HESI H

716. An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? a- 0800, 1200, 1600, 2000 b- Administer with meals and a bedtime snack c- Five in equally divided doses during waking hours d- 1000, 1600, 2200, 0400

1000, 1600, 2200, 0400.

749. The nurse suspect may be hemorrhaging internally. Which findings of an orthostatic test may indicate to the nurse of major bleed?

A decrease in the systolic b/p of 10mm/hg with a corresponding increase of heart rate of 20.

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

B. Persistent coughing while drinking

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first?

Begin manual ventilation immediately.

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take?A. Ask the UAP to take the blood pressure in the other arm B. Tell the UAP to use a different sphygmomanometer. C. Review the client's serum calcium level D. Administer PRN antianxiety medication.

C. Review the client's serum calcium level

799. A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? A. Knows that insulin must be given 30 min before eating B. Frequently eats fruits and vegetables at meals and between meals/ C. Has someone available who can prepare and oversee the diet D. Demonstrates willingness to adhere to the diet consistently

Demonstrates willingness to adhere to the diet consistently.

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? A. Instruct the mother to change the child's diaper more often. B. Encourage the mother to apply lotion with each diaper charge C. Tell the mother to cleanse with soap and water at each diaper change D. Ask the mother to decrease the infant's intake of fruits for 24 hours.

Instruct the mother to change the child's diaper more often

796. A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide? A. soft pretzels B. fruit-flavored yogurt C. oatmeal cookies D. low fat cheese sticks

Oatmeal cookies.

798. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first? A. A client with congestive heart failure who reports a 3 pound weight gain in the last two days B. An immobile client with a stage 3 pressure ulcer on the coccyx who is having low back pain C. A client diagnosed with chronic obstructive pulmonary disease (COPD) who is short of breath D. A terminally ill older adult who has refused to eat or drink anything for the last 48 hours

A client with congestive heart failure who reports a 3 pound weight gain in the last two days.

770. 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 bedside commode is positioned near the bed B. A saline lock is present in the right forearm C. A full pitcher of water is on the bedside table D. The client is lying in a supine position in bed E. A low sodium diet tray was brought to the room

A full pitcher of water is on the bedside table. The client is lying in a supine position in bed.

An older male client with a history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? A. Record pain evaluation B. Assess blood glucose C. Identify pills in the bag D. Obtain a medical history

C. Identify pills in the bag

789. A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client? A. Remain on clear liquids until the vomiting subsides B. Come to the clinic to be seen by a healthcare provider C. Make an appointment at the clinic if a fever occurs D. Take nothing by mouth until there is no more nausea

Come to the clinic to be seen by a healthcare provider.

731. A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? A. Regular insulin. B. Hydrocortisone C. Broad spectrum antibiotic D. Potassium chloride

Hydrocortisone.

722. The nurse enters a client's room and observe the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. What action should the nurse take first? a- Provide the gloves for the UAP to apply b- Offer to help reposition the client c- Instruct the UAP to raise the bed level d- Place the side rails in an up position

Place the side rails in an up position. Rationale: To maintain the client safety, it is most important for the nurse to place the side rails in a up position to reduce the risk of falls and injury. A, B and C can then be completed.

730. During discharge teaching, an overweight client heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (Select all that apply) A. Canned fruit in heavy syrup. B. Plain, air-popped popcorn. C. Cheddar cheese cubes. D. Natural whole almonds. E. Lightly salted potato chips

Plain, air-popped popcorn. Natural whole almonds.

A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child?

Sitting up and leaning forward

754. To reduce the risk of symptoms exacerbation for a client with multiple sclerosis (MS), which instructions should the nurse include in the client's discharge plan? (Select all that apply). A. Practice relaxation exercises B. Limit fluids to avoid bladder distention C. Space activities to allow for rest periods D. Avoid persons with infections E. Take warm baths before starting exercise

Space activities to allow for rest periods. Take warm baths before starting exercise .

767. An elderly male client is admitted to the urology unit with acute renal failure due to a post-renal obstruction. Which questions best assists the nurse in obtaining relevant historical data? A. "Have you had a heart attack in the last 6 months" B. "Have you had any difficulty in starting your urinary stream" C. "Have you taken any antibiotics recently" D. "Have you received any blood products in the last year"

"Have you had any difficulty in starting your urinary stream".

732. An adolescent, whose mother recently died, comes to the school nurse complain headache. Which statement made by the students should warrant further explanation nurse? A. "I've had dreams about Mom since she died." B. "I've been very sad and cry a lot at night." C. "I miss Mom and would like to go see her'". D. " it's hard to concentrate on my homework"

"I miss Mom and would like to go see her'".

