HESI module 10
The nurse is conducting the initial assessment of a child with rheumatic fever. Which question does the nurse ask the parents to elicit information specific to the development of the disease? "Has he had any loss of appetite?" "Has he complained of a backache recently?" "Has he been excessively tired or lethargic?" "Has he had a sore throat in the last few months?"
"Has he had a sore throat in the last few months?"
A client has just had a plaster leg cast applied, and the nurse has given the client instructions on cast care. Which statement by the client indicates the need for further instruction? "I may feel cool while the cast is drying." "I shouldn't use anything to scratch underneath the cast." "If I smell any odor from the cast, I should call the doctor." "I can dry the cast faster if I use a hairdryer on the hot setting."
"I can dry the cast faster if I use a hairdryer on the hot setting."
The nurse has instructed a client who is about to begin external radiation therapy in how to maintain optimal skin integrity during therapy. Which statement by the client indicates a need for further instruction? "I need to keep the sun off the radiation site." "I can use over-the-counter cortisone cream on the radiation site if it gets red." "I need to be careful not to wash off the marks that the radiologist made on my skin." "I need to wash the skin at the radiation site with a mild soap and water and pat it dry."
"I can use over-the-counter cortisone cream on the radiation site if it gets red."
The nurse provides instructions to a client about measures to prevent an acute attack of gout. What client statement does the nurse determine indicates that the client needs additional instructions? "It's important for me to drink a lot of fluids." "A fad diet or starvation diet can cause an acute attack." "I don't need medication unless I'm having a severe attack." "Physical and emotional stress can cause an attack."
"I don't need medication unless I'm having a severe attack."
The nurse provides instructions to a client with rheumatoid arthritis about joint exercises that are important to prevent deformity and reduce pain. Which statement by the client indicates the need for further instruction? "I should always maintain good posture." "I should stop my exercises if I get tired." "I should avoid all exercise when my joints are inflamed." "Doing range-of-motion exercises every day will ease the pain."
"I should avoid all exercise when my joints are inflamed."
The nurse provides instructions to a client with chronic obstructive pulmonary disease (COPD) about the positions that are most effective in alleviating dyspnea. Which statement by the client indicates a need for further instruction? "I should sit up in my recliner." "I should lie on my right side in bed." "I should sit on the side of my bed and lean on the overbed table." "I should stand with my back and hips against the wall and my shoulders bent slightly forward."
"I should lie on my right side in bed."
The home care nurse has provided instructions to the father of a child with croup regarding treatment measures. Which statement by the father indicates a need for further instruction? "I should put a steam vaporizer in her room." "I'll take her out into the cool, humid night air." "I can open the freezer door and encourage her to breathe in the cool air." "I can run the hot water in my bathroom and cuddle her in the steamy room."
"I should put a steam vaporizer in her room."
The nurse teaches a client with gastroesophageal reflux disease (GERD) about measures to prevent reflux during sleep. The nurse determines that the client needs additional instructions if the client makes what comment? "I should take an antacid at bedtime." "I should sleep flat on my right side." "The histamine antagonist will help me." "I should avoid eating in the 3 hours before bedtime."
"I should sleep flat on my right side."
The home care nurse is providing instructions to the mother of a 3-year-old with hemophilia regarding care of the child. Which statements by the mother indicate a need for further instructions? Select all that apply. "I will be so glad when my baby outgrows all of this bleeding." "I need to cancel all of the dental appointments that I've made for him." "If he gets a cut, I should hold pressure on it until the bleeding stops." "I should check the house for any household items that could fall over easily." "I should move furniture with sharp corners out of the way and pad the corners of the furniture."
"I will be so glad when my baby outgrows all of this bleeding." "I need to cancel all of the dental appointments that I've made for him."
The nurse provides home care instructions to a client with a below-the-knee amputation (BKA) about residual limb and prosthesis care. Which statement by the client indicates a need for further instruction? "I should wear a sock over my stump." "I can wash my leg with a mild soap." "I need to check my leg for irritation every day." "I'll put lotion on my leg a few times a day."
"I'll put lotion on my leg a few times a day."
