HESI Med Surg
A client is prescribed codeine USP 60 mg every 4 hours. The available medication is codeine USP 30 mg/tablet. How many tablets should the practical nurse administer? Fill in the blank.
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*** The practical nurse (PN) is taking vital signs on a client who has been treated for melanoma in the past. Which findings would cause the PN to consult the charge nurse?
A mole that is purple in color (An asymmetrical mole, answer I chose) The practical nurse needs to consult the charge nurse about the asymmetrical mole. Melanoma is a skin cancer that is first identified by obvious change in the appearance of skin moles, which is one of the American Cancer Society's caution signs. The American Cancer Society uses the A, B, C, D method. A—asymmetry (a mole that is irregular in shape or two different looking halves); B—border; irregular, blurred, rough, or notched edges; C—changes in color or irregularity in the color of the appearance of the mole; D—diameter; moles larger than ¼ inch or 6 mm larger than a pencil.
A client is admitted to the hospital for a Crohn's disease flare up and severe dehydration. Which findings should the practical nurse report to the registered nurse and/or health care provider immediately?
A rigid hard abdomen and elevated white blood cell count A hard, rigid abdomen and elevated white blood cell (WBC) count are indicative of peritonitis, which is a medical emergency and should be reported to the RN and health care provider immediately.
A client sustained a burn injury greater than 25% of total body surface with majority of it lower extremities during a house fire. During the acute phase of care, which intervention is most important for the practical nurse to implement?
Administer 0.5 mL of tetanus toxoid IM. Prevention of infection from Clostridium tetani by administering tetanus toxoid has the highest priority for care of a client in the acute phase of burn care.
The practical nurse (PN) is reviewing high-risk factors for type 2 diabetes with a client? Which of the following characteristics are risk factors for the development of diabetes? (Select all that apply.)
Age 40 years or older African American Obesity Hispanic Risk factors for developing type 2 diabetes include being 40 years or older, African American, Hispanic, and obese.
A client diagnosed with a skull hematoma and fractured (L) clavicle status post a six foot fall from a ladder is admitted to the unit. Which sign should the practical nurse (PN) report immediately?
Answers questions, but is confused. Confusion status post a head injury is usually the first sign of increased intracranial pressure.
A client status post-48 hours femoral rod placement surgery, suddenly complains of chest pain and becomes short of breath, pale, and diaphoretic. The practical nurse (PN) immediately assesses their vital signs and obtains 100/80 mm Hg blood pressure, 110 beats/min heart rate, and 36 breaths/min respiratory rate. What nursing action should the PN to do next?
Apply oxygen at 2 L per nasal cannula. The PN should immediately provide oxygen while performing further assessment. Pulmonary embolism and pneumothorax are risks associated with major surgery.
A client comes to the clinic and reports the presence of a painful lesion in the genital area; they described it as a blister 2 days earlier that is now crusty. Which intervention should the practical nurse (PN) implement first?
Ask the client if they have had unprotected sex. These are typical signs and symptoms of herpes simplex virus 2 (HSV2), a sexually transmitted disease (STD), so the PN should ask the client if they had unprotected sex and if the client has exposed others to the disease.
A client diagnosed with bacterial meningitis is admitted to the unit and is prescribed neuro checks every 2 hours. Which manifestation would the practical nurse monitor for that would provide the first indication of altered neurological function?
Change in level of consciousness A decrease or change in the level of consciousness is usually the first indication of neurological deterioration.
The practical nurse (PN) is assigned a client diagnosed with a hemothorax who had a chest tube inserted 36 hours ago; upon entering the room, the PN observes the client resting comfortably in the semi-Fowler position; respirations appear even and unlabored; the water in the water-seal chamber is bubbling; and there is serous drainage noted in the collection chamber. What is the best initial action for the PN to take?
Change the client to a high-Fowler position. The client should be placed in the high-Fowler position to facilitate the draining of the fluid from the hemothorax. Clients with pneumothorax may be placed in a semi-Fowler position.