In early septic shock states, what is the primary cause of hypotension? A. Cardiac failure B. A vagal response C. Peripheral vasoconstriction D. Peripheral vasodilation

D. Peripheral vasodilation

703. A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse? a- Thyroxine 12 ug/dl b- Total calcium 5.0 mg/dl c- T3 uptake at 50% d- Glucose 150 mg/dl

Total calcium 5.0 mg/dl.

753. The nurse applies a blood pressure cuff around a client's left thigh. To measure the client's blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.)

"On left thigh with arrow pointing to inner thigh".

733. When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top last action on bottom.)

1. Rub hands palm to palm. 2. Interlace the fingers. 3. Dry hands with paper towel. 4. Turn off the water faucet.

743. A male client is admitted with a severe asthma attack. For the last 3 hours he has experienced increased shortness of breath. His arterial blood gas results are: pH 7.22 PaCO2 55 mmHg; HCO3 25 mEq/L or mmol/L (SI). Which intervention should the nurse implement? A. Space care to provide periods of rest B. Instruct client to purse lip breathe C. Administer PRN dose of albuterol D. Position client for maximum comfort

Administer PRN dose of albuterol.

766. Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN)?

An elderly female client with cancer whose children who are trying to decide whether to change to palliative care measures or continue disease control.

748. An antacid is prescribed for a client with gastroesophageal (GERD). The client asks the nurse, "How does this help my GERD?" What is the best response by the nurse? A. This medication will coat the lining of your esophagus B. Antacids will neutralize the acid in your stomach C. It will improve the emptying of food through your stomach D. antacids decrease the production of gastric secretions

Antacids will neutralize the acid in your stomach.

793. While removing staples from a male client's postoperative wound site, the nurse observes that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed." After acknowledging the client's anxiety, what action should the nurse implement? a- Encourage the client to continue verbalize his anxiety b- Attempt to distract the client with general conversation c- Explain the procedure in detail while removing the staples d- Reassure the client that this is a simple nursing procedure.

Attempt to distract the client with general conversation.

800. Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? A. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen? B. Avoid administration of oxygen at high levels for extendedperiods. C. Increase oxygen rate during sleep to compensate for slower respiratory rate. D. Oxygen is less toxic when it is humidified with a hydration source.

Avoid administration of oxygen at high levels for extended periods.

768. A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? A. Bone marrow transplantation B. Blood transfusion C. Chemotherapy D. Immunosuppressive therapy

Bone marrow transplantation.

726. A nurse plans to call the healthcare provider to report an 0600 serum potassium level of 2 mEq/L or mmol/L (SI), but the charge nurse tells the nurse that the healthcare provider does not like to receive early morning calls and will make rounds later in the morning. What action should the nurse make? a- Contact the healthcare provider immediately to report the laboratory value regardless of the advice. b- Call the lab to draw an additional blood sample for a repeat evaluation of the potassium level STAT. c- Flag the client's medical record to alert the healthcare provider immediately upon arrival to the unit. d- Ask the charge nurse to contact the healthcare provider with the laboratory results by mid-morning.

Contact the healthcare provider immediately to report the laboratory value regardless of the advice. Rationale: A serum potassium level of 2 mEq/L or mm/L (SI) is dangerous low and requires immediate intervention A to prevent potentially fatal cardiac dysrhythmias, regardless of the charge nurse concern regarding disturbing the healthcare provider, B, C and D may result in a potentially fatal delay in responding to the hypokalemia.

721. During a clinic visit, a client with a kidney transplant ask, "What will happen if chronic rejection develops?" which response is best for the nurse to provide? a- The immunosuppressant medication will be increased until the rejection subside b- Dialysis may be necessary until the chronic rejection can be reversed. c- Dialysis would need to be resumed if chronic rejection becomes a reality d- A different combination of immunosuppressant medications will be implemented.

Dialysis would need to be resumed if chronic rejection becomes a reality. Rationale: Chronic rejection is managed conservatively by treating the symptoms until dialysis is needed. Immunosuppressant medication dosage are not increased when chronic rejection occurs, but are during acute rejection.

795. The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation? A. Determine the presence of hematemesis as the UAP irrigates the NGT B. Instruct the UAP to bring an antiemetic to the nurse at the bedside C. Assess the appearance of the emesis while the UAP checks bowel sounds D. Direct the UAP to measure the emesis while the nurse irrigates the NGT

Direct the UAP to measure the emesis while the nurse irrigates the NGT.

794. A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first? A. Ensure client takes a diuretic q AM B. Obtain serum creatinine levels daily C. Measure ankle circumference D. Monitor daily sodium intake

Ensure client takes a diuretic q AM.

704. A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

Explore the client's reasons for wanting to be discharged.

756. During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy? A. Family history of adult onset diabetes. B. Treatment for chlamydia in the past year C. Client's age and previous sexual behavior D. Three year history of taking oral contraceptives

Family history of adult onset diabetes. Three year history of taking oral contraceptives.