A female client who has undergone placement of a sealed radiation implant asks the nurse whether she can take a walk around the nursing unit. How should the nurse respond to the client's request? "Short walks are OK." "You need to stay in your room for now." "Yes, it's fine to take a walk around the nursing unit." "Do you think that a walk around the unit will tire you out?"
"You need to stay in your room for now."
The pediatric nurse finds a hospitalized child unresponsive. A quick assessment reveals that the child is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR). How many chest compressions per minute does the nurse deliver? 15 30 50 100
100
The nurse arrives at the scene of a code and begins to assist with cardiopulmonary resuscitation (CPR) of an adult. The nurse delivers compressions by pushing down on the chest by what depth? ½ inches (1.27 cm) 1½ inches (3.8 cm) 2 inches (5 cm) 4 inches (10 cm)
2
The nurse notes that a client has ST-segment depression on the electrocardiogram (ECG) monitor. With which serum potassium reading does the nurse associate this finding? 3.1 mEq/L (3.1 mmol/L) 4.2 mEq/L (4.2 mmol/L) 4.5 mEq/L (4.5 mmol/L) 5.4 mEq/L (5.4 mmol/L)
3.1
The nurse is administering cardiopulmonary resuscitation (CPR) to an adult client. Which compression-ventilation ratio is correct? 15:1 15:2 20:2 30:2
30:2
The nurse is working in the emergency department. Which client should be assessed first? A client with new-onset dizziness A client admitted with a recent ear injury A client who has been experiencing nausea and vomiting for 12 hours A client with new-onset atrial fibrillation with a rate of 118 beats/min
A client with new-onset atrial fibrillation with a rate of 118 beats/min
The nurse is assigned to care for four clients on the medical-surgical unit. Which client should the nurse see first on the shift assessment? A client admitted with pneumonia with a fever of 100° F (37.8°C) and some diaphoresis A client with congestive heart failure with clear lung sounds on the previous shift A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema (PE) A client undergoing long-term corticosteroid therapy with mild bruising on the anterior surfaces of the arms
A client with new-onset of shortness of breath (SOB) and a history of pulmonary edema (PE)
The nurse is caring for a client with Crohn's disease whose magnesium level is 1.0 mEq/L (0.5 mmol/L). Which assessment findings does the nurse expect to note? Select all that apply. Hypotension Abdominal distention Trousseau sign Skeletal muscle weakness Decreased deep tendon reflexes
Abdominal distention Trousseau sign
The nurse notes that a client's serum potassium level is 5.8 mEq/L(5.8 mmol/L). What does the nurse interpret this expected finding to be related to? Diarrhea Wound drainage Addison disease Heart failure being treated with loop diuretics
Addison disease
The emergency department (ED) nurse receives a telephone call from emergency medical services and is told that a client who has sustained severe burns of the face and upper arms is being transported to the ED. Which action does the nurse, preparing for the arrival of the client, plan to implement first? Inserting a Foley catheter Initiating an intravenous (IV) line Cleansing the burn wound Administering 100% humidified oxygen
Administering 100% humidified oxygen
A client arrives at the emergency department with reports of a headache, hives, itching, and difficulty swallowing. The client states that he/she took ibuprofen 1 hour earlier and believes that he/she is experiencing an allergic reaction to this medication. After ensuring that the client has a patent airway, which intervention does the nurse prepare the client for first? Administration of normal saline solution Administration of an intravenous (IV) glucocorticoid Administration of pain medication to relieve the client's headache Administration of a subcutaneous injection of epinephrine
Administration of a subcutaneous injection of epinephrine
A client who is recovering from a brain attack (stroke) has residual dysphagia. Which measure does the nurse plan to implement at mealtimes? Giving the client thin liquids Alternating liquids with solids Giving foods that are primarily liquid Placing food in the affected side of the client's mouth
Alternating liquids with solids
The nurse is reviewing medical records to assigned clients on the 7 am to 7 pm shift. Which client will the nurse monitor most closely for excessive fluid volume? A 48-year-old client receiving diuretics to treat hypertension A 35-year old client who is vomiting undigested food after eating An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr A 65-year-old client with a nasogastric tube attached to low suction following partial gastrectomy
An 85-year-old client receiving intravenous (IV) therapy at a rate of 100 mL/hr
A client in the third trimester of pregnancy is experiencing painless vaginal bleeding, and placenta previa is suspected. For which intervention does the nurse prepare the client? An ultrasound examination Internal fetal monitoring Administration of oxytocin A manual (digital) pelvic examination
