiate teaching for client care after discharge.
B) Receive a postoperative client and conduct the assessment.
A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider? A) Mild sedation.• B) Somnambulism. C) A change in the sleep-wake cycle. D) Dizziness reported after initial dose.
B) Somnambulism.
The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L) ; Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mol/L); and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm° (14 × 10oL). Which intervention should the nurse implement? Reference RangeHemaglobin [Reference Range: Male: 14 to 18 g/dL (140 to 180 g/L)]Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]White Blood Cells [Reference Range: 5000 to 10,000/mm3 (5 to 10 × 10°/L)] A) Increase Client A's oxygen to 4 liters a minute per cannula. B) Verify that Client B has two units of packed cells available. C) Move Client D into an isolation room 24 hours before surgery.• D) Ask the dietitian to add a banana to Client C's breakfast tray.
B) Verify that Client B has two units of packed cells available
The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father. Which intervention(s) should the nurse implement? (Select all that apply.) A) Provide the daughter with written instructions. B) Encourage the client to attend reading classes. C) Speak loudly when teaching. D) Face client when speaking. E) Include the family in the discharge teaching.
B. Face client when speaking. D.Provide the daughter with written instructions. E. Include the family in discharge teaching.
The computer documentation system shuts down while the nurse is entering pt's physical assessment data. What should the nurse do first? A. Print electronic medical record from backup server B. Wait for notification services department of the situation C. Notify info services department of the situation D. Identify info as late as last entry in the record
B. Wait for notification services department of the situation***
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? A Change the client's position. B Irrigate the dialysis catheter. C Continue to monitor intake and output with next exchange. D Check the client's blood pressure and serum bicarbonate.
C Continue to monitor intake and output with next exchange.
When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mol/L), which intervention is most important for the nurse to implement?Reference Rangelonized Calcium [Reference Range: Adult 4.5 to 5.6 mg/dL (1.05 to 1.3 mol/L)]• A Assess strength of deep tendon reflexes. B Compare muscle strength bilaterally.O C Determine apical pulse rate and rhythm. D Observe color and amount of urine.
C Determine apical pulse rate and rhythm.
A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? A Decreased urinary output. B Profound weight gain. C Ventricular arrhythmias. D Low blood glucose levels.
C Ventricular arrhythmias.
A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, "My favorite nurse is on duty now.Which response is best for the nurse to provide to this client's dichotomous tendency? A) "Tomorrow I will talk to that nurse about how you were treated last night." B) "I am glad you like me. Which nurse was acting aloof to you?" C) "I am happy that you are getting better and will be able to go home." D) "What did the night nurse do that makes you think she is aloof?"
C) "I am happy that you are getting better and will be able to go home."
After reviewing the Braden Scale findings of residents at a long-term facility, the charge nurse should tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client? A) A woman with osteoporosis who is unable to bear weight. B) A poorly nourished client who requires liquid supplements. C) An older man whose sheets are damp each time he is turned. D) An older adult who is unable to communicate elimination needs.
C) An older man whose sheets are damp each time he is turned.
An older client with a history of diabetes mellitus for 20 years is taking furosemide 40 mg by mouth daily. Which action should the nurse implement first? A) Review the daily serum electrolyte results. B) Encourage the client to eat more bananas.• C) Assess for muscle weakness, fatigue, or leg cramps.• D) Determine if a potassium supplement is prescribed.
C) Assess for muscle weakness, fatigue, or leg cramps.•
An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HT), is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.) A) Bowel sounds. B) Range of motion. C) Daily weight. D) Blood pressure. E) Heart sounds.
C) Daily weight. D) Blood pressure
To prevent infection by autocontamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?• A) Implement protective isolation. B) Use gown, mask, and gloves with dressing change. C) Dress each wound separately. D) Avoid sharing equipment between multiple clients.
C) Dress each wound separately.
When developing a teaching plan for a client with newly diagnosed Type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?• A) Drink electrolyte fluid replacements. B) Resume normal physical activity. C) Give a dose of regular insulin as prescribed. D) Measure urine output over the next 24 hours.