Which foods should the practical nurse encourage a client to eat to increase their potassium intake? (Select all that apply.)
Green beans Milk Flounder Sweet potatoes Cantaloupe Flounder, sweet potatoes, milk, green beans, and cantaloupe are all potassium-rich foods.
The practical nurse has been assigned a client with a history of chronic obstructive pulmonary disease (COPD) who has been admitted to the hospital with a medical diagnosis of pneumonia. Which intervention poses the greatest risk of respiratory depression for a client with a history of COPD should the practical nurse determine is most significant in the development of this client's COPD?
Oxygen administration via nasal cannula 4 L/minute. Clients with COPD drive to breathe is a hypoxic state. Their body becomes use to the high CO2 levels and too much oxygen could cause the client to decrease their respiratory drive to breath. Oxygen administration in clients with COPD needs to be carefully monitored.
A client diagnosed with rheumatoid arthritis is prescribed splints for night time use. Which statement by the client demonstrates to the practical nurse (PN) an accurate understanding of the use of the splints?
Prevention of deformities Splints may be used at night by clients with rheumatoid arthritis to prevent deformities caused by muscle spasms and contractures.
A client diagnosed with congestive heart failure has developed increasing pedal edema and pulmonary edema. What dietary modification is most important for the practical nurse (PN) to reinforce with this client?
Restrict salt and fluid intake. Salt and fluid restrictions are the first dietary modifications for a client who is retaining fluid as manifested by edema and pulmonary edema.
A client is diagnosed with fluid volume deficit. Which findings would the practical nurse document consistent with fluid volume deficit? (Select all that apply.)
Tachycardia Cool skin Decreased urine output Increased thirst Fluid volume deficit causes tachycardia because the body tries to compensate and pump blood efficiently. Cool skin is consistent with fluid volume deficit. Decreased urine output results from reduced fluid volume perfusing the kidneys. Thirst will be stimulated by the hypothalamus because of decreased fluid volume.
A client diagnosed with ulcerative colitis (UC) asks the practical nurse why they are prescribed a low-residue diet. Which is the most appropriate response?
To reduce the amount and frequency of stool The purpose of a low-residue diet is to reduce the amount and frequency of stooling to promote healing of the bowels by consuming foods that do not irritate the intestinal lining and prolong intestinal transit time to encourage optimal absorption of nutrients.
In order to provide culturally competent care, what action must the practical nurse do first?
Understand one's own world views in addition to the client's. The nurse should understand their own values and views to prevent those beliefs being imparted to others, in addition to understanding the client's cultural views when providing cultural competent care. Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity.
An elderly client diagnosed with dementia was admitted from a long-term facility to the hospital two days ago. The client's children express concern that their parent's confusion has gotten worse since being admitted. How should the practical nurse (PN) respond?
"Confusion in an older person is expected with a relocation to new surroundings." Relocation often results in confusion among elderly clients and is stressful for clients of all ages.
A client status post closed-appendectomy is prescribed to begin ambulation the next day. The next day when the practical nurse (PN) goes to assist the client with ambulation, the client yells they are watching the television and they don't feel like getting out of bed. Which response should the PN provide?
"I'll be back in 30 minutes to help you get out of bed and walk around the room." Returning within 30 minutes provides a "cooling off" period, is firm, direct, and nonthreatening, and avoids arguing with the client.
The practical nurse (PN) is assigned a client with a medical history of diabetes and gangrene who had an (R) below the knee amputation. At the time of rewrapping and inspecting the stump, the client refuses to look at their stump. The practical nurse (PN) tells the client that the incision is healing well, but the client refuses to talk about it. What is the best response to this client's silence?
"It is okay if you don't want to talk about your surgery. I will be available when you are ready." Informing the client that it is okay they don't want to talk about their surgery and stating that the PN is available when they need them, displays sensitivity and understanding without judging the client.
What is the depth of the compression the practical nurse (PN) should do when performing the manual chest compressions during cardiopulmonary resuscitation (CPR) on an adult client?