An ultrasound examination
The nurse attending a recertification course in basic life support (BLS) for health care professionals is practicing BLS on an infant mannequin. Where does the nurse place the fingers to assess the infant's pulse? Neck Wrist Behind the knee Antecubital fossa of the arm
Antecubital fossa of the arm
The nurse receives a telephone call from a neighbor, who says that her child was just hit in the eye with a swing. The nurse rushes to the neighbor's house and notes that the child has sustained a contusion of the eye. What does the nurse advise the child's mother to immediately do? Call an ambulance Call an optometrist Apply ice to the affected eye Irrigate the eye with cool water
Apply ice to the affected eye
A client who sustained a fracture of the left arm requires the application of a plaster cast. What does the nurse tell the client that the procedure for applying the cast involves? Administering a local anesthetic to the fractured arm Soaking the left arm in a warm-water bath for 2 hours before cast application Debriding any open wounds and applying antibiotic ointment before the cast material is applied Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material
Applying soft padding and stockinette over the fractured arm, followed by the application of the cast material
A cardiac monitor alarm sounds, and a nurse notes a straight line on the monitor screen. What does the nurse immediately do? Call a code Assess the client Check the cardiac leads and wires Obtain a rhythm strip from the monitor device
Assess the client
A client arrives in the emergency department for treatment of a surface injury sustained when sand blew into the eye. Which action does the nurse take first? Assessing the client's vision Placing ice on the eye Removing the sand particles Irrigating the eye with sterile saline solution
Assessing the client's vision
A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives to the unit, what should the nurse do first? Weigh the child Take the child's temperature Attach the child to a pulse oximeter Administer the prescribed antibiotic
Attach the child to a pulse oximeter
A stapedectomy is performed on a client with otosclerosis. During the preparations for discharge, which home care instruction does the nurse give the client? Expect excessive ear drainage for about 2 weeks. Avoid rapidly moving the head and bending over for at least 3 weeks. Rinse the ear canal at least twice a day to clear out any excess drainage. It is all right to shower as long as the ear dressing is changed immediately after the shower.
Avoid rapidly moving the head and bending over for at least 3 weeks.
The nurse enters a client's room and finds the client unconscious. The nurse quickly performs an assessment and determines that the client is not breathing. Which action does the nurse take first? Beginning chest compressions Checking the client's pulse oximetry reading Placing an oxygen mask on the client Counting the client's carotid pulse for 15 seconds
Beginning chest compressions
The alarm on a client's cardiac monitor goes off, and the nurse rushes to the client's bedside and finds the client unconscious. After noting the following rhythm on the monitor, what does the nurse immediately do? Checks for a radial pulse Assesses the client's neurological status Increases the flow rate of the client's intravenous infusion Begins cardiopulmonary resuscitation (CPR)
Begins cardiopulmonary resuscitation (CPR)
A hospitalized client with chronic renal failure has returned to the nursing unit after a hemodialysis treatment. Which parameters contained in the predialysis and postdialysis documentation does the nurse utilize to determine if the procedure was effective? Weight and BUN Blood pressure and weight Potassium and creatinine levels Blood urea nitrogen (BUN) and creatinine levels
Blood pressure and weight
The nurse is obtaining subjective data from the mother of a child admitted to the hospital with a diagnosis of intussusception. Which occurrence does the nurse expect the mother to report? Scleral jaundice Projectile vomiting Hard, pale stools Bloody mucus stools and diarrhea
Bloody mucus stools and diarrhea
The nurse provides instructions to the mother of a newborn with hyperbilirubinemia who is being breastfed. The nurse determines that the mother understands the instructions if the mother says that she will do what? Bottle feed only Breastfeed the newborn every 2 to 3 hours Provide water feedings between breast feedings Feed her newborn less frequently until the bilirubin level drops
Breastfeed the newborn every 2 to 3 hours
The nurse is preparing a teaching plan for the parents of an infant with a ventricular peritoneal shunt. Which instruction does the nurse plan to include? Call the primary health care provider if the infant is lethargic. Expect increased urine output with the shunt. Call the primary health care provider if the anterior fontanel bulges when the infant cries. Position the infant on the side of the shunt for sleep.
