HESI FINAL - preguntas que estan saliendo

A healthcare provider prescribes haldoperidol (Haldol) for a client. What should the nurse teach the client to avoid while taking this medication?

Staying in the sun

The client who has been taking the prescribed dose of Zoldipem (Ambien) for 5 days returns to the clinic for a follow up visit. When interviewing the client, the nurse identifies that the medication has been effective when the client says:

"I have been sleeping better"

During an assessment interview the nurse concludes that the client has been experiencing menorrhagia. What client statement led to this conclusion?

"I have severe bleeding during my menstrual periods."

A carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm and I'll be scarred forever." The nurse's best initial response is...

"I know you're worried, but it is too early to tell how much scarring will occur."

When determining whether a client has anorexia nervosa or bulimia nervosa, the nurse should identify those characteristics that relate only to anorexia nervosa. Select all that apply.

- Cachexia --- (wasting disorder - extreme weight and muscle loss) - Delayed psychosexual development

Cambios secundarios de un adolescente en el cuerpo SATA

- cambia la voz - sale pelo en la cara - crece el pecho - menstruacion

Immediately after a bilateral adrenalectomy a client is receiving corticosteroids that are to be continued after discharge from the hospital. The nurse evaluates a need for further teaching when the client states:

"I am glad that I only have to take the medication once a day."

An infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. What physiological imbalances will the nurse most likely encounter? SATA

- hypovolemia - metabolic acidosis

A nurse is assessing a male newborn. Which characteristics should alert the nurse to conclude that the newborn is a preterm infant? SATA

- small breast buds - wrinkled thin skin - pinnae that remain flat when folded

A nurse is caring for a client with end-stage kidney disease who is about to receive a transplant. When he returns from post anesthesia care unit after the transplant, how often should the nurse measure the client's urinary output?

1 hour

A 10-year-old child sustains partial-thickness burns of the entire right arm and hand, upper anterior left arm, and anterior chest. The nurse calculates the percent of total body surface area (TBSA) burned with the use of the modified "rule of nines." What percentage of the child's body is burned?

24.5%

A blood transfusion of packed cells has been prescribed for a client with leukemia. The nurse will complete the following steps in what order?

1. Check health care provider's prescription 2. Obtain vital signs and history of transfusions 3. Ascertain that intravenous catheter size is 18 or 20 gauge 4. Change main line solution to normal saline 5. Check client identification before hanging unit of blood..

A client is admitted to the hospital with a diagnosis of pneumonia. List the following nursing actions in the order they should be accomplished.

1. Obtain data about the client's history and physical status. 2. Insert an intravenous (IV) catheter to establish venous access. 3. Collect a sputum sample for culture and sensitivity. 4. Administer prescribed antibiotic intravenous piggyback. 5. Check peak and trough levels of the antibiotic

A nurse is being oriented to a prenatal clinic after graduation. The new nurse takes a course on several tests during pregnancy. Place the tests in order in which they should be performed during pregnancy.

1. Sickle cell screening 2. a-fetoprotein (AFP) testing for neural tube defects 3. Serum glucose for gestational diabetes 4. Fetal movement test 5. Group B Streptococcus culture

A client with a gastric hemorrhage is to receive 2 units of whole blood. List the nurse's activities in the order that they should be performed when administering a blood transfusion.

1. Verify that typing and crossmatching of the prescribed blood has occurred. 2. Flush the infusion tubing with normal saline. 3. Ask another nurse to check the blood at the client's bedside. 4. Run the blood at a slower rate during the first 10 minutes of the transfusion.

A 5-year-old child is admitted with burns covering the face and anterior arms and hands. Using the total body surface area (TBSA) percentages shown in the diagram, determine what percentage of the child's body has been burned. Record your answer using a whole number.

15%

A client with stage 4 ovarian cancer is admitted for dehydration. The client is to receive an intravenous bolus of 500 mL DSW for 1 hour, after which the rate is changed to 150 mL/hr. The drop factor is 15 ggt/mL. At what rate , in drops per minute should the nurse regulate the IV after delivery of the 500 mL bolus?

38

A male client with the diagnosis of primary hypertension is started on a regimen of hydrochlorothiazide (HydroDIURAL). The nurse is providing instructions regarding this medication. What information should the nurse include?

An antihypertensive medication will likely be required for the remainder of his life.

In the diagram, which letter identifies the patent ductus arteriosus?

B

Which statement is accurate for adolescent suicide behavior?

Boys are more likely to use lethal methods than girls

The nurse understands that the action of an antidiuretic hormone (ADH) is to:

Decrease water loss in urine.

A client arrives at the clinic in preterm labor, and terbutaline (Brethine) is prescribed. For what therapeutic effect should the nurse monitor the client?

Decreased frequency and duration of contractions

SATA - embarazada con trombophlebitis. Que abticoagulante le prescriben?