2 inches (5 cm) to 2.4 inches (6 cm) According to the American Heart Association 2015 guidelines, the depth of compressions on an adult during CPR should be at least 2 inches (5 cm) to 2.4 inches (6 cm).
A client diagnosed with emphysema that is oxygen-dependent lives alone at home and manages self-care with no difficulty. Which finding should prompt the home health practical nurse to consult the registered nurse case manager?
A weight loss of five pounds since the last monthly home visit A weight loss of five pounds in 1 month is a concern. Clients with COPD need additional calorie intake because they are using up a lot from the energy they are using to breath. The practical nurse needs to consult with the registered nurse case manager for a Nutrition Consult.
A client scheduled for open heart surgery is prescribed a transfusion of 4 units of packed red blood cells (RBCs). Which intervention is the best method to prevent a blood transfusion reaction?
An autologous transfusion The best method for preventing transfusion reaction is an autologous transfusion (the client's own blood). A client's blood is generally collected 4 weeks before a scheduled surgery.
The practical nurse is reinforcing osteoporosis prevention education to a group of senior citizens. What life style choices will help decrease the risk of developing osteoporosis? (Select all that apply.)
Alcohol in moderation and smoking cessation. Regular weight-bearing exercises. Consumption of a diet rich in calcium and vitamin D. Alcohol in moderation and smoking cessation, regular weight-bearing exercises at least 30 minutes a day, and consumption of a diet rich in calcium and vitamin D are life style choices that decrease the risk for developing osteoporosis.
A client is diagnosed with the hepatitis B virus (HBV) infection. The practical nurse (PN) who has been vaccinated with the hepatitis B series is assigned the client. What precautions should the PN implement when providing caring for this client?
Appropriate PPE should be worn if the possibility of increased risk of bodily fluid exposure. Standard precautions should be implemented at all times regardless of a client's or health care personnel health status. Hepatitis B is spread from contact of bodily fluids, mask and gloves are not necessary if there is no increased risk of exposure to bodily fluids. Health care personnel who have not been vaccinated for hepatitis B can still provide care to the client; they need to ensure to follow standard precaution protocol.
The health care provider informed a client diagnosed with stage 4 liver cancer that the cancer has spread to their spine. The client states to the practical nurse, "I have a cancer, but it is not malignant." What is the best initial nursing action?
Ask the client to explain his understanding of the term malignancy. The best initial action is to assess the client's knowledge of the term malignancy when used to describe cancer. The client appears to have inaccurate knowledge. Stage 4 cancer means the cancer has spread (metastasized) from where it has started to another body part.
A client diagnosed with diabetic neuropathy has a nonhealing ulcer on the lateral aspect of their (R) foot. Which question should the practical nurse (PN) ask to gather objective data for the development of a diabetic foot care teaching plan?
Ask to look at the pair of shoes they wear. Asking to look at the client's shoes will give the most objective data. The PN needs to inspect the client's shoes' inside for any area such as a seam that may be rubbing against the client foot causing trauma to their feet. Well-fitted shoes are very important to prevent the development of foot ulcers for the diabetic client.
A client is status post-bowel resection and has a nasogastric tube (NGT) attached to low intermittent suction. The client complains to the practical nurse of abdominal distention and nausea. What action should the PN take first?
Assess the NGT drainage in the collection container. The immediate priority is to determine if the tube is functioning correctly, which the PN can do first by assessing the amount and characteristic of the drainage from the nasogastric tube. Based on the findings of the drainage will determine the PN next nursing intervention.
A client diagnosed with chronic obstructive pulmonary disease complains to the practical nurse of extreme fatigue after coughing. Which self-care measures can help minimize the client's dyspnea? (Select all that apply.)