Call the primary health care provider if the infant is lethargic.
A client with a spinal cord injury suddenly complains of a pounding headache. The nurse quickly assesses the client and notes that the client is diaphoretic, that his blood pressure has increased, and that his heart rate has slowed. Suspecting that the client is experiencing autonomic dysreflexia, the nurse elevates the head of the client's bed and immediately does what? Document the event Notify the primary health care provider Check the client's bladder for distention Check to see whether the client has a prescription for an antihypertensive
Check the client's bladder for distention
The nurse is caring for a hospitalized client who is undergoing peritoneal dialysis. The nurse notes that the outflow is less than the inflow on the first exchange. What should the nurse do first? Irrigate the catheter Reposition the client Check the system for kinks Hang the second exchange and continue to monitor the outflow
Check the system for kinks
Buck extension traction is applied to the right leg of a client who sustained a right hip fracture. Which intervention should the nurse include in the plan of care? Assessing the pin sites at least every 8 hours Removing the traction weights to provide skin care Applying lanolin to the skin of the right leg once per shift Checking the skin integrity of the right leg at least every 8 hours
Checking the skin integrity of the right leg at least every 8 hours
The home care nurse visits a pregnant client with a diagnosis of mild preeclampsia. During the assessment, the client tells the nurse that she has had an upset stomach and pain in the epigastric area. What should the nurse most appropriately do? Contact the primary client's health care provider Tell the client to avoid lying flat Instruct the client to eat a small portion of food every 2 to 3 hours Administers an antacid to the client and tell her to take a dose every 6 hours
Contact the primary client's health care provider
The nurse is monitoring a client who has just undergone radical neck dissection. The nurse notes that the client's blood pressure has dropped from 132/84 to 90/50 mm Hg and that the pulse has increased from 78 to 96 beats/min. On the basis of these findings, what should the nurse immediately do? Suction the client Obtain a pulse oximeter Contact the primary health care provider Increase the rate of the client's intravenous (IV) solution
Contact the primary health care provider
The nurse is monitoring a client after transurethral resection (TUR) of the prostate for benign prostatic hypertrophy (BPH). The client has a bladder irrigation infusing, and the urine output is a light cherry color. The nurse performs a follow-up assessment 1 hour later and notes that the urine output is now bright red in color with clots and that the client's blood pressure has dropped. Which action by the nurse is appropriate? Contacting the primary health care provider Continuing to monitor the client Increasing the flow rate of the intravenous (IV) solution Placing pressure on the bladder to aid expulsion of any additional clots
Contacting the primary health care provider
The nurse is monitoring a client who is in the active phase of labor and has been experiencing contractions that are coordinated but weak. Which assessment finding indicates to the nurse that the client may be experiencing hypotonic contractions? Fetal hypoxia Discomfort with each contraction Increased frequency and longer duration of contractions Contractions that can be indented easily with fingertip pressure at their peak
Contractions that can be indented easily with fingertip pressure at their peak
A client with gastroenteritis who has been vomiting and has diarrhea is admitted to the hospital with a diagnosis of dehydration. For which clinical manifestations that correlate with this fluid imbalance would the nurse assess the client? Select all that apply. Decreased pulse Decreased urine output Increased blood pressure Increased respiratory rate Decreased respiratory depth
Decreased urine output Increased respiratory rate
A client with cancer of the larynx is receiving external radiation therapy of the neck. Which side effect related specifically to the site of irradiation does the nurse tell the client to expect? Diarrhea Dyspnea Headache Dysphagia
Dysphagia
The emergency department nurse assesses a client who has a diagnosis of left-sided heart failure. Which findings does the nurse expect to note? Select all that apply. Dyspnea Dependent edema Neck vein distention Abdominal distention Crackles on auscultation of the lungs
Dyspnea Crackles on auscultation of the lungs
A client is found to have viral hepatitis, and the nurse provides home care instructions to the client. What should the nurse tell the client to do? Maintain strict bed rest Limit the intake of alcohol Take acetaminophen for discomfort Eat small frequent meals that are low in fat and protein and high in carbohydrates