Heparin y Enoxaparin

A 25-year-old woman is seeking outpatient counseling after thinking about suicide. The nurse realizes that there some factors place individuals at a higher risk for suicide. Which of these factors increases the risk for suicide? Select all that apply.

Impulsivity Panic attacks Unemployment Substance abuse

A nurse is assessing an adolescent child with the diagnosis of hemophilia. In what part of the body does the nurse expect bleeding to occur?

Joints

A health care provider prescribes verapamil (Calan) to be administered intravenously to an older adult client with hypertension. Which nursing intervention is specific to the intravenous administration of verapamil?

Keep the client in the recumbent position for one hour after administration.

A parent brings a 2-week-old infant to the clinic because the infant continually regurgitates. Chalasia, an incompetent cardiac sphincter, is suspected. What instructions should the nurse give the parent?

Keep the infant in an upright position after feedings.

A nurse on the pediatric unit is admitting an adolescent child with acute glomerulonephritis (AGN). What is the priority nursing intervention?

Monitoring the child for hypertension

A client who had a suprapubic prostatectomy returns from the postanesthesia care unit and accidentally pulls out the urethral catheter. What should the nurse do first?

Notify the healthcare provider

Clients who have casts applied to an extremity must be monitored for complications. The most significant complication for which the nurse should assess the client's extremity is:

Numbness

Which sign indicates to the nurse that a neonate is preterm?

Numerous superficial veins

According to Erikson's theory of psychosocial development, which attribute plays an important role in the development of a healthy personality from birth to 1 year of age?

Trust versus mistrust

Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes?

Urine negative for ketones and hyperglycemia.

A nurse is caring for a client who had a pneumonectomy. What is the priority nursing assessment?

Ventilatory exchange

A preschool child with a spinal cord injury will be on prolonged bedrest. The nurse explains to the parents that certain foods will be restricted to prevent complications associated with immobility. What food should be noted as restricted in the teaching plan?

cheese

What is the first heart sound?

closing of atrioventricular valves: mitral and tricuspid

Paciente que le estan dando radiacion. Que cuidados hay que tener con la piel?

evitar poner locion o talco en esa area de la piel.

Hypertension develops in a school-aged child with acute glomerulonephritis. What medication does the nurse anticipate that the practitioner will prescribe?

furosemide

A client comes to the emergency department reporting symptoms of the flu. When the health history reveals intravenous drug use and multiple sexual partners, acute retroviral syndrome is suspected, and a test for the human immunodeficiency virus (HIV) is performed. Which clinical responses are associated most commonly with this syndrome? Select all that apply.

- Malaise - Swollen lymph glands

Clients who have casts applied to the lower extremities must be monitored for complications. Which finding during assessment of the extremities of these clients is indicative of a complication? Select all that apply.

- Numbness - Prolonged capillary refill

The nurse accompanies a 3 year old to the playroom. The toddler seems afraid to select a toy or activity. What age appropriate play materials should the nurse offer? SATA

- Plastic tea set - Mold and clay - Play telephone

A nurse is assessing a newborn of a known opioid user for signs of withdrawal. What symptoms does the nurse expect to identify? SATA

- Sneezing - Hyperactivity - High-pitched cry

The nurse is teaching a sex education course to high school students. What should the nurse teach them about why gonorrhea is difficult to control? SATA

- Symptoms of the disease are vague. - The incubation period is relatively short. - Causative organisms have become resistant to treatment.

The primary health care provider has prescribed for a client's apical pulse to be taken. Place the steps in the order that the nurse should follow to identify the client's point of maximal impulse when taking the client's apical pulse.

1. Slide the finger down from the sternal notch to the angle of Louis (the bump where the manubrium and sternum meet). 2. Slide the finger to the edge of the left sternal border to the second intercostal space 3. Place the index finger in the second intercostal space and continue palpating downward to the fifth intercostal space 4. Move the finger laterally along the fifth intercostal space to the midclavicular line

A nurse is preparing for discharge a school-aged child who has undergone splenectomy for β-thalassemia (Cooley anemia). What information should the discharge teaching include?

A high fever should be reported to the child's health care provider

A client with a small nodule of the thyroid gland is to have subtotal thyroidectomy. The client asks the nurse for clarification about what this surgery involves. What information should the nurse include in a response to the question?

A small part of the gland is left intact

The parents of an infant with cerebral palsy ask the nurse if their child will have a cognitive impairment. The nurse's response should be based on which knowledge?

About 45% of affected children have normal intelligence.

A client with a history of atrial fibrillation has a brain attack, and vascular dementia (multi-infarct dementia) is diagnosed. In a comparison of assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia?

Abrupt onset of symptoms

Although a client in labor is prepared and plans to participate in the labor and birth process, she states that she is in severe discomfort. The nurse administers the prescribed butorphanol (Stadol). Which phase of labor is the safest time for the nurse to administer this medication?