Assume a sitting position with shoulders relaxed and knees flexed. Support forearms with a pillow and place both feet flat on the floor. Slightly drop the head, bend forward, and slowly exhale with pursed lips. Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply. Effective coughing can help the client to cough secretions, therefore improving gas exchange and minimize fatigue. The client should assume the sitting position with shoulders relaxed and knees flexed. Their forearms should be supported with a pillow and both feet place flat on the floor. The client should slightly drop their head, bent forward, and slowly exhale through pursed lips using slow and deep diaphragmatic breathing to help facilitate effective coughing. The client should repeat the previous steps two or three times. The client should initiate the cough reflex, not wait for it. The client should also take a deep abdominal breath before initiating a cough.
A 70-year-old client status post-hip replacement is transferred to a rehabilitation facility. Which scale should the practical nurse (PN) identify as the best tool to predict the client's risk for developing skin breakdown?
Braden Scale The Braden Scale is made up of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A hospitalized adult with a score 16 or below or an older adult with a score of 18 or below is at an increased risk for skin breakdown.
A client diagnosed with Guillain-Barré syndrome is hospitalized. Which finding is most important for the practical nurse to report to the primary health care provider?
Decrease in cognitive status of the client. A decline in cognitive status in a client is indicative of symptoms of hypoxia that are the result of the respiratory muscles being affected and an indication that the client may require the assistance of mechanical ventilation.
A client diagnosed with viral influenza is prescribed vitamin C 1000 mg PO daily and acetaminophen 650 mg PO every 4 hours PRN. The client complains to the practical nurse of abdominal cramping and increasing episodes of diarrhea. Which prescription change should the nurse anticipate?
Decrease the dose of vitamin C. Diarrhea is an adverse effect of high doses of vitamin C, so the nurse should anticipate a reduction in the dose of vitamin C.
An elderly client with a history of cardiac disease is admitted to the hospital. Since admission, the client has been confused and complaining about muscle cramps and has vomited twice. The client's vital signs are BP 130/70, P-47, and R-18. Which medication in the client's history should the practical nurse (PN) be most concerned?
Digitalis Elderly clients are particularly susceptible to the accumulation and toxicity of cardiac glycosides, such as digoxin or digitoxin (digitalis derivatives). Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, muscle cramps, and fatigue.
A client is diagnosed with acute myocardial infarction (MI). Which diagnostic laboratory value should the practical nurse (PN) anticipate to be the first to elevate to establish a diagnosis of an acute myocardial infarction (MI)?
Elevated troponin Tissue damage in the myocardium causes the release of cardiac enzymes into the blood system. According the American College of Cardiology (ACS) and the European Society of cardiology (ESC), an elevation of the troponin will occur within 2 to 3 hours of an MI and is use to establish the diagnosis. It takes the CK-MB level 6 to 9 hours or longer to elevate.
The home health practical nurse is visiting with a client who has a history of second degree heart block and pacemaker placement six months ago. Which symptom compliant by the client would be indicative of pacemaker failure?
Feelings of dizziness Feelings of dizziness may occur as the result of a decreased heart rate, leading to decreased cardiac output as a result of pacemaker failure.
A client is status post-48 hours a colon resection. Which finding requires the most immediate intervention by the practical nurse (PN)?
Fever of 102° F (38.9° C) and chills A sudden increase in temperature is an indicator of peritonitis and chills, along with abdominal pain and tenderness. The PN should immediately notify the charge nurse, who should notify the health care provider.
A client diagnosed with prostate cancer is prescribed radioactive seed implantation (brachytherapy). What is the most important nursing action for the practical nurse (PN) to do?
Follow radiation exposure precautions. Clients being treated for prostate cancer with brachytherapy (radioactive seeds implant) should be placed on radiation exposure precautions. The PN needs to follow the institution's protocols put in place regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others.
A client diagnosed with diabetes mellitus complains of vomiting and feeling confused to the practical nurse. Which of the following symptoms are possible signs of diabetic ketoacidosis (DKA)? (Select all that apply.)
Fruity breath odor Rapid, weak pulse Extreme thirst Urinary frequency Diabetic ketoacidosis is caused by a profound deficiency of insulin. Some common characteristics include a sweet, fruity breath odor; a rapid weak pulse; extreme thirst; urinary frequency; and sunken-appearing eyeballs.