C) Give a dose of regular insulin as prescribed.
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? A) Peripheral edema. B) Ketonuria. C) Hypokalemia D) Elevated blood pressure
C) Hypokalemia
The nurse is providing supplemental oxygen to a client who is experiencing a cluster headache. In evaluating the effectiveness of the oxygen therapy, which assessment is most important for the nurse to make? A) Assess oxygen saturation. B) Auscultate breath sounds. C) Measure pain level. D) Observe skin color.
C) Measure pain level.
By using correct handwashing technique between client contact, the nurse is affecting which link in the chain of infection? A) Susceptible host. B) Portal of entry. C) Mode of transmission. D) Portal of exit.
C) Mode of transmission.
A male client who is admitted with bipolar disorder, manic psychosis, is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife. The client is given haloperidol 5 mg intramuscularly STAT prior to seclusion. Which intervention is most important for the nurse to implement immediately after seclusion? A) Provide one-on-one observation at all times. B) Secure the room with padded walls and minimal furnishings. C) Observe for extrapyramidal symptoms, such as dystonia. D) Release the client as soon as composure is regained.
C) Observe for extrapyramidal symptoms, such as dystonia.
The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client? A) Obtain satisfaction with appearance. B) Achieve a steady weight loss. C) Regulate food portions. D) Institute an exercise plan.
C) Regulate food portions.
A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take? A) Remind the UAP to apply a fitted respirator mask before entering the client's room. B) Assign the UAP to provide care for another client and assume full care of the client. C) Review the need for the UP to wear a face mask while in close contact with the client. D) Instruct the UAP to notify the nurse of any changes in the client's emesis.
C) Review the need for the UP to wear a face mask while in close contact with the client.
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide? A) Inform the client that gradual tapering must be used to discontinue the medication. B) Tell the client that the medication's side effects will most likely dissipate over time. C) Tell the client to discuss the medication side effects with the healthcare provider. D) Remind the client that feeling better is the therapeutic effect of the medication.
C) Tell the client to discuss the medication side effects with the healthcare provider.
A client who is admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor. Which assessment finding places the client at greatest risk? A)Presence of hematemesis. B) Incontinent with blood in urine. C) Unresponsive to painful stimuli. D) Blood pressure of 100/60 mm Hg.
C) Unresponsive to painful stimuli.
After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? A) take out dentures and place in a labeled cup B) apply a body shroud C) place a small pillow under the head D) remove resuscitation equipment from the room E) gently close the eyes F) place a small pillow under the head
C) place a small pillow under the head D) remove resuscitation equipment from the room E) gently close the eyes
The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress? A) Left lateral position. B) Reverse Trendelenburg. C)High-Fowler's position. D) Supine.
C)High-Fowler's position.
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/mm? (20 × 109L). Which intervention should the nurse include in the client's plan of care? Reference RangePlatelet [Reference Range: 150,000 to 400,000/mm3 (150 to 400 ×10°/L)]FIl Show calculator• A) Pace activities between planned rest periods.• B) Limit exposure to visitors with respiratory infections. C) Monitor intake and output. D) Avoid intramuscular injections.
D) Avoid intramuscular injections.
The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL (32.22 mol/L) about preventing complications related to diabetes mellitus. Which response by the client indicates understanding?Reference RangeGlucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)] A) Eat a protein snack 30 minutes before any exercise workout. B) Do not take diabetes medication when feeling sick. C) Avoid seasoning foods with salt and salt-containing spices.• D) Check blood sugar levels every four to six hours every day.
D) Check blood sugar levels every four to six hours every day.