718. A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) a- Headache and tremors b- Irregular heart rate c- Skin hyperpigmentation d- Postural hypotension e- Pallor and diaphoresis

Headache and tremors. Postural hypotension. Pallor and diaphoresis. Irregular heart beat.

792. A male client is admitted with a bowel obstruction and intractable vomiting for the last several hours despite the use of antiemetics. Which intervention should the nurse implement first? (Please scroll and view each tab's information in the client's medical record before selecting the answer.) A. Infuse 0.9 % sodium chloride 500 ml bolus B. Insertnasogastrictubetointermittentsuction. C. Maintain head of bed at 45 degrees D. Document strict intake and output

Infuse 0.9 % sodium chloride 500 ml bolus.

710. A client with pneumonia has arterial blood gases levels at: PH 7.33; PaCO2 49 mm/hg; HCO3 25 mEq/L; PaO2 95. What intervention should the nurse implement based on these results? a- Instruct the client to breath into a paper bag. b- Prepare to administer sodium chloride fluids c- Institute coughing and deep breathing protocols d- Initiate oxygen administration at 2 to 3 L per nasal cannula

Institute coughing and deep breathing protocols. Rationale: Pulmonary hygiene measures will clear the respiratory tract of mucus and purulent drainage, thereby improving ventilation, since these ABG's reveal respiratory acidosis, and treatment should be directed to improving ventilation. A would be good for respiratory alkalosis, B for metabolic alkalosis A paO2 of 95 is within normal limits do D is not necessary

776. The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take? A. Plan to observe the secured IV site after the insertion procedure B. Confirm that the nurse has gathered the necessary supplies C. Remind the nurse to tape the gauze dressing securely in place D. Instruct the nurse to use a transparent dressing over the site

Instruct the nurse to use a transparent dressing over the site.

786. A male client with an antisocial personality disorder is admitted to an in-patient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior this client's history is most likely to include which finding? A. Phobias and panic attacks when confronted by authority figures. B. Suicidal ideations and multiple attempts/ C. Multiple convictions for misdemeanors and class B felonies. D. Delusions of grandiosity and persecution

Multiple convictions for misdemeanors and class B felonies.

712. While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement? a- Administer a PRN dose of pain medication b- Place a portable toilet next to the bed c- Restrict activity to complete bed rest d- Evaluate the client's leg muscular strength.

Place a portable toilet next to the bed. Rationale: Due to the contractures and muscle weakness that progress with MD, the client's awkward movements and clumsiness is an expected sequela. Using assistive devices, such as bedside toilet, should be implement to help limit the client's frustration and ensure client safety, Discomfort is constant and may not always require pain medication (A). Activity should be encouraged (C) as long as the client is capable. (D) should be implemented before mobilizing the client.

739. The nurse is collecting sterile sample for culture and sensitivity from a disposable three chamber water-seal drainage system connected to a pleural chest tube. The nurse should obtain the sample from which site on the drainage system? A. Stopper port located above the water-seal level B. Plastic tubing located at the chest insertion site C. Rubberized port at the bottom of collection chamber D. Tubbing located on the top of the suction chamber

Plastic tubing located at the chest insertion site.

790. The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats / minute. Which action should the nurse take? A. Continue the insertion since this is a typical response B. pause and monitor for a continues drop of the heart rate C. Insert the feeding tube into the infant's nasal passage D. Postpone the feeding until the infant's vital signs and stable

Postpone the feeding until the infant's vital signs and stable.

778. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum sodium of 145 mEq/L (145 mmol/L SI) C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) D. White blood cell count of of 12,000 mm3 (12 x 109/L SI)

Serum creatinine of 4.5 mg/dl (398 mcmol/L SI).

791. An infant is receiving gavage feedings via nasogastric tube. At the beginning of the feeding, the infant's heart rate drops to 80 beats / minute. What action should the nurse take?

Slow the feeding and monitor the infant's response.

762. The nurse is caring for a 17-year-old male who fell 20 feet 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. Inquire about food allergies and food likes and dislikes B. Talk directly to the adolescent while providing care C. Initiate open communication with the teen's parents D. Monitor vital signs and neuro status every 2 hours

Talk directly to the adolescent while providing care.

774. An alert older client with diabetes mellitus type 1 is admitted with a serum glucose of 420 mg/dl (23.31 mmol/L (SI)). As the nurse administers 10 units of regular insulin intravenous (IV), the client immediately begins to vomit. What action should the nurse implement first?

Turn the client to a lateral position.

738. Immediately after extubation, a client who has been mechanically ventilated is placed on a 50% non-rebreather. The client is hoarse and complaining of a sore throat. Which assessment finding should the nurse report to the healthcare provider immediately? A. Blood tinged sputum B. Expiratory wheezing C. Upper airway stridor D. Oxygen saturations 90%

Upper airway stridor.