A client status post-cholecystectomy three days is being prepared to be discharged home. Which client finding is the best indication to the practical nurse that postoperative nursing interventions have prevented respiratory complications?
Has a 95% pulse oximeter value on room air Pulse oximetry of 95% on room air, indicates adequate oxygenation.
A client diagnosed with a brain tumor is receiving radiation beam treatments to the right frontal area. The practical nurse (PN) should observe this client for which problem during the early post-therapy days?
Headache Radiotherapy is a local treatment, and most side effects are site-specific, such as inflammation of surrounding brain tissue, swelling, headache, and fatigue.
A client diagnosed with a seizure disorder is prescribed phenobarbital. While attempting to administer the medication to the client, the practical nurse has difficulty trying to arouse the sleepy client. What nursing action should the practical nurse implement?
Hold the medication and notify the health care provider. The client is exhibiting signs of antiepileptic drug (AED) toxicity, and a serum phenobarbital level needs to be obtained to determine if the client is experiencing drug toxicity.
The practical nurse (PN) is reinforcing colostomy care teaching to a client who is three days following placement of their colostomy. The client asked the PN why is it necessary to measure the colostomy's stoma each time when changing into a new appliance/wafer. What is the best response by the PN?
Inform the client that the stoma will become smaller when the initial swelling diminishes. Post-operative swelling causes enlargement of the stoma. The PN needs to reinforce to the client that the stoma will become smaller when the swelling is diminished. This is necessary in order to prevent irritation to the surrounding skin from the colostomy's drainage (effluent). The purpose of the colostomy appliance is to provide a protective barrier surrounding the stomal skin, along with containing effluent from the colostomy.
A client diagnosed with osteoarthritis. Which intervention should the practical nurse implement to help relieve joint pain and stiffness?
Instruct the client to take an analgesic before walking daily. Adequate pain management is important for the success of an exercise program. Keeping the joints active decreases pain, so taking an analgesic and walking daily is likely to help decrease joint pain and stiffness.
A client diagnosed with diabetes complains to the practical nurse of decreased tactile sensation in their feet and feelings like their feet are on fire sometimes. Which abnormal laboratory finding should the practical nurse (PN) identify that indicates that a client with diabetes needs further evaluation for diabetic nephropathy?
Microalbuminuria Microalbuminuria is the earliest sign of diabetic nephropathy and indicates the need for follow-up evaluation.
A client has a serum potassium level of 3 mEq/L. Which findings should the practical nurse report to the charge nurse? (Select all that apply.)
Muscle cramps Abnormal heart rhythms A normal potassium level ranges from 3.5 to 5 mEq/L (mmol/L). Signs and symptoms of low potassium include muscle cramps and dysrhythmias.
A client diagnosed with duodenal ulcers is admitted to the hospital. The client was administered ranitidine hydrochloride 150 mg PO at bedtime. Which finding would indicate a therapeutic response of the medication?
No complaints of abdominal pain or heartburn verbalized. Lack of abdominal pain within 4 hours after meals indicates decreased duodenal irritation, a positive outcome in the treatment of duodenal ulcer.
The practical nurse receives shift report on their assigned clients. Based on the change of shift report which situation has the highest priority?
No output in a hemovac from the abdominal incision of a client who is post-op day 1. The PN should first evaluate the client who has no hemovac output from the abdominal surgical site to determine if the hemovac needs to be compressed, drainage tube kinked, or if the drain is displaced from the wound.
A client diagnosed with epilepsy is admitted to the unit. What intervention should the practical nurse (PN) implement if the client experiences a seizure?
Observe the length and activity of the seizure The PN should observe the client as they have their seizure. The length of time and movement by the client needs to be observed and then documented once the client is stable. The client should be placed on their side to help prevent aspiration.
A client residing in a memory care nursing facility with a diagnosis of diabetes approaches the nurse crying, saying "I just don't feel good." What action should the practical nurse take first?