Eat small frequent meals that are low in fat and protein and high in carbohydrates
The primary health care provider writes a prescription for the administration of intravenous (IV) potassium chloride to a client with hypokalemia. What does the nurse plan to do when preparing and administering this medication? Insert a Foley catheter in the client Prepare the client for insertion of a central IV line Administer the medication with the use of a macrodrip IV tubing set Ensure that the medication is diluted in an appropriate amount of normal saline solution
Ensure that the medication is diluted in an appropriate amount of normal saline solution
A nurse is providing discharge instructions to a client after outpatient surgery for cataract removal. The nurse determines that the client needs additional instructions if the client indicates what? Limit activity for 24 hours Take acetaminophen for discomfort Leave the eye patch in place until he has been seen by the primary health care provider Expect to experience pain, nausea, and vomiting after the procedure
Expect to experience pain, nausea, and vomiting after the procedure
The nurse is providing instructions to an unlicensed assistive personnel (UAP) about effective measures for communicating with a hearing-impaired client. What does the nurse instruct the UAP to do? Raise his/her voice when talking to the client Talk directly into the client's impaired ear Be cordial and smile when talking to the client Face the client when talking, keeping the hands away from the mouth
Face the client when talking, keeping the hands away from the mouth
The nurse is caring for a child with newly diagnosed type 1 diabetes mellitus who is receiving insulin. The child suddenly exhibits tachycardia and begins to sweat and tremble, and the nurse determines that the child is experiencing a hypoglycemic reaction. What should the nurse immediately give the child? A sugar cube A teaspoon of sugar ½ cup (118 mL) of diet cola ½ cup (118 mL) of fruit juice
Fruit juice
The wife of a client with angina pectoris calls the primary health care provider's office and reports to the nurse that her husband is experiencing chest pain and has taken 2 sublingual nitroglycerin tablets 5 minutes apart, with no relief. What does the nurse tell the client's wife to do? Have her husband rest and, if no relief is obtained, call back Discuss the situation with the doctor, who will call her as soon as he gets into the office Call Emergency Medical Services to take her husband to the emergency department (ED) immediately Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED
Give her husband a third tablet and, if no relief is obtained, call an ambulance to have him transported to the ED
The ambulatory care nurse is providing home care instructions to the mother of a child who had a tonsillectomy. The nurse determines that the mother needs further instruction if she indicates what? Avoid giving citrus juices to her child Have her child use a straw to make drinking easier Give acetaminophen to her child for discomfort Give her child extra fluids to relieve a foul odor from the mouth
Have her child use a straw to make drinking easier
A client with chronic kidney disease is undergoing his/her first hemodialysis treatment. The nurse is monitoring the client for signs/symptoms of disequilibrium syndrome. For which signs/symptoms of this syndrome does the nurse monitor the client? Fever and tachycardia Headache and confusion Bradycardia and hypothermia Irritability and generalized weakness
Headache and confusion
The nurse is reviewing the assessment findings and laboratory results of a child with a diagnosis of new-onset glomerulonephritis. Which finding would the nurse expect to note? Hypertension Low serum potassium Increased creatinine level Cloudy yellow urine
Hypertension
The nurse is assessing a child with increased intracranial pressure who has been exhibiting decorticate posturing. The nurse notes extension of the upper and lower extremities, with internal rotation of the upper arms and wrists and the knees and feet. What does the nurse determine about the child's condition? Indicates improved neurological status Indicates decreased intracranial pressure Indicates deterioration in neurological function Is unchanged from the previous neurological assessment
Indicates deterioration in neurological function
A client is found to have AIDS. What is the nurse's highest priority in providing care to this client? Providing emotional support to the client Discussing the cause of AIDS with the client Instituting measures to prevent infection in the client Identifying risk factors related to contracting AIDS with the client
Instituting measures to prevent infection in the client