Active phase

The ANA Guidelines on Psychopharmacology emphasizes that psychiatric-mental health nurses understand how psychotropic drugs affect neurotransmitter systems in the brain. Therefore the nurse should know that a decreased in y-aminobutyric acid (GABA), according to the basic neurotransmitter theory, causes...

Anxiety

To begin the administration of total parental nutrition (TPN), a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, the priority nursing action is to:

Auscultate the lungs to evaluate breath sounds

According to Erikson's stages of life, which is the stage of development when a child begins walking, feeding, and using the toilet

Autonomy versus sense of shame and doubt

A nurse is giving an educational program to paramedics who have volunteered to give the smallpox vaccine in a community vaccination drive. Which type of needle and method of administration should the nurse teach the volunteers to use when administering the smallpox vaccine?

Bifurcated needle for 15 injections within 5 mm

On the third postpartum day a mother visits the clinic and asks why her newborn's skin has begun to appear yellow. The nurse explains that the change in her infant's skin tone is the result of:

Breakdown of fetal red blood cells

When planning long-term care for a 2 year old child with cerebral palsy (CP), it is important for the nurse to consider that:

CP is not progressively degenerative

A client is on a cardiac monitor. The monitor begins to alarm showing ventricular tachycardia. What should the nurse do first?

Check for a pulse

A client with type 2 diabetes travels frequently and asks how to plan meals during trips. What is the nurse's best response?

Choose the foods you normally do and follow your food plan wherever you are.

A client is admitted to the hospital for surgery for a laparoscopic cholecystectomy. To monitor the flow of bile to the gastrointestinal tract, the nurse assesses the client's:

Color of the stool

The nurse provides discharge teaching to a client with tuberculosis and reinforces that the treatment measure with the highest priority is:

Consistently taking prescribed medication

An emergency department nurse assesses an older client who reports cramping pain in the left lower quadrant, weakness, bloating, and malaise. The client also has a low-grade fever. Which condition does the nurse suspect as the most likely cause of the client's clinical findings? A. Pancreatitis B. Appendicitis C. Cholecystitis D. Diverticulitis

D. Diverticulitis Rationale: Although diverticula can occur at any point within the gastrointestinal tract, they are most common in the sigmoid colon; therefore, pain associated with diverticulitis occurs in the left lower quadrant.

A client who takes multiple medications complains of severe nausea, and the client's heartbeat is irregular and slow. The nurse determines that these signs and symptoms are toxic effects of which medication?

Digoxin

A client visits the mental health clinic because of an aversion to arachnids. The client reports screaming hysterically when a spider is in the vicinity and indicates that this phobia is interfering with her job performance. What defense mechanisms does the nurse conclude that the client is using?

Displacement and projection

The nurse is assisting a client with myasthenia gravis to bathe. The nurse identifies that the client's arms become weaker with sustained movement. What action should the nurse take?

Encourage the client to rest for short periods

A pregnant client's last menstrual period was on February 11. A physical assessment on July 18 should reveal the top of the fundus:

Even with the umbilicus

A client with a benign ovarian tumor undergoes laparoscopic surgery. What should the nurse include in the postoperative teaching?

Expect shoulder pain for 12 to 24 hours.

A nurse in the fertility clinic works with couples who have been trying to become pregnant for more than 1 year. How can the nurse help ease the feeling of isolation that infertile couples often experience?

Explore ways to promote communication with family and friends.

When performing the initial history and physical examination of a client with a tentative diagnosis of peptic ulcer, the nurse expects the client to describe the pain as:

Gnawing epigastric pain or boring pain in the back

A nurse is evaluating a client's fluid loss resulting from extensive burns. What is the most valuable blood test to use when monitoring a client's fluid loss?

Hematocrit

The nurse suspects that a newborn has toxoplasmosis. How and when may it have been transmitted to the newborn?

In utero through the placenta

A nurse is caring for two clients; one has polycythemia and the other has prolonged anemia. What do these clients have in common?

Increased cardiac workload

A health care provider informs a client that midazolam (Versed) will be administered preoperatively. Later, the client asks the nurse why this medication is given. What primary reason should the nurse consider when formulating a response?

Induces sedation.

A preschooler with partial-thickness burns on 21% of the total body surface area progresses from the emergency phase to the acute phase of burn care. What is the most important nursing intervention at this time?

Instituting a pain management plan

A school nurse is teaching a group of parents about the early signs of rubeola (measles). What sign related to rubeola should alert the parents to seek medical help?

Macular rashes.

A client with type 1 diabetes consistently has high glucose levels on awakening in the morning. What should the nurse instruct the client to do to differentiate between the Somogyi effect and the dawn phenomenon?

Measure the blood glucose level between 2 AM and 4 AM.

After a 4-year-old child undergoes craniotomy the nurse performs a neurological assessment that includes level of consciousness, pupillary activity, and reflex activity. What else should the nurse include in this assessment?

Motor function

A nurse is teaching a female client about the side effects of estrogen in an oral contraceptive. Which common side effect identified by the client indicates to the nurse that the teaching was effective?

