Hesi Funda
A nurse is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable.Correct1.Meta-analysis2.Randomized controlled trial3.Expert opinion based on scientific principles4.Cohort study5.Controlled trial without randomization
1
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A) Tossed salad, low-sodium dressing, bacon and tomato sandwich. B) New England clam chowder, no-salt crackers, fresh fruit salad. C) Skim milk, turkey salad, roll, and vanilla ice cream. D) Macaroni and cheese, diet Coke, a slice of cherry pie
C
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply.1Clean the eyelid and eyelashes.2Place the dropper against the eyelid.3Apply clean gloves before beginning of procedure.4Instill the solution directly onto cornea.5Press on the nasolacrimal duct after instilling the solution.
1,3,5
A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit?1Apathy2Euphoria3Detachment4Emotionalism
3
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A) Arms. B) Upper torso. C) Head. D) Feet
B
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values?1White blood cell (WBC) count of 15,000 mm32Negative protein in the urine3Blood urea nitrogen (BUN) of 20 mg/dL4Prothrombin of 12.0 seconds
1
A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the nurse?1"We have no record of that client on our unit. Thank you for calling."2"The new privacy laws prevent me from providing any client information over the phone."3"The client has requested that no information be given out. You'll need to call the client directly."4"It is against the hospital's policy to provide you with any information regarding any of our clients."
1
Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include?1Encouraging daily physical exercise2Performing yearly physical examinations3Providing hypertension screening programs4Teaching a person with diabetes how to prevent complications
1
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply.1Whole grains2Cooked fruit and vegetables3Nuts and seeds4Lean red meats5Milk and eggs
1,2,5
A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply.1Ask the client what is the client's acceptable level of pain.2Eliminate all activities that precipitate the pain.3Administer the pain medications regularly around the clock.4Use a different pain scale each time to promote patient education.5Assess the client's pain every 15 minutes
1,3
During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?1The nurse also should have instituted a plan to increase activity.2The nurse provided supportive nursing care for the well-being of the client.3Debridement of the pressure ulcer should have been done before the dressing was applied.4Treatment should not have been instituted until the health care provider's prescriptions were received.
2
While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take?1Immediately stop the infusion.2Lower the height of the enema bag.3Advance the enema tubing 2 to 3 inches.4Clamp the tube for 2 minutes, then restart the infusion.
2
The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply.Incorrect 1Dyspnea2Flushed face3Precordial pain4Increased pulse rate5Increased blood pressure
2, 4
The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply.1Orientation2Capillary refill3Pupillary response4Respiratory rate5Pulse and skin temperature6Movement and sensation
2,5,6
A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the nurse monitor this client?1Curling ulcer2Renal shutdown3Metabolic acidosis4Hemolysis of red blood cells
3
The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication?1Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care.2Develop a chart for the client, listing the times the medication should be taken.3Contact the primary health care provider and discuss the possibility of simplifying the medication regimen.4Instruct the client and client's children to put medications in a weekly pill organizer
3
The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery?Incorrect1Occipital headache2Periorbital crepitus3Expectoration of blood4Changes in vocalization
3
The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may:1Force urine to back up into the kidneys.2Suppress production of urine.3Cause the device to pull away from the skin.4Tear the ileal conduit
3
The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last?1Multipara in active labor2Middle-aged woman with substernal chest pain3Older adult male with a partially amputated finger4Adolescent boy with an oxygen saturation of 91%
3
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse expect the dietary plan to include?1Low in fat2High in iron3High in fluids4Low in residue
3
When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:1Evidence2Tort discovery3Proximate cause4Common cause
3
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer?1Stage I2Stage II3Stage III4Unstageable
4
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? A.Tell the client it is nothing to worry about. B.Talk with the client further to identify the specific cause of the problem. C.Instruct the client to attempt to avoid situations that cause irritation. D.Interview the client to determine whether other mood swings are being experienced.
4
A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions?1Anger2Denial3Bargaining4Acceptance
4
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication?1Prolonged use can cause dark concentrated urine.2The medication is best absorbed when taken on an empty stomach.3Take the medication with aluminum hydroxide to minimize GI upset.4Drinking alcohol daily can cause drug-induced hepatitis
4
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question?1Oral psyllium (Metamucil)2Oral potassium supplement3Parenteral half normal saline4Parenteral albumin (Albuminar)
4
A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation?1Tell the neighboring client to stop singing.2Close the doors to both clients' rooms at night.3Give the complaining client the prescribed as needed sedative.4Move the neighboring client to a room at the end of the hall
4
A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take?1Ask the client if he is okay.2Call security from the room.3Find out if there is anyone else in the room.4Ask security to make sure the room is safe
4
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason?1To avoid strain on the incision2To promote drainage of the wound3To provide stimulation for the client4To reduce edema at the operative site
4
Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client?1Anger2Denial3Depression4Acceptance
4
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to:1Promote equalization of osmotic pressures.2Prevent hypoxia associated with diaphoresis.3Promote integrity of intracerebral neurons.4Reduce brain metabolism and limit hypoxia.