The nurse is assessing a 12-month-old child with iron-deficiency anemia. Which finding does the nurse expect to note in this child? Lethargy Bradycardia Hyperactivity Reddened cheeks
Lethargy
The nurse provides home care instructions to a client with Ménière disease about measures to control and treat vertigo. What should the nurse tell the client to do? Limit sodium in the diet Increase fluid intake to at least 3000 mL/day Lie down when vertigo occurs and keep a light on in the room Move the head from the right to the left when vertigo occurs to determine the extent of its effects
Limit sodium in the diet
The nurse is caring for a client who has undergone resection of an abdominal aortic aneurysm (AAA). Which action should the nurse implement to prevent graft occlusion? Monitoring urine output Monitoring bowel sounds Checking pedal pulses distal to the graft site Limiting elevation of the head of the bed to 45 degrees
Limiting elevation of the head of the bed to 45 degrees
A ventilator's low exhaled volume (low-pressure) alarm sounds, and the nurse rushes to the client's room and quickly assesses the client. The client appears to be having respiratory difficulty. What should the nurse do first? Call a code Suction the client Call the anesthesiologist Manually ventilate the client, using a resuscitation bag
Manually ventilate the client, using a resuscitation bag
Mastitis is diagnosed in a client who recently gave birth. What does the nurse tell the woman? Wearing a bra will increase the discomfort Antibiotics are not usually used to treat this disorder Breastfeeding must be discontinued until the condition resolves Moist heat will increase circulation and may be used before the breasts are emptied
Moist heat will increase circulation and may be used before the breasts are emptied
The nurse is monitoring a client with hyperparathyroidism for signs/symptoms of hypercalcemia. For which clinical manifestations, associated with this electrolyte imbalance, does the nurse assess the client? Select all that apply. Paresthesias Muscle weakness Increased urine output Chvostek sign Hyperactive deep tendon reflexes
Muscle weakness Increased urine output
The nurse is assessing a client with AIDS for signs/symptoms of Pneumocystis jiroveci infection. Which sign/symptom of the infection is the earliest manifestation? Fever Dyspnea at rest Dyspnea on exertion Nonproductive cough
Nonproductive cough
The nurse is reviewing this rhythm strip from a cardiac monitor. Which type of abnormal beat does the nurse recognize?
PVCs
A client has an arteriovenous fistula in place for hemodialysis. What should the nurse do to assess the patency of the fistula? Irrigate the fistula with 3 mL of normal saline solution Infuse 50 mL of normal saline once per 24 hours Palpate for a vibrating sensation at the fistula site Flush the fistula with 1 mL of heparin solution once per shift
Palpate for a vibrating sensation at the fistula site
The nurse in the labor room is performing a vaginal assessment of a pregnant client who is in active labor. The nurse notes that the umbilical cord is protruding from the vagina. What does the nurse immediately do? Push the cord gently back into the vagina Prepare the client for cesarean delivery Place the client in the knee-chest position Prepare to administer a tocolytic medication
Place the client in the knee-chest position
The nurse has been assigned to care for an infant with tetralogy of Fallot. The infant suddenly exhibits rapid, deep respirations; irritability; and cyanosis. The nurse determines that the infant is experiencing a hypercyanotic episode. What does the nurse immediately do? Call a code Hold the infant in an upright position Place the infant in the knee-chest position Contact the respiratory therapy department
Place the infant in the knee-chest position
The nurse is monitoring a client with deep vein thrombosis (DVT) for signs/symptoms of pulmonary embolism (PE). For which sign/symptom of PE, the most common, does the nurse assess the client? Cough Hemoptysis Diaphoresis Pleuritic chest pain
Pleuritic chest pain
The nurse has admitted a client with a diagnosis of tuberculosis (TB) to the nursing unit. Which finding that confirms the diagnosis does the nurse expect to see documented in the client's record? Night sweats and a low-grade fever Positive result on an acid-fast bacillus smear Cough and expectoration of mucopurulent sputum A tuberculin skin test result that indicates 5 mm of redness
Positive result on an acid-fast bacillus smear
The nurse is caring for a client in the intensive care unit (ICU) who is being mechanically ventilated. As the nurse prepares medications, the client suddenly becomes anxious and pulls out the endotracheal tube. After the nurse assesses the client for spontaneous breathing, what does the nurse do next? Prepares for reintubation Restrains the client's wrists Calls the rapid response team (RRT) Administers an antianxiety medication to the client