A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a Pa02 of 92 mm Hg. Which intervention should the nurse implement? Reference Range pH Reference Range: Adult/child: 7.35 to 7.45] PaCO2 [Reference Range: Adult/child: 35 to 45 mm Hg] HCO3 Reference Range: Adult/child: 21 to 28 mEq/L (21 to 28 mmol/L)] Pa02 [Reference Range: Adult/child: 80 to 100 mm Hg] FIl Show calculator A) Increase rate of ventilation. B) Increase ventilator tidal volume. C) Decrease expiratory pressure. D) Decrease expiratory flow time
D) Decrease expiratory flow time
A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? A) Review the UP's skills checklist and experience with the person who hired the UAP.• B) Ask the most experienced UP on the team to partner with the newly hired UAP. C) Assign the newly hired UAP to clients who require the least complex level of care. D) Evaluate the newly hired UP's level of competency by observing the UAP deliver care.
D) Evaluate the newly hired UP's level of competency by observing the UAP deliver care.
A 38-week gestational age infant of a diabetic mother (IDM) is admitted to the newborn nursery weighing 8 pounds and 2 ounces, and is transitioning without respiratory distress. Within the first hours of transition after birth, what priority nursing assessment is necessary for this infant? A) Congenital anomalies. B) Birth injuries. C) Hyperbilirubinemia D) Hypoglycemia
D) Hypoglycemia
The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately? A) Change the dressing using a compression bandage. B) Document the findings in the electronic medical record. C) Mark the drainage area with a pen and continue to monitor. D) Test the fluid on the dressing for glucose.
D) Test the fluid on the dressing for glucose.
The nurse is preparing to suction a client with an oral airway. Which action should the nurse include? A) Apply a water soluble lubricant to the catheter. B) Instill 3 mL of normal saline before suctioning. C) Instruct the client to cough as the suction tip is removed. D) Wear protective goggles while performing the procedure.
D) Wear protective goggles while performing the procedure.
An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. Which action should the nurse take? A Give the wife a straw to help facilitate the client's drinking.• B Obtain thickening powder before providing any more fluids.• C Assist the wife and carefully give the client small sips of water.• D Ask the wife to stop and assess the client's swallowing reflex.
D)Ask the wife to stop and assess the client's swallowing reflex.
The nurse is developing a postoperative plan of care for a client with type 2 diabetes who will need to begin insulin after colostomy placement surgery for diverticular disease. Which outcome statement should the nurse use in the in the planning stage of the nursing process for this client?• A) The client's breath sounds will be auscultated by the nurse every 4 hours. B) The client will demonstrate ability to change the ostomy bag in two days. C) The client will adhere to the medication regimen after discharge. D)The client attempts to self-administer insulin but is unable to perform injection.
D)The client attempts to self-administer insulin but is unable to perform injection.
The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.) Obtain blood glucose level. Verify the insulin prescription. Draw insulin into insulin syringe. Cleanse the selected site.
Obtain blood glucose level. Verify the insulin prescription. Draw insulin into insulin syringe. Cleanse the selected site.
When conducting diet teaching for a client who was diagnosed with hypertension, which food should the nurse encourage the client to eat? (select all that apply.) a. Fruits without sauce b. Canned soup. c. Fresh or frozen vegetables without sauce. d. Cottage cheese. e. Pickled olives.
a. Fruits without sauce c. Fresh or frozen vegetables without sauce.
The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client? a. Identifies 2 treatments for constipation due to immobility b. Names 3 home safety hazards to be resolved immediately c. States 4 risk factors for the development of osteoporosis d. Lists five calcium rich foods to be added to her daily diet
b. Names 3 home safety hazards to be resolved immediately
The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients? a. Ensure supplemental oxygen and respiratory medications are available at all times. b. Use nasal or cough tissues followed by hand washing at all times. c. Get annual flu and Pneumococcal vaccine polyvalent (PPSV23) vaccines. d. Avoid large crowded areas during the colder months of the year.
d. Avoid large crowded areas during the colder months of the year.
A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care? A) Replace fluids intravenously based on intake and output. B) Record the amount of daily wound drainage. C) Turn every 2 hours around the clock from side-to-side. D) Assess skin condition and turgor for breakdown.
• D Assess skin condition and turgor for breakdown.