Nausea.

A client in a psychiatric hospital with the diagnosis of major depression is tearful and refuses to eat diner after a visit with a friend. What is the most therapeutic nursing action?

Offering an opportunity to discuss the visit

What group of clients should the nurse anticipate to have the highest incidence of non-Hodgkin lymphomas?

Older adults

A 37-year-old client with endometriosis visits the women's health clinic because she has dysmenorrhea and dyspareunia. What is a description of dysmenorrhea?

Pain with menses

Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia?

Paroxysmal hypertension and bradycardia

A nurse is assessing the condition of a school-aged child with acute glomerulonephritis. What clinical finding does the nurse anticipate?

Periorbital edema.

A 7-year-old child who has sustained frostbite of the toes after skiing in below-freezing weather is brought to the emergency department. What is the nurse's initial intervention?

Rapidly rewarming the toes by placing the feet in warm water.

A nurse is caring for a 3-month-old infant who was admitted to the pediatric unit with severe dehydration caused by diarrhea. After fluid and electrolyte balance is restored, Lactobacillus granules (Lactinex) are prescribed. The nurse expects this medication to:

Recolonize flora in the intestinal tract.

Pregunta con fotos de mascaras. Cual es la Venturi?

Respuesta correcta es la D

When the nurse is planning care for a school-aged child with autism, the best choice for a play activity to suggest to the parents is:

Riding on a playground merry-go-round.

A client with myasthenia gravis improves and is discharged from the hospital. Discharge medications include pyridostigmine (Mestinon) 10 mg orally every six hours. The nurse evaluates that the drug regimen is understood when the client says, "I should:

Set my alarm clock to take my medication."

A nurse is teaching a client with diabetes about the treatment of hypoglycemia. The nurse knows that teaching was effective if the client picks which foods to treat a hypoglycemic attack?

Sugar and a slice of bread

Parents are considering a bone marrow transplant for their child who has recurrent leukemia. The parents ask the nurse for clarification about the procedure. What is the best response by the nurse?

Your child's immune system must be destroyed before the transplantation can take place.

Madre q parió a las 39 semanas, weight del Niño 4LB and 8oz- q condición esperaba la nurse encontrar

intrauterine weight restriction

Shortly after birth a newborn is found to have Erb's palsy. What condition does the nurse suspect caused this problem?

Injury to brachial plexus during birth

The nurse is performing cardiac compression on an adult client. How far must the nurse depress the lower sternum to maintain circulation until a defibrillator is available?

2 to 2.5 inches

Pregunta de cuantos dientes debe tener un bebe de 10 meses

6 Restarle 4 a la edad. Por ejemplo: 10 meses - 4 = 6 dientes

Which instructions should the nurse include in the teaching plan for a client who will be taking simvastatin (Zocor) when discharged? SATA

- Avoid prolonged exposure to the sun. - Schedule regular ophthalmic examinations. - Contact your health care provider if skin becomes gray-bronze.

A client with bipolar disorder has been admitted for alcohol detoxification, and laboratory tests are performed. Which results should prompt the nurse to notify the admitting health care provider? Select all that apply.

- Blood urea nitrogen: 25 mg/dL - Serum albumin: 2.9 g/dL - Prothrombin time: 13.9 seconds

A teenager has a prescription for oral solution levofloxacin (Levaquin) to treat a sinus infection, and the nurse explains when the medication should be taken. The nurse concludes that the teaching has been effective when the teenager

"I should take the medication 1 hour before a meal.

During a routine physical examination a 10-year-old girl is discovered to have scoliosis. The curve is diagnosed as mild and functional, and a daily exercise program is established. The next month, at the follow-up visit, the nurse determines that the child is complying with the exercise program when the girl states:

"I think my exercises will make me a better softball and soccer player.

What statement by a 45-year-old woman scheduled for an abdominal hysterectomy and bilateral salpingo-oophorectomy should alert the nurse to the potential for postoperative coping difficulties?

"I'm not the least bit worried."

On the morning of a scheduled visit the parents of a client hospitalized for incapacitating obsessive behavior call to say that they cannot come because of problems with the accountant for their small business. The client appears upset and goes into elaborate detail about the parents' business and the monthly visit of the accountant. What is the best response by the nurse?

"It's disappointing to have plans change at the last minute."

An x-ray film indicates that an older client has a fractured femur. The client asks the nurse, "Will I be able to walk again?" What is the best response by the nurse?

"Tell me more about your concerns about being able to walk."

Which of these statements are true about an adolescent according to Lawrence Kohlberg's theory of moral development? SATA

- An individual's thoughts are influenced by moral decisions and behaviors. - An individual expands his or her focus from a relationship with others to societal concerns

The nurse is providing postoperative care for a client who has received a prescription for nalbuphine (Nubain) for pain. For which side effects or adverse reactions should the nurse assess this client after administering this medication? (Select all that apply.)