4
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care?1Risk for pressure ulcer2Risk for impaired skin integrity3Impaired skin integrity, related to infrequent turning and repositioning4Impaired skin integrity, related to the effects of pressure and shearing force
4
The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is:1A physiological response to stress2A conscious defense against anxiety3An intentional attempt to gain attention4An unconscious means of reducing stress
4
When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response?1Negligence2Malpractice3Breach of duty4False imprisonment
4
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A) What is your daily calorie consumption? B) What vitamin and mineral supplements do you take? C) Do you feel that you are overweight? D) Will a clear liquid diet be okay after surgery?
A
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take?A) Commend the client for selecting a high biologic value protein.B) Remind the client that protein in the diet should be avoided.C) Suggest that the client also select orange juice, to promote absorption.D) Encourage the client to attend classes on dietary management of CRF
A
After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals.
A
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A.It is important that you continue your medication while learning to meditate. B)Is okay to stop your medication
A
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A) Be sure to have a complete physical examination before beginning your planned exercise program. B) Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C) Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D) Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
A
During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A) Listen and show interest as the client expresses these feelings. B) Reinforce that this behavior means they were not true friends. C) Ask the healthcare provider for a psychiatric consult. D) Continue with the assessment and tell the client not to worry.
A
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A) 11,000 units. B) 13,000 units. C) 15,000 units. D) 17,000 units
A
The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A) Genetic and familial health disorders. B) Chronic health problems. C) Reason for seeking health care. D) Undetected disorders.
A
The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A) Client .B) Healthcare provider. C) A family member. D) Previous medical records
A
Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? A.Give the infant to the client and instruct her regarding the infant's care. B.Explain to the client that she can leave, but her infant must remain in the hospital C.Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. D.Tell the client that hospital policy prevents the staff from releasing the infant until ready for discharge
A
What should the nurse consider when obtaining an informed consent from a 17-year-old adolescence A.If the client is allowed to give consent B.The client cannot make informed decisions about health care. C.If the client is permitted to give voluntary consent when parents are not available D.The client probably will be unable to choose between alternatives when asked to consent
A
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion.
A
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses
B
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?A) 13 ml/hour.B) 63 ml/hour.C) 80 ml/hour.D) 125 ml/hour
B
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A) Autopsy of the body is prohibited. B) Blood transfusions are forbidden. C) Alcohol use in any form is not allowed. D) A vegetarian diet must be followed
B
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A) Irrigate the nasogastric tube with sterile normal saline. B) Reposition the client on her side. C) Advance the nasogastric tube an additional five centimeters. D) Administer an intravenous antiemetic prescribed for PRN use.
B
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A) 9 a.m., 1 p.m., and 5 p.m. B) 8 a.m., 4 p.m., and midnight. C) Before breakfast, before lunch and before dinner. D) With breakfast, with lunch, and with dinner.
B
A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? A.Limits had to be set to control the child's crying. B.The child had a right to remain in the room with the other children. C.The child had to be removed because the other children needed to be considered. D.Segregation of the child for more than half an hour was too long a period of time
B
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors
B
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's. C) Sims'. D) Supine.
B
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A) prone. B) Fowler's. C) Sims'. D) supine
B
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
B
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderlyA) is to be expected, and progresses with age.B) often follows relocation to new surroundings.C) is a result of irreversible brain pathology.D) can be prevented with adequate sleep
B
In what position should the nurse place a client recovering from general anesthesia? A.SupineCorrect B.Side-lying C.High Fowler D.Trendelenburg
B
On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment.
B
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A) 0.5 tablet. B) 1 tablet. C) 1.5 tablets. D) 2 tablets.
B
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min?A) 42 gtt/min.B) 83 gtt/min.C) 125 gtt/min.D) 250 gtt/min
B
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. B) 1.5 ml. C) 1.75 ml. D) 2 ml.
B
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A) A college-age track runner with a sprained ankle. B) A lactating woman nursing her 3-day-old infant. C) A school-aged child with Type 2 diabetes. D) An elderly man being treated for a peptic ulcer.