Obtain a fingerstick blood glucose test. An early sign of hypoglycemia is increase confusion and/or irritability, sometimes described as "feeling bad." Based on the history of diabetes, the PN should first obtain objective data of a fingerstick blood glucose level to provide information to guide further nursing actions.
A client diagnosed with diabetes has a prescription of 5 units of regular insulin and 15 units of NPH insulin. In which order should the practical nurse prepare to administer the insulin? List in order the nursing actions to be performed.
Perform hand hygiene according to facility policy. Inspect insulin vials for type and expiration dates. Inject 15 units of air into NPH insulin vial. Inject 5 units of air into regular insulin vial. Withdraw 5 units of regular insulin from vial. Withdraw 15 units of NPH insulin from vial. The first nursing action is to perform hand hygiene. The next action is to inspect vials for type and expiration dates and then add 15 units of air to NPH insulin vial. Next add 5 units of air into regular insulin vial, then withdraw 5 units of regular insulin from vial, and withdraw 15 units of NPH insulin from vial. Note that it is important to fill the syringe with regular insulin (shorter acting insulin) first to prevent contamination of the NPH insulin (intermediate-acting insulin).
A client demonstrated pupillary constriction when a pen light was shine in their eyes. Which nursing action should the practical nurse perform?
Record the finding on the assessment notes. Pupillary constriction to light is a normal finding and should be documented in the assessment notes.
During a clinic visit, a client reports to the practical nurse (PN) that they felt a solid mass in their breast during self-examination, but it was not painful. What instruction should the PN reinforce with the client?
Schedule an appointment with the health care provider for evaluation. A painless breast mass is an abnormal finding, and the PN should instruct the client to obtain prompt medical evaluation.
A client with severe Parkinson disease diagnosed with anorexia, dysphagia, drooling, generalized weakness, and slurred speech is admitted to the unit. Which nursing action should the practical nurse implement first for this client?
Set up a suction and Yankauer at client's bedside. Dysphagia and drooling predispose this client to aspiration. A suction machine and Yankauer should be set up and near the client to be use to help prevent aspiration pneumonia. Aspiration is the primary concern in this situation.
The practical nurse is preparing a room for a client being admitted from the Emergency Department with a diagnosis of new onset of seizures. Which intervention should the nurse implement first?
Set-up and check for functioning of a suction apparatus and oxygen delivery system at bedside Maintaining the airway during a seizure is a priority for safety. The practical nurse needs to ensure there is a functioning suction apparatus to ensure airway clearance and an oxygen delivery system at bedside in the event of a seizure.
A client diagnosed with hypertension is prescribed a low-sodium diet. Which food choices selected from the hospital's menu demonstrates to the PN that the client understands their dietary restrictions?
Skim milk, turkey salad, roll, vanilla ice cream The client's selection of skim milk, turkey salad, roll, and vanilla ice cream, although containing some sodium, are considered low-sodium foods.
A client diagnosed with ovarian cancer has just been informed that their cancer has metastasized to their liver. The client is quietly crying in their room. Which statement is appropriate for the practical nurse to say?
Tell me about what you are feeling right now. The most appropriate response and therapeutic action is for the nurse to be an active listener and to encourage the client to explore their feelings.
A client diagnosed with lymphoma is receiving chemotherapy. The client's hemoglobin is currently 6 g/dL. The practical nurse (PN) assigns an unlicensed assistive personnel (UAP) to provide personal hygiene for this client. What instruction should the PN provide to the UAP?
The client will be weak and unsteady and tire easily. A hemoglobin of 6 g/dL indicates anemia (normal for a female is 12 to 16 g/dL, for a male is 14 to 18 g/dL), which is a common adverse effect of chemotherapy. The UAP should be given instructions about how this will cause weakness and unsteadiness in the client and they will tire easily.
A plan of care for a 56-year-old client who has been diagnosed with osteopenia has been developed. The plan is focused on preventing further bone resorption and increasing bone mass. Which outcome statement should be included in the plan of care?