- Dry mouth - Palpitations - Constipation - Orthostatic hypotension

A nurse is caring for a school-aged child with type 1 diabetes and determines that the child is experiencing an episode of hyperglycemia. What assessments led the nurse to this conclusion? Select all that apply.

- Dry skin - Increased thirst - Deep, rapid breathing

A client with vascular dementia (formerly known as multiinfarct dementia) has signs and symptoms that are different from dementia of the Alzheimer type. What characteristics unique to vascular dementia should the nurse expect when assessing a client with this diagnosis? Select all that apply.

- Exaggerated deep tendon reflexes - Episodic progression of symptoms

A nurse is teaching a client about a diet that permits 190 g of carbohydrates, 90 g of fat, and 100 g of protein. How many calories per day should the client eat? Record your answer using a whole number and no comma. __ calories per day

1970 4x carbohydrates + 4x proteins + 9x fats

Four near-drowning victims are admitted to the emergency department. The nurse determines that which victim is at greatest risk for hypovolemia?

50-year-old rescued from the ocean

After assessing a newborn infant, the nurse finds that the infant has a heart rate of 90 beats/minute, irregular respirations with a weak cry, limp extremities, sneezing reflex, and a completely pink body. What would be the Apgar score of the child? Record your answer using a whole number.

6

How long after the last dose should the nurse schedule to have a client's blood drawn to evaluate the serum lithium level?

8 to 12 hours

The nurse is reviewing blood screening tests of the immune system of a client with acquired immunodeficiency syndrome (AIDS). The nurse expects to find:

A decrease in CD4 T cells

A 29-year old gravida 3 para 3, was admitted to the recovery unit 2 hours after the birth of a 9-lb baby girl. The nurse assesses the client an hour later and finds her fundus, which is slightly boggy, three fingerbreadths above the umbilicus and displaced to the right. The peripad, which was changed before the client's transfer, is now saturated. The nurse recognizes...

A distended bladder

Una mujer con premenopausal. Cual es el mejor tiempo para performar un breast self examination?

A week after menses ends

A delirious client sees a design on the wallpaper and perceives it as an animal. How should a nurse communicate what the client perceived in the change-of-shift report?

An illusion

A client has cancer of the prostate, and a suprapubic prostatectomy is to be performed. The client asks the nurse how this surgery differs from other prostatic procedures. What difference associated with a suprapubic prostatectomy should the nurse include in the response?

An incision is made directly into the urinary bladder

The nurse is teaching an adolescent wit type 1 diabetes about taking a combination of regular insulin (Novolin R) and an intermediate-acting insulin (Novolin N). The nurse asks the adolescent at what time of day the second dose of Novolin N should be administered. Which response by the adolescent demonstrates that the teaching has been understood?

At dinnertime

An infant is found to have cerebral palsy (CP) several months after birth. When the infant is 10 months old the mother comes to the pediatric clinic because the child has begun to exhibit slow writhing movement. The nurse explains that these movements are characteristically associated with the type of CP known as:

Athetoid

An infant is admitted to the nursery after a difficult shoulder birth. For what condition should the nurse assess this newborn?

Brachial plexus injury

During the physical assessment of a recently born neonate, the nurse palpates the infant's femoral pulses. For which cardiac defect is the nurse looking?

Coarctation of the aorta

A client is experiencing an exacerbation of ulcerative colitis. A low-residue, bland, high protein diet and parenteral vitamines B, C, and K have been prescribed. The nurse explains that this dietary regimen is designed to reduce:

Colonic irritation

A client who is to receive nitrogen mustard as part of a drug protocol for cancer asks how this drug works in the body. Before responding in language the client can understand, the nurse considers the actions of nitrogen mustard, which include:

Combining with DNA strands and interfering with cell replication

A nurse who is monitoring the blood glucose level of the term infant of a diabetic mother (IDM) identifies a blood glucose level of 48 md/dL. What should the nurse do?

Continue to monitor the blood glucose level per policy

The parent of a 2-year-old child tells a nurse at the clinic, "Whenever I go to the store, my child has a screaming tantrum because he wants a toy or candy on the shelves. How can I deal with this situation?" What is the best response by the nurse?

Don't say anything—just let the tantrum play itself out."

A nurse in the pediatric clinic should be most observant for signs of cerebral palsy in a 6 month old infant who was born:

During the 32nd week of gestation

A nurse is evaluating the results of the treatment with erythropoietin (Epogen). Which client response is considered significant?

Elevation in hematocrit level

A client's nipples become sore and tender as a result of her newborn's vigorous suckling. What should the nurse recommend that the mother do to alleviate the soreness? Select all that apply.

Expose the nipples to air several times a day Apply hydrogel pads to the nipples after each feeding.

A nurse is teaching a class of nursing assistants about the differences in care among various age groups. Care of which age group of children does the nurse describe as the most challenging?

From 1 to 4 years of age.