783. The nurse is preparing to mix two medications from two different multidose vials, A and B. In which order should these actions be implemented when drawing the solutions from the vials? (Arrange from first on top to last on the bottom)

Verify the drug and dose with the label on the vial. Inject the volume of air to be aspirated from each vial. Aspirate the desired volume from vial A. Aspirate the desired volume from vial B.

782. In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider? A. Watery diarrhea B. Yellow-tinged sputum C. Increased fatigue D. Nausea and headache

Watery diarrhea.

787. An adult male who fell from a roof and fractures 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. Pain score 8 out of 10 C. Pale, diaphoretic skin D. Weak palpable distal pulses

Weak palpable distal pulses.

797. After multiple attempts to stop drinking, an adult male is admitted to the medical intensive care unit (MICU) with delirium tremens. He is tachycardic, diaphoretic, restless, and disoriented. Which finding indicates a life- threatening condition? A. CIWA-Ar for alcohol withdrawal score of 30 B.. Acute onset of unrelenting chest pain C. Widening QRS complexes and flat waves D. Intense tremor and involuntary muscle activity

Widening QRS complexes and flat waves.

727. Which actions should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom.)

1. Place stethoscope in suprasternal area to auscultate from bronchial sounds. 2. Auscultate bronchovesicular sounds from side to side of the first and second intercostal spaces. 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds. 4. Document normal breath sounds and location of adventitious breath sounds.

736. A client with a history of using illicit drugs intravenously is admitted with Kaposi's sarcoma. Which intervention should the nurse include in this client's admission plan of care? A. Identify local support HIV support groups. B. Assess for symptoms of AIDS dementia. C. Observe for adverse drug reaction. D. Monitor for secondary infections.

Monitor for secondary infections.

734. The nurse is caring for four clients who are on the rehabilitation unit, which client should the nurse assess first? A. A client with an above-the-knee amputation who is complaining of phantorn pain. B. A client who is receiving a continuous tube feeding and is now vomiting. C. A client with left hemiplegia who is scheduled for hemodialysis today. D. A client with pneumonia who is scheduled for pulmonary function studies.

A client who is receiving a continuous tube feeding and is now vomiting.

705. The nurse is assessing a primigravida a 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider? a- Complain of early morning heart burn b- Report intermittent low back pain c- Fetal heart rate of 200 beats/minute d- Maternal hemoglobin of 11.0 grams

Fetal heart rate of 200 beats/minute.

781. The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply.) A. Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). B. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty C. Perform daily surgical dressing change for a client who had an abdominal hysterectomy D. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperative E. Start the second blood transfusion for a client twelve hours following a below knee amputation

Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM). Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty. Perform daily surgical dressing change for a client who had an abdominal hysterectomy.

771. A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously schedules. What action should the nurse take? A. Advise the UAP to resume positioning the client on schedule B. Encourage the UAP to provide comfort care measures only C. Assume total care of the client to monitor neurologic function D. Assign a practical nurse to assist the UAP in turning the client

Advise the UAP to resume positioning the client on schedule.

751. A client arrives in the emergency center with a blood alcohol level of 500 mg/dl. When transferred to the observation unit, the client becomes demanding, aggressive, and shouts at the staff. Which assessments finding is most important for the nurse to identify in the first 24 hours? A. Decreased appetite B. Nausea and elevated blood pressure C. Difficulty walking D. Agitation and threats to harms staff

Agitation and threats to harms staff.

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client?

Anxiety

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

Appearance of wound.

711. The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and the interpreter then speak together in the foreign language for an additional 2 minutes until the interpreter concludes, "She says it is OK." What action should the nurse take next? a- Have the interpreter co- sign the consent to validate client understanding b- Have the client sign the consent and the nurse witness the signature c- Ask for a full explanation from the interpreter of the witnessed discussion. d- Clarify the client's consent through the use of gestures and simple terms.

Ask for a full explanation from the interpreter of the witnessed discussion.

708. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? a- Ask the client about gastrointestinal pain b- Auscultate for bowel sounds in all quadrants c- Measure the client's fluid intake and output d- Monitor the client's serum electrolyte levels.

Ask the client about gastrointestinal pain. Rationale: Proton pump inhibitor suppress gastric acid secretion, relieving the symptoms of peptic ulcer disease and GERD. To evaluate the effectiveness of PPIs, the client should be asked about the relief of symptoms such as gastrointestinal discomfort.