The client will decrease the number of cigarettes smoked by 50% within 2 weeks. A desired outcome statement should be client-centered with a measurable outcome, and the client decreasing the number of cigarettes smoked by 50% within 2 weeks is both client-centered and measurable. Cigarette smoking has a negative effect on bone resorption, so the client should be advised to stop smoking.
The practical nurse (PN) is reviewing the health histories of the following individuals. Which factor does have a potential for development of throat cancer?
Tobacco use The most common risk factors for throat cancer are tobacco use, alcohol abuse, human papillomavirus (HPV), a diet lacking in fruits and vegetable and gastroesophageal reflux disease (GERD). Foods seasoned with herbs and spices have shown to have some health benefits in decreasing the risk of developing cancer.
Which educational materials should the practical nurse select for reinforcement of teaching for secondary prevention? (Select all that apply.)
Video that teaches client to do breast self-examinations Pamphlets describing how to do testicular self-examinations Postcard reminders for clients to get papanicolaou (Pap) smears and mammograms Secondary prevention deals with early diagnosis to treat disease in the beginning of its development. Breast self-examinations, testicular self-examinations, mammograms, and Pap smears are considered secondary prevention methods.
A client diagnosed with status asthmatic is admitted to the unit. Which breath sounds would the practical nurse anticipate to hear when auscultating the client's lungs?
Wheezes Wheezes are continuous, high-pitched musical or squeaking-type sounds. They are reflective of the narrowing of the airways as a result of the inflammation from the asthma. Wheezes are generally heard with expiration, but can be heard with inspiration in severe cases of asthma.
A client asks the practical nurse what type of food is the best to eat reduce their chances of getting colon cancer. Which type of food should the PN suggest to the client?
Whole grains According to the American Cancer Society, "studies suggest that fiber in the diet, especially from whole grains, may lower colorectal cancer risk."
A hospitalized client is receiving continuous nasogastric tube feedings at 90 mL/hour via a small-bore tube and an enteral infusion pump. Upon entering the client's room, which action should the practical nurse (PN) take first?
Ensure the client's head of bed is raised at least 30°. The 30° is the minimum degree elevation of the head of the bed for a client receiving continuous tube feedings to prevent aspiration.
A practical nurse (PN) reinforced client teaching regarding the transmission of the HIV virus. Which statement by the client demonstrates an understanding of the reinforced teaching?
"I may still contract HIV even though I am 62 years old." More than 10% of all AIDS cases in the United States are among those older than 50 years of age.
The practical nurse (PN) is interviewing a male client diagnosed with hypertension. Which finding places the client at the greatest risk for development of a cerebral vascular accident (CVA)?
A waistline greater than 40 inches (101.6 cm) Males with waist sizes larger than 40 inches (101.6 cm) and females with waist sizes larger than 35 inches (88.9 cm) are at greater risk of cardiac disease increasing the risk of CVA. The more abdominal fat an individual has the more the risk goes up.
A client status post-AV (arteriovenous) fistula placement in the right forearm is transferred from the PACU to the unit. Which nursing measure is essential in promoting safe, effective care for the client?
Avoid BPs or needle sticks in right arm. To prevent damage to the fistula from trauma or injury so that it can mature and be used as a future access site for hemodialysis, all blood pressures, blood draws, and IVs should be avoided to the affected (right) arm.
A client diagnosed with a fracture of the (L) radius has a plaster cast applied. Which instruction should the practical nurse give the client to dry the cast over the next 24 hours?
Do not cover and keep the cast surfaces exposed to circulating air. The nurse should instruct the client to keep the cast exposed to circulating air and avoid covering it with material that might keep it moist.
A client is admitted from the Emergency Department with a diagnosis of (L) tibia fracture and the (L) leg has a splint in place. The client was medicated approximately 2 hours ago with a prescribed analgesic. The client is now complaining of excruciating leg pain and demanding "stronger pain medications." What initial action is most important for the practical nurse (PN) to take?