A client is admitted to the birthing unit with uterine tenderness and minimal dark-red vaginal bleeding. She has a marginal abruptio placentae. the priority assessment includes fetal status, vital signs, skin color, and urine output. What additional assessment is essential?

Fundal height

A nurse is teaching an athletic teenager about nutrients that provide the quickest source of energy. Which food selected from a menu indicates to the nurse that the adolescent understands the teaching?

Glass of orange juice

A 5-year-old child who is HIV positive is taken to the health department for immunizations before the start of school. The CD4 count shows severe immunosuppression. What immunizations can the child be given safely at this time? Select all that apply.

Hepatitis A Polio vaccine (IPV) Diphtheria, tetanus, pertussis (DTaP)

A nurse is reviewing the physical examination and laboratory tests of a client with malaria. For which important clinical indicators should the nurse be alert when reviewing data about this client? Select all that apply.

Hyperthermia Splenomegaly (fever and enlarged spleen)

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingle and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the monitor. What should the nurse conclude is causing these clinical findings?

Hypokalemia

A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong?

Hypotonic

An infant with persistent diarrhea is subject to significant fluid and electrolyte alterations. What physiological imbalances will the nurse most likely encounter? Select all that apply.

Hypovolemia --- (due to fluid loss) Metabolic acidosis

A teenager has a prescription for oral solution levofloxacin (Levaquin) to treat a sinus infection, and the nurse explains when the medication should be taken. The nurse concludes that the teaching has been effective when the teenager says:

I should take the medication 1 hour before a meal

The nurse is caring for a client with diabetes mellitus. What is the primary fluid shift that occurs with this condition?

Intracellular to intravascular because of hyperosmolarity.

An adult is found to have schizotypal personality disorder. How should a nurse describe the client's behavior?

Introverted and emotionally withdrawn

A client experiences crushing chest pain and is brought to the emergency department. When assessing the ECG tracing, the nurse concludes that the client is experiencing premature ventricular complexes (PVCs). Which abnormalities of the electrocardiogram support this conclusion?

Irregular rhythm, absence of a P wave, wide and distorted QRS

A 40 year old multigravida's pregnancy is confirmed at 8 weeks gestation. She says "I can't wait another 2 months for an amniocentesis to find out whether my baby has a chromosomal anomaly like my first child." The nurse responds that she can have chorionic villus sampling between the 10th and 12th weeks because if it is performed before this time:

It can cause fetal anomalies

A client with untreated type 1 diabetes mellitus may lapse into a coma because of acidosis . An increase in which component in the blood is a direct cause of this type of acidosis?

Ketones

A client with a detached retina is scheduled for surgery to reattach the retina. What should the nurse address in the preoperative teaching plan about the procedure used with this surgery?

Laser technique

A client is scheduled to have a contraction stress test (CST) to determine fetal well-being. Which type of fetal heart rate (FHR) decelerations constitutes a non-reassuring outcome?

Late

A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility complains of constipation. What is most important for the nurse to determine when collecting information about the constipation?

Length of time this problem has existed

The nurse is assessing newborns 24 hours after birth in a pediatric healthcare setting. Which neonate requires priority action from the nurse?

Neonate 3 = body weight in kg = 3.8; urine output per 24 hours = 40 mL

Which substance would pose the greatest risk for addiction for clients attending an alcohol rehabilitation program?

Nicotine

Image of EKG

Normal Sinus Rhythm

While assessing an infant, the nurse finds the presence of white, adherent patches on the tongue, palate, and inner aspects of the cheeks. The mother also states that the infant is refusing to suck the milk. Which medication does the nurse expect to be prescribed?

Nystatin (Mycostatin)

A primigravida has just given birth. The nurse is aware that the client has type AB Rh-negative blood. Her newborn's blood type is B positive. What should the plan of care include?

Obtaining a prescription to administer RhoGAM to the mother

Nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which ABGs report is indicative of diabetic ketoacidosis?

PCO2 28, HCO3 18, pH 7.28

A client with preeclampsia is to receive a magnesium sulfate infusion, and the nurse assesses the client's status to obtain baseline information. Which assessments are necessary? Select all that apply.

Patellar reflex Output of urine Respiratory rate

A client is admitted to the hospital for general paresis as a complication of syphilis. Which therapy should the nurse anticipate will most likely be prescribed for this client?

Penicillin therapy

A low dose of intravenous dopamine hydrochloride (Dopamine) infusion drip is prescribed for a client with acute renal failure (ARF). What is the most appropriate way for the nurse to administer this intravenous medication to the client?

Peripherally inserted central line catheter (PICC line)

A client with a history of heart disease has been receiving a calcium channel blocker and morphine sulfate for pain from abdominal surgery. When getting the client out of bed, the nurse first should have the client sit on the edge of the bed with feet on the floor . What untoward client response can be prevented by this nursing action?