717. A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, II, aVF and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement? a- Obtain the results for STAT serum cardiac biomarkers b- Asses for contraindications for thrombolytic therapy c- Measure ST-segment height and waveform changes. d- Transfer for percutaneous coronary intervention (PCI)

Asses for contraindications for thrombolytic therapy. Rationale: ST segment elevation myocardial infarction (STEMI) usually occurs with complete occlusion of an epicardial coronary artery which requires early reperfusion therapy. Screening the client for fibrinolytic therapy (B) is most important to determine PCI option for rapid reperfusion. If the client is not a candidate for fibrinolytic therapy, then transfer to a PCI unit or facility is indicated. Reperfusion therapy should be delayed in STEMI (A). (C) is of significant concern in ECG interpretation with ST-segment depression, not STEMI

755. A preoperative client states he is not allergic to any medications. What is the most important nursing action for the nurse to implement next? A. Record "no known drug allergies" on preoperative checklist B. Assess client's allergies to non-drug substances C. Assess client's knowledge of an allergy response D. Flag "no known drug allergies" on the front of the chart

Assess client's knowledge of an allergy response.

780. A confused, older client with Alzheimer's disease becomes incontinent of urine when attempting to find the bathroom. Which action should the nurse implement? A. Instruct the client to use the call button when a bedpan is needed B. Apply adult diapers after each attempt to void C. Check residual urine volume using an indwelling urinary catheter D. Assist the client's to a bedside commode every two hours

Assist the client's to a bedside commode every two hours.

The nurse is triaging several children as they present to the emergency room after an accident. Which child requires the most immediate intervention by the nurse? A. A 12-year-old with complaints of neck and lower back discomfort B. An 11-year-old with a headache, nausea, and projectile vomiting C. A 6-year-old with multiple superficial lacerations of all ectremities D. An 8-year-old with a full leg air splint for a possible broken tibia

B. An 11-year-old with a headache, nausea, and projectile vomiting

729. A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?

Blood pressure 90/76 mm Hg.

746. The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply)

Ease the client to the floor. Loosen restrictive clothing. Note the duration of the seizure.

779. The unit clerk reports to the charge nurse that a healthcare provider has written several prescriptions that are illegible and it appears the healthcare provider used several unapproved abbreviations in the prescriptions. What actions should the charge nurse take? A. Complete and file an incident (variance) report Call the healthcare provider who wrote the prescription C. Contact the healthcare provider review board for instructions D. Report the situation to the house supervisor

Call the healthcare provider who wrote the prescription. Report the situation to the house supervisor.

724. A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication? a- Chest pain and dysrhythmia b- Vasodilation of the extremities c- Hypotension and tachycardia d- Decreasing GI cramping and nausea.

Chest pain and dysrhythmia. Rationale: In large doses, vasopressin may produce increased blood pressure, coronary insufficiency, myocardial ischemia or infarction and dysrhythmias.

761. An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? A. Prepare for emergent oral intubation B. Offer sips of favorite beverages C. Clarify end of life desires D. Initiate comfort measures

Clarify end of life desires.

765. The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply)

Close car windows and use air conditioner. Avoid sudden changes in temperature. Keep away from pets with long hair. Stay indoors when grass is being cut.

702. Which assessment finding of a postmenopausal woman necessitates a referral by the nurse to the healthcare provider for evaluation of thyroid functioning? a- Slow weight loss b- Muscle weakness c- Cold sensitivity d- Leg numbness

Cold sensitivity.

740. While the nurse is preparing a scheduled intravenous (IV) medication, the client states that the IV site hurts and refuses to allow the nurse to administer a flush to assess the site. Which intervention should the nurse implement? A. Apply ice first, then a warm compress to the IV site B. Discontinue the painful IV after a new IV is inserted C. Review the medical record for the date of insertion D. Document that the medication was not administered

Discontinue the painful IV after a new IV is inserted.

750. A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan? A. Avoid exposure to large crowds B. Do not take any over-the-counter medications C. Call the crisis hot line if feeling lonely D. Eat a high carbohydrate, low fat, low protein diet

Do not take any over-the-counter medications.

An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? a- Immediately apply a pressure dressing b- Document the ongoing wound healing. c- Irrigate the wound with sterile saline d- Obtain a capillary INR, measurement

Document the ongoing wound healing. Rationale: Appearance of granulation tissue is the best indicator of increased venous retuns and ongoing wound healing

775. A client is admitted to the surgical unit with symptoms of a possible intestinal obstruction. When preparing to insert a nasogastric (NG) tube, which intervention should the nurse implement? A. Elevate the head of the bed 60 to 90 degrees B. Measure from corner of mouth to angle of jaw C. Administer a PRN analgesic D. Assess for a gag reflex

Elevate the head of the bed 60 to 90 degrees.

764. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate? A. Blood pressure fluctuations means that the condition has become chronic B. Elevated blood pressure must be anticipated and identified quickly C. Hypotension leading to sudden shock can develop at any time D. Sodium intake with meals and snacks affects the blood pressure

Elevated blood pressure must be anticipated and identified quickly.

719. A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care? a- Monitor deep vein blood flow using Doppler b- Evaluate daily blood clotting factors. c- Apply antiembolism stockings. d- Maintain strict bed rest.