Measure the pulse volume and capillary refill distal to the fracture. The PN needs to measure the pulse volume and capillary refill distal to the fracture. Pain and diminished pulse volume are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast) or internal pressure after an injury resulting in inflammation and edema building up in the fascia space of the muscle which results in the pressure in this space building up and stopping the flow of blood to the tissues in the compartment. This is a medical emergency requiring a fasciotomy to relieve the pressure.
A client with a vaginal discharge and pruritus is diagnosed a yeast infection (Candidiasis) and is prescribed a 7-day course of an intravaginal tioconazole. What information should the practical nurse provide to the client about using this form of medication?
Remain recumbent for 5 to 15 minutes after insertion of the medication. The client should remain recumbent for 5 to 15 minutes after inserting the medication to facilitate absorption and to prevent loss of medication from the vagina.
Which interventions should the practical nurse implement to decrease the possibility of the client developing hypercalcemia? (Select all that apply.)
Remind the client to ambulate around the room at least three times daily. Increase fluid intake. Hypercalcemia can result from immobility. Ambulation of the client helps to prevent calcium from leaking out of bones into the serum. Increasing fluid volume PO or IV helps to decrease calcium levels in the blood.
An adult client is admitted to the Emergency Department with partial-thickness and full-thickness burns over 40% of the body surface area resulting from a car collision fire. While the health care provider and nurse are preparing to intubate the client, which intervention should the practical nurse (PN) do first?
Remove all the client's clothing, shoes, and jewelry. Interventions for moderate to severe burns of deep partial-thickness and full-thickness, once an airway and circulation is established, then the next thing is to remove all the victims clothing, shoes, and jewelry before the edema sets in and they become constricting, also it is possible to cause more severe burns by leaving clothing on.
Which of the following actions demonstrate to the practical nurse that the client understands the correct procedure administration of a metered dose inhaler (MDI)? (Select all that apply.)
Shake the inhaler. Attach the canister of medication to the mouthpiece. Use a spacer attachment and place the mouthpiece in the mouth. Close the lips around the mouthpiece. After inhaling the medication, hold the breath 10 seconds. The correct sequence of MDI administration includes shaking the inhaler, attaching the canister to the mouthpiece, attaching the spacer, the client should then let their breath out through the mouth to empty the lungs and place the mouthpiece in the mouth, closing the lips and mouth around the mouthpiece, and inhaling medication and holding the breath for 10 seconds.
The practical nurse (PN) is providing care to a client who is experiencing slight scrotal edema following indirect herniorrhaphy. Which postoperative action is not recommended for this client?
Encourage deep breathing and coughing. A client should be discouraged from coughing following a hernia repair. The coughing will create too much intra-abdominal pressure putting increase pressure on the abdominal wall and could cause a dehiscence and/or evisceration of the surgical site. All other interventions are recommended for postop care of a hernia.
The practical nurse (PN) received report on their assignment of clients. In which order should the PN assess these clients?
The client with aphasia and right hemiplegia who is scheduled for gastrostomy tube (GT) placement today. The client who has chronic renal disease is scheduled for hemodialysis today and three times weekly. The client who has had GI bleeding but had a negative guaiac test for the last three stools. The client who is recovering from a left total knee replacement and who ambulates with a walker. The client with aphasia should be seen first because this client has safety risks related to limited mobility and communication and requires assessment before the GT is placed. The client with chronic renal disease should be seen next to evaluate the impact of fluid balance and potassium on cardiac function between dialysis treatments. The client with GI bleeding is stable and should be seen third to evaluate resolution of bleeding. The ambulatory client is progressing toward independence and is the least likely to need immediate attention.
The Centers for Disease Control and Prevention (CDC) has issued guidelines for health care workers in relation to protection from HIV. The practical nurse (PN) who suspects they may be pregnant is assigned a client who is HIV+. What action should the PN implement?
Wear gloves when coming in contact with the blood or body fluids of a client. The CDC guidelines for standard precautions recommend that health care workers use gloves when coming in contact with blood or body fluids from any client because HIV is infectious before the client becomes aware of symptoms. Pregnancy of a nurse should not inhibit the nurse for taking care of a HIV+ client as long as standard precautions are observed.