Postural hypotension

A client sustains multiple internal injuries in a motor vehicle accident. While performing the client's initial assessment, the nurse identifies that the client's blood pressure suddenly drops from 134/90 to 80/60 mmHg. What most likely has caused this drop in blood pressure?

Reduction of the circulating blood volume

Nurse has administered sublingual nitroglycerine. Which parameter should the nurse use to determine the effectiveness of sublingual nitroglycerine?

Relief of anginal pain

PT que le estan poniendo infusion de magnesio sulfate por severa preeclampsia. Que intervencion?

Restricting visitor y maintaining a quiet environment

A client with type 1 diabetes comes to the clinic because of concerns regarding erratic control of blood glucose with the prescribed insulin therapy. The client has been experiencing a sudden fall in the blood glucose level, followed by a sudden episode of hyperglycemia. Which complication of insulin therapy should the nurse conclude that the client is experiencing?

Somogyi effect If the blood sugar level drops too low in the early morning hours, hormones (such as growth hormone, cortisol, and catecholamines) are released. These help reverse the low blood sugar level but may lead to blood sugar levels that are higher than normal in the morning

At 7 am a nurse learns that an adolescent with diabetes had a 6:30 am fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

Telling the adolescent that the prescribed dose of rapid-acting insulin should be administered.

A client is to receive total parenteral nutrition (TPN) via a central venous access device/catheter. Before preparing a client for the insertion of the catheter, the nurse is aware that:

The TPN may be administered intermittently rather than continuously.

A client who is visiting the prenatal clinic for the first time has a serology test for toxoplasmosis. What information about the client's activities in the history indicates to the nurse that there is a need for this test?

The client takes care of a cat

The parents of an infant with tetralogy of Fallot ask a nurse about the problems involved with this disorder. When answering, what must the nurse consider?

The disorder consists of right ventricular hypertrophy, ventricular septal defect, pulmonic stenosis, and overriding aorta.

A newborn with respiratory distress syndrome (RDS) is receiving continuous positive airway pressure therapy by way of an endotracheal tube. The nurse determines that he infant's breath sounds on the right side are dimished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. What is the interpretation of these assessment data and the appropriate nursing action?

The infant may have a pneumothorax, and the practitioner should be called so that corrective therapy can be started immediately.

When assessing a neonate immediately after birth, the nurse observes an inability to close the eyes completely. The nurse also observes drooping of the corner of the neonate's mouth, and the absence of wrinkling of the forehead and nasolabial fold. What does the nurse infer from these findings?

The neonate has cranial nerve VII pressurized during labor.

A client at 7 weeks' gestation tells a nurse in the prenatal clinic that she is sick every morning with nausea and vomiting and adds that she does not think she can tolerate it throughout her pregnancy. The nurse assures her that this is a common occurrence in early pregnancy and will probably disappear by the end of the:

Third month

A 42-year-old client at 39 weeks' gestation has a reactive nonstress test (NST). What should the nurse explain to the client about the positive result?

This is the desired response at this stage of gestation

The nurse is caring for a client that experienced a myocardial infarction (MI). The nurse monitors for the most serious complications that occurs within 48 hours after an MI, which is:

Ventricular tachycardia

The nurse is providing education about care of the residual limb to a client that had a below-the-elbow amputation. The teaching should include:

Washing and drying the residual limb at least once a day

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply.

Wheezing Tachycardia

A client scheduled to begin electroconvulsive therapy to treat severe depression that has not responded to any of the antidepressant medications tells the nurse, "I'm scared that I'll lose my memory forever after the treatment." What is the most therapeutic response by the nurse?

You'll experience a temporary loss of memory, and feeling frightened about it is expected."

The nurse is providing care for a client with small-cell carcinoma of the lung that develops the syndrome of inappropriate secretion of antidiuretic hormone (SIaDH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? SATA

- Edema - Hyponatremia

A 17 year old teenager is found to have leukemia. Which statements by the teenager reflect Piaget's cognitive processes associated with adolescence? SATA

- I'm going to do my best to fight this awful disease. - Now I can't go to the prom because I have this stupid disease. - "This illness is serious, but with treatment I think I have a chance to get better."

A client has serially decreasing blood pressures after surgery. Which mechanism (...) blood pressure should the nurse consider? SATA

- activation of regulators that control renal angiotensin 2 - increase of left ventricle stroke volume to maintain blood volume - enervation of the sympathetic nervous system to constrict arterioles

A nurse is teaching the parents of an adolescent with iron-deficiency anemia how to administer oral iron to their child. What instructions should be included in the lesson? SATA

- anticipate that stools tend to be blackish-green - give the medication with a glass of orange juice - use a needleless syringe to administer the medication

A client is admitted to the psychiatric unit with the diagnosis of schizophrenia, undifferentiated type. When assessing the client, the nurse identifies the presence of the characteristics related to this disorder. SATA

- bizarre behavior - disorganized speech - auditory hallucinations

A school-aged child with sickle cell anemia is admitted to the pediatric unit in a vaso-occlusive crisis. The nurse's priority is to relieve the excruciating pain. What interventions should be implemented after the pain is under control? SATA