Evaluate daily blood clotting factors. Rationale: Monitoring clotting factors is the most important intervention to include in this client's plan of care following oxygen administration, IV fluids and heparin administration to prevent clot enlargement. Ac and D should be included in the client's plan of care, but these interventions do not have the priority of B

720. The nurse enters a client's room to administer scheduled daily medications and observes the client leaning forward and using pursed lip breathing. Which action is most important for the nurse to implement first? a- Administer schedule medications b- Offer the client PRN anxiolytic c- Assess the lungs for wheezing d- Evaluate the oxygen saturation.

Evaluate the oxygen saturation. Rationale: The client is exhibiting symptoms of an acute exacerbation of a chronic obstructive lung disease such as emphysema. The client... baseline oxygen level should be compared to the current level to determine if respiratory decompensation is occurring. Schedule medications can be administered after completing the oxygen saturation assessment. Respiratory distress often makes a client anxious, which may worsen the symptoms, so should be considered after implementing D. Assessing the lung for wheezing does not reveal further respiratory compromise

The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer's disease. What action should the nurse take? a- Explain that memory loss and confusion are common with vitamin B12 deficiency. b- Ask if the client is experiencing any changes in bowel habits c- Determine if the client is taking iron and folic acid supplements d- Encourage the husband to bring the client to the clinic for a complete blood count.

Explain that memory loss and confusion are common with vitamin B12 deficiency Rationale: Pernicious anemia is related to the absence of intricic factor in gastric secretions, leading to malabsorption of vit B12, and commonly causes memory loss, confusion and cognitive problems, and GI manifestations. The nurse should reassure the husband that the client's signs are consistent with the primary disease. Although B, C and D provide additional information about the client's compliance and response to therapy, a quick and dramatic response can occur after 72 hrs. of B12 injections.

The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history? a- Genetically inherited disorders of family members b- Length and frequency of the client's tobacco use. c- Ingestion of selfish or fish oil capsules daily. d- Frequency of laxative use for chronic constipation

Frequency of laxative use for chronic constipation

757. When conducting diet teaching for a client who was diagnosed with a myocardial infarction, which snack foods should the nurse encourage the client to eat? (Select all that apply). A. Fresh turkey slices and berries B. Fresh vegetables with mayonnaise dip C. Soda crackers and peanut butter D. Chicken bouillon soup and toast E. raw unsalted almonds and apples

Fresh turkey slices and berries. Chicken bouillon soup and toast. Raw unsalted almonds and apples.

744. A young adult female with chronic kidney disease (CKD) due to recurring pyelonephritis is hospitalized with basilar crackles and peripheral edema. She is complaining of severe nausea and the cardiac monitor indicates sinus tachycardia with frequent premature ventricular contraction. Her blood pressure is 200 /110 mm Hg, and her temperature is 101 F which PRN medication should the nurse administers first? A. Enalapril B. Furosemide C. Acetaminophen D. Promethazine

Furosemide.

736. A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression, after another minute of compression , the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor, at this point , what is the priority intervention for the nurse? A. Prepare for transcutaneous pacing B. Administer IV epinephrine per ACLS protocol C. Give IV dose of adenosine rapidly over 1-2 seconds. D. Deliver another defibrillator shock.

Give IV dose of adenosine rapidly over 1-2 seconds.

741. During a staff meeting, a nurse verbally attacks the nurse manager conducting the meeting, stating, "you always let your favorites have holidays off give then easier assignments. You are unfair and prejudiced" how should the nurse-manager respond? A. I would prefer to discuss this with you privately. B. Give me specific examples to support your statements. C. Does anyone else on the staff fell the same way D. Your remarks are not true and are very unkind

Give me specific examples to support your statements.

760. A mother brings her 3-week-old son to the clinic because he is vomiting "all the time." In performing a physical assessment, the nurse notes that the infant has poor skin turgor, has lost 20% of his birth weight, and has a small palpable oval-shaped mass in his abdomen. What intervention should the nurse implement first? A. Give the infant 5% dextrose in water orally B. Insert a nasogastric tube for feeding C. Initiate a prescribed IV for parental fluid D. Feed the infant 3 ounces of Isomil

Initiate a prescribed IV for parental fluid.

A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman?

Inform her that some antianxiety medications are safe to take while breastfeeding

745. When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? A. Ignore the behavior and hang the IV antibiotic B. tell the client to stop the inappropriate behavior C. Leave the room and close the door quietly D. Complete an unusual occurrence report

Leave the room and close the door quietly.

742. An adult is admitted to the emergency department following ingestion of a bottle of antidepressants secondary to chronic paint. A nasogastric tube and a left subclavian venous catheter are placed. The nurse auscultates audible breath sounds on the right side, faint sounds procedure should the nurse prepare for first? A. Insertion of a left- sided chest tube. B. Placement of an endotracheal tube. C. Retraction of the nasogastric tube D. Setup of patient- controlled analgesia

Insertion of a left- sided chest tube.