B
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A) Immediately after exhalation. B) During the inhalation. C) At the end of three inhalations. D) Immediately after inhalation
B
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A) Reassure the client that he will become accustomed to the stoma appearance in time. B) Instruct the client that the stoma will become smaller when the initial swelling diminishes. C) Offer to contact a member of the local ostomy support group to help him with his concerns. D) Encourage the client to handle the stoma equipment to gain confidence with the procedure
B
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure
B
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? A)Chlorothiazide (Diuril) B)Acetazolamide (Diamox) C)Bendroflumethiazide (Naturetin) D)emecarium bromide (Humorsol)
B
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: A)Respiratory rate. B)Amount of oxygen in the blood. C)Percentage of hemoglobin-carrying oxygen. D)Amount of carbon dioxide in the blood
C
A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV.
C
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A) Record the coughing incident. No further action is required at this time. B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
C
A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? A.Droplet precautions B.Reverse isolation C.Surgical asepsis D.Medical asepsis
C
A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review? A)Nursing's Social Policy Statement B)State law regarding protection of minors C)ANA Standards of Clinical Nursing Practice D)References regarding a child's right to consent
C
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The clientA) asks relevant questions regarding the dressing change.B) states he will be able to complete the wound care regimen.C) demonstrates the wound care procedure correctly.D) has all the necessary supplies for wound care.
C
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified
C
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?A) Position the client on the right side of the bed in reverse Trendelenburg.B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.C) Reposition in a Sim's position with the client's weight on the anterior ilium.D) Raise the side rails on both sides of the bed and elevate the bed to waist level
C
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take?A) Request another nurse to complete the physical assessment.B) Ask the client to stop crying and tell the nurse what is wrong.C) Acknowledge the client's distress and tell her it is all right to cry.D) Leave the room so that the client can be alone to cry in private.
C
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?A) Adequate venous blood flow to the lower extremities.B) Estimated amount of body fat by an underarm skinfold.C) Degree of flexion and extension of the client's knee joint.D) Change in the circumference of the joint in centimeters
C
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A) ½ tablet. B) 1 tablet. C) 1½ tablets. D) 2 tablets.
C
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A) Remain calm with the client and record abnormal results in the chart. B) Notify the medication nurse immediately if the pulse or blood pressure is low. C) Report the results of the vital signs to the nurse. D) Reassure the client that the vital signs are normal.
C
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr D) Obtain a stat blood glucose level and notify the healthcare provider.
C
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase.
C
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A) Complimentary healing practices interfere with the efficacy of the medical model of treatment .B) Conventional medications are likely to interact with folk remedies and cause adverse effects. C) Many complimentary healing practices can be used in conjunction with conventional practices. D) Conventional medical practices will ultimately replace the use of complimentary healing practices.
C
Which action is most important for the nurse to implement when donning sterile gloves? A) Maintain thumb at a ninety degree angle. B) Hold hands with fingers down while gloving. C) Keep gloved hands above the elbows. D) Put the glove on the dominant hand first.
C
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted.
C
Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met?A) Expresses concern about the meaning and importance of lifeB) Remains angry at God for the continuation of the illness.C) Accepts that punishment from God is not related to illness.D) Refuses to participate in religious rituals that have no meaning.
C
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best respons A)Tell the client it is nothing to worry about. B)Talk with the client further to identify the specific cause of the problem. C)Instruct the client to attempt to avoid situations that cause irritation. D)Interview the client to determine whether other mood swings are being experienced.
D
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match.
D
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take?A) Explain that anyone who speaks her language can answer her questions.B) Provide a translator only in an emergency situation.C) Ask a family member or friend of the client to translate.D) Request and document the name of the certified translator.
D
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A) demonstrates loss of remote memory. B) exhibits expressive dysphasia. C) has a diminished attention span. D) is disoriented to place and time.
D
An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client?A) Obtain an interpreter to explain the procedure to the client.B) Encourage the client to make her own decision regarding surgery.C) Ask the family members to provide an interpretation of the surgeon's explanation to the client.D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.
D
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request.
D
An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions
D
At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs .D) Immediately after the assessments are completed
D
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot
D
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions. D) Re-oxygenate the client before attempting to suction again.
D
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?A) 31 gtt/min.B) 62 gtt/min.C) 93 gtt/min.D) 124 gtt/min
D
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A) The belief is held that the "evil eye" enters the child if anything cold is ingested. B) After surgery the child probably has refused all foods except broth. C) Eating broth strengthens the child's innate energy called "chi." D) Hot remedies restore balance after surgery, which is considered a "cold" condition.
D
The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? A.Institute the prescribed blood transfusion because the client's survival depends on volume replacement. B.Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. C.Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. D.Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought
D
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A) Height in inches or centimeters. B) Weight in kilograms or pounds. C) Triceps skin fold thickness. D) Upper arm circumference.
D