- rehydration - oxygen therapy

A client is admitted to the hospital with the diagnosis of myocardial infarction. The nurse should monitor this client for which signs and symptoms associated with heart failure? SATA

- unusual fatigue - dependent edema - nocturnal dyspnea

One day in the well-child clinic a mother asks at what age her baby should first be able to drink from a cup. The nurse responds:

At around 12 months

While supervising a smallpox vaccination program, a nurse manager observes a nurse cleansing the arm of a client with an alcohol swab before giving the vaccination. What should the nurse manager's first reaction be? A) Continue observing the vaccination. B) Stop the nurse from giving the vaccination C) Give the nurse a povidone-iodine (Betadine) swab to use instead. D) Notify the members of the team about the need to use antiseptic swabs.

B) Stop the nurse from giving the vaccination RATIONALE: Alcohol deactivates the smallpox vaccine. Cleansing of the arm should not be done before the immunization is given unless the arm is dirty; if dirty, only water should be used to cleanse the site.

A client has mitral valve insufficiency (regurgitation). The nurse is auscultating the heart to determine the presence of regurgitation. Where should the stethoscope go

D Heard best at the apex of the heart (mitral).

A client with acute glomerulonephritis reports feeling thirsty. What should the nurse offer the client?

Hard candy

A nurse is caring for a client with a diagnosis of type 1 diabetes who has developed diabetic co(..) element excessively accumulates in the blood to precipitate the signs and symptoms associated with this condition?

Ketones as a result of rapid fat breakdown, causing acidosis

Which action would the nurse take to minimize agitation in a disturbed client?

Limit unnecessary interactions with the client

What is the priority nursing action in the care of a young child with severe diarrhea?

Maintaining fluid and electrolyte balance.

A client admitted to the cardiac care unit with a myocardial infarction complained of chest pain. The nursing intervention most effective in relieving the clients pain is to administer the prescribed:

Morphine sulfate 2 mg intravenously (IV)

What antidote to the side effects of terbutaline should the nurse have available?

Propanolol (inderal)

A client is admitted to the hospital with a diagnosis of deep vein thrombosis, and intravenous (IV) heparin sodium is prescribed. If the client experiences excessive bleeding, the nurse should be prepared to administer:

Protamine sulfate

A client has a thermodilution pulmonary catheter inserted for monitoring cardiovascular status. With this type of catheter, the nurse recalls that the most accurate measurement of the client's left ventricular pressure is the

Pulmonary capillary wedge pressure

A client with early stage cancer of the esophagus is treated with laser therapy. What type of food the nurse instructs the client to select when oral intake is permitted?

Pureed

Which characteristics of a therapeutic milieu would the nurse consider important for a confused older adult with socially aggressive behavior?

Sets limits

After many years of coping with colitis, a client makes the decision to have a colectomy as advised by the healthcare provider. Which is the most likely significant factor that impacted on the client's decision?

Surgical treatment cures ulcerative colitis

A client with hyperthyroidism is treated initially with propylthiouracil (PTU). What should the nurse include when teaching the client about this medication?

Symptoms may not subside until the client has taken the medication for several weeks.

The nurse is caring for a client who has had frequent premature ventricular complexes (PVCs) and monitors the client closely for ventricular fibrillation. The nurse recalls that the risk for ventricular fibrillation is greatest during which phase of the cardiac cycle?

T wave

A girl arrives at the school health office in tears, telling the nurse that several of her classmates have been teasing her. Which is the most therapeutic response by the nurse?

Tell me more about it

A client with a parotid tumor expresses anxiety about the surgery to remove the tumor. The client states that perhaps surgery should be performed soon, even if the preoperative radiotherapy is not completed. The best response by the nurse is:

You are concerned about the delay of surgery?"

A client with osteomyelitis is receiving antibiotic therapy via a central line. Trough blood levels were obtained immediately before a prescribed dose of antibiotics and peak levels were obtained 30 minutes after the infusion was completed. The laboratory results reveal that the trough level is higher than the peak level. The nurse concludes that this finding probably indicates that...

There was a problem with the obtaining of blood specimens. Rationale: Peak levels will always be higher than trough levels; therefore, it indicates some mix-up in the drawn samples.

A client is hospitalized because of severe depression. The client refuses to eat, stays in bed most of the time, does not talk with family members, and will not leave the room. The nurse attempts to initiate a conversation by asking questions but receives no answers. Finally the nurse tells the client that if there is no response, the nurse will leave and the client will remain alone. How should the nurse's behavior be interpreted?

This threat is considered assault, and the nurse should not have reacted in this manner

A nurse is caring for a client who was diagnosed with a myocardial infarction. While caring for the client two days after the event, the nurse identifies that the client's temperature is elevated. The nurse concludes that this increase in temperature is most likely the result of:

Tissue necrosis