723. A client is receiving continuous bladder irrigation via a triple-lumen suprapubic catheter that was placed during prostatectomy. Which report by the unlicensed assistive personnel (UAP) requires intervention by the nurse? a- Pale pink urine output b- Dark red clot in urine c- Leakage around catheter insertion site d- Urinary output greater than 90 ml/hour.

Leakage around catheter insertion site. Rationale: After genitourinary surgery, the client is at risk for blood clots and mucus fragments occluding the catheter. Leakage of urine around the suprapubic insertion site indicates blockage of the catheter that causes urine back-up resulting in bladder distention and overflow leakage around the catheter. Pink urine and clots are normal finding

701. A client is admitted for cellulitis surrounding an insect bite on the lower, right arm and intravenous (IV) antibiotic therapy is prescribed. Which action should the nurse implement before performing venipuncture? a- Lower the right arm below the level of the heart b- Elevate both arms on two pillows c- Lower the left arm below the level of the heart d- Apply a tourniquet above the right antecubital fossa

Lower the left arm below the level of the heart. Rationale: Since the client has an infection in the right lower arm, the IV should be started in the opposite arm, and the nurse should lower the left arm to dilate the vessels and facilitate cannulation of a vein. May be elevate the affected arm should help but not both arms.

752. A male client who had a small bowel resection acquired methicillin- resistant Staphylococcus aureus (MRSA) while hospitalized. He was treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention? a- Maintain contact transmission precaution b- Review white blood cell (WBC) count daily c- Instruct visitors to gown and wash hands d- Collect serial stool specimens for culture

Maintain contact transmission precautions. Rationale" The client may have residual postoperative MRSA infection, a resistant and highly contagious healthcare-associated infection (HAI), that requires strict contact precautions (A), as recommend by the Center for Disease Control (CDC).

777. An adult client comes to the clinic and reports his concern over a lump that "just popped up on my neck about a week ago." In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these finding suggest? A. Bacterial infection B. Lymphangitis C. Malignancy D. Viral infection

Malignancy.

737. After an elderly female client receives treatment for drug toxicity, the HCP prescribes a 24- hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3mg/dl. What action should the nurse implement? A. Initiate the urine collection as prescribed. B. Notify the HCP of the results. C. Evaluate the client's serum BUN level. D. Assess the client for signs of hypokalemia.

Notify the HCP of the results.

785. An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. Which action should the nurse take? A. Notify the healthcare provider of the client's refusal B. Administer an oral PRN medication for agitation C. Ask for staff assistance with administering the injection D. explain that oral medications will no longer be required

Notify the healthcare provider of the client's refusal.

713. A client with hyperthyroidism who has not been responsive to medications is admitted for evaluation. What action should the nurse implement? (Click on each chart tab for additional information. Please scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) a- Give acetaminophen 650 mg PO b- Obtain a STAT 12 lead electrocardiogram c- Encourage the client to rest d- Notify the healthcare provider

Notify the healthcare provider. a- Notify the healthcare provider Rationale: The client TSH assay reveals a decreased serum TSH and elevated free thyroxine (T4) and triiodothyronine (T3) which are indicative of a hyperthyroid state. An increase in 1 to 2 degree of temperature within a 2-hour period is indicative of a thyroid storm, which is a life-threatening medical emergency, so the health care provider should be notified immediately (D). The client temperature is not elevated enough to warrant using acetaminophen (A) as an antipyretic. Although an electrocardiogram may be needed, (B) ignores the important warning signs of a thyroid storm. C is not indicated at this time.

An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? a- Auscultate for renal bruits b- Obtain a clean catch mid-stream specimen c- Use a dipstick to measure for urinary ketone d- Begin to strain the client's urine.

Obtain a clean catch mid-stream specimen

788. A client who has a suspected brain tumor is schedules for a computed (CT) scan. When preparing the client for the client for the CT scan, which intervention should the nurse implement? A. Determine if the client has had a knee or hip replacement B. Immobilize the client's neck before moving onto stretcher C. Give an antiemetic to control nausea D. Obtain the client's food allergy history

Obtain the client's food allergy history.

763. Following an open reduction of the tibia, the nurse notes bleeding on the client's cast. Which action should the nurse implement? A. No action is required since postoperative bleeding can be expected B. Lower the client's head while assessing for symptoms of shock C. Call the health care provider and prepare to take the client back to the operating room D. Outline the area with ink and check it every 15 minutes to see if the area has increased

Outline the area with ink and check it every 15 minutes to see if the area has increased.

784. An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping, and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Ask the client to write feeling in a journal and then review it together C. Explain the purpose of each medication the client is currently taking D. Play a board game with the client and begin taking about stressors

Play a board game with the client and begin taking about stressors.

714. While taking vital signs, a critically ill male client grabs the nurse's hand and ask the nurse not to leave. What action is best for the nurse to take? a- Allow the client to hold the nurse's hand until the vital signs can be completed b- Reassure the client that the nurse will return after all vital signs are taken c- Tell the client that he must release the nurse's hand. d- Pull up a chair and sit beside the client's bed

Pull up a chair and sit beside the client's bed. Rationale: The critically ill client is most likely pleading for the presence of another person. D is the action that a compassionate nurse would implement. A, B, C do not demonstrate the compassion of D

709. To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement? a- Confirm that all the staff nurses are being assigned to equal number of clients. b- Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. c- Assign each staff nurse a turn unit charge nurse on a regular, rotating basis. d- Analyze the amount of overtime needed by the nursing staff to complete assignments.

Review the staff nurse job description to ensure that it is clear, accurate, and current. Rationale: Role ambiguity occurs when there is inadequate explanation of job descriptions and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. A and D may be implemented if the nurse manager is concerned about role overload, which is the inability to accomplish the tasks related to one's role. C is not related to ambiguity.

Which needle should the nurse use to administer intravenous fluids (IV) via a client's implanted port?

See Picture

For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? a- Loss of appetite b- Serum K 4.0 mEq/or mmol/dl (SI) c- Loose, runny stool d- Tented skin turgor.

Tented skin turgor Rationale: D indicate dehydration, a serious complication following prolonged diarrhea that requires further interventions by the nurse.

725. A male client with cancer who has lost 10 pounds during the last months tells the nurse that beef, chicken, and eggs, which used to be his favorite foods, now they taste "bitter". He complains that he simply has no appetite. What action should the nurse implement? a- Instruct the client to add ground beef and chicken in small amount to casseroles. b- Encourage the client to try to eat these foods in moderation despite the taste c- Advise the client to replace the bitter-tasting foods with fruits and vegetables. d- Suggest the use of alternative sources of protein such as dairy products and nuts.

Suggest the use of alternative sources of protein such as dairy products and nuts. Rationale: Beef, chicken, and eggs are good source of protein. To promote weight gain and adequate protein intake, the nurse should teach the client about another source of protein. Attempting to eat food that cause a bitter taste A and B is likely to increase the client's anorexia. C does not provide a sufficient source of protein.

706. A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnose osteoporosis. What instruction should the nurse include in the client's teaching plan? a- Consume a light snack with the medication b- Take on an empty stomach with a full glass of water c- Ingest an antacid 30 minutes of taking the medication. d- Eat within 30 minutes of taking the medication.

Take on an empty stomach with a full glass of water.

728. The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? a- Recommend weigh bearing physical activity b- Reduce intake of foods high in vitamin D c- Decrease intake of foods high in fat d- Minimize heavy lifting and bending.

a- Recommend weigh bearing physical activity Rationale: Active weight-bearing exercise is a primary preventive measure for osteoporosis. C is indicated for client with cardiac and liver diseases. D may decrease injuries but is not directed toward slowing bone loss and promoting bone formation.

715. The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN? a- Diabetic ketoacidosis whose Glasgow coma Scale score changed from 10 to 7 b- Myxedema coma whose blood pressure changed from 80/50 to 70/40 c- Viral meningitis whose temperature changed from 101 F to 102 F. d- Subdural hematoma whose blood pressure changed from 150/80 to 170/60.

Viral meningitis whose temperature changed from 101 F to 102 F. Rationale: The most stable patient should be assigned to the PN, changes in the Glasgow coma Scale indicated the client's neurological status is worsening. The client decreasing BP is physiologically unstable. An increasing systolic blood pressure and widening pulse pressure is indicative of increasing intracranial pressure.

747. A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? A. Tachycarcia B. Dyspnea C. Vomiting D. Muscle cramps

Vomiting.

707. The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm hg and as soon as the cuff is deflated a korotkoff sound is heard. Which intervention should the nurse implement next? a- Wait 1 minute and palpate the systolic pressure before auscultating again. b- Educate the client about risk factor that predispose one for hypertension c- Obtain a medication history to assess for drugs that affect blood pressure d- Provide a quiet environment and retake the blood pressure in 20 mints.

Wait 1 minute and palpate the systolic pressure before auscultating again. Rationale: To accurately assess blood pressure, the sphygmomanometer cuff should be inflated above the client's usual systolic reading, but a Korotkoff sound heard immediately upon deflating the cuff indicated that the cuff was insufficiently inflated. The systolic pressure should be palpated at the radial pulse, which provides a reference as to how high to inflate the cuff when auscultating the blood pressure. B, there is insufficient date to suggest that the client has hypertension. C A medication history can be obtained after an accurate blood pressure measurement is obtained