Prepares for reintubation
The nurse is developing a plan of care for a client with a new diagnosis of Graves disease. Which intervention does the nurse include in the plan? Keeping the room warm Placing extra blankets on the client Providing a high-calorie, high-protein diet Encouraging frequent ambulation and activities
Providing a high-calorie, high-protein diet
The nurse assessing a client in the fourth stage of labor notes that the uterine fundus is firmly contracted and is midline at the level of the umbilicus. On the basis of this finding, what does the nurse most appropriately do? Record the findings Massage the fundus Contact the primary health care provider Help the mother void
Record the findings
The nurse in the newborn nursery is monitoring a neonate born to a mother with diabetes mellitus. For which finding does the nurse monitor the neonate most closely? Hypercalcemia Hyperglycemia Hypobilirubinemia Respiratory distress syndrome
Respiratory distress syndrome
The nurse provides dietary instructions to the mother of a child with celiac disease. Which food does the nurse tell the mother to include in the child's diet? Rice Wheat cereal Rye crackers Oatmeal biscuits
Rice
The nurse is providing home care instructions to a client with Parkinson disease about measures to avoid rigidity and to overcome tremor and bradykinesia. What does the nurse tell the client to do? Sit in soft, deep chairs Rock back and forth to start movement Exercise in the evening to combat fatigue Perform tasks with only the hand that has the tremor
Rock back and forth to start movement
A client who experiences frequent episodes of chest pain is admitted to the hospital for cardiac monitoring. The client suddenly complains of chest pain, and the nurse obtains a 12-lead electrocardiogram (ECG). Which finding would the nurse expect to note in the event of an ischemic episode? Peaked T waves ST-segment depression Widened QRS complex An isolated premature ventricular contraction (PVC)
ST-segment depression
A client is transported to the recovery area of the ambulatory care unit after cataract surgery. In which position does the nurse place the client? Supine Semi-Fowler On the side that has undergone surgery Prone on the side that has undergone surgery
Semi-Fowler
A woman in labor suddenly complains of abdominal tenderness and pain and states that she felt as though "something ripped." For which manifestations does the nurse, suspecting uterine rupture, assess the client? Select all that apply. Bradypnea Severe chest pain Absence of fetal heart tones Increased blood pressure Increased frequency of uterine contractions
Severe chest pain Absence of fetal heart tones
The nurse is assessing a newborn for fetal alcohol syndrome (FAS). Which finding would the nurse expect to note in the newborn? Greater-than-average length Higher-than-normal birth weight Short palpebral fissures and a flat midface Greater-than-average head circumference
Short palpebral fissures and a flat midface
The nurse is caring for a hospitalized child with a diagnosis of Kawasaki disease. During the subacute phase, what does the nurse monitor the child closely for? Bleeding A high fever Failure to thrive Signs/symptoms of congestive heart failure (CHF)
Signs/symptoms of congestive heart failure (CHF)
The nurse is caring for a client experiencing hyponatremia who was admitted to the medical-surgical unit with fluid-volume overload. For which clinical manifestations of this electrolyte imbalance does the nurse monitor this client? Select all that apply. Slow pulse Decreased urine output Skeletal muscle weakness Hyperactive bowel sounds Hyperactive deep tendon reflexes
Skeletal muscle weakness Hyperactive bowel sounds
The nurse in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which item does the nurse, preparing for the arrival of the newborn, make a priority of placing at the newborn's bedside? Flashlight Sterile dressing Cardiac monitor Blood pressure cuff
Sterile dressing
The nurse is administering care to a client with angina pectoris who is attached to a cardiac monitor. The monitor alarm sounds, and the nurse notes the rhythm shown here. How does the nurse interpret the rhythm?
Tach
The nurse is teaching a client with diabetes mellitus who requires insulin about methods of preventing diabetic ketoacidosis (DKA) when the client is ill. What does the nurse tell the client to do? Contact the primary health care provider if a fever over 102° F (38.9°C) occurs Refrain from eating or drinking during periods of vomiting Take the prescribed insulin dose even if he/she is unable to eat Contact the primary health care provider when the premeal blood glucose value is greater than 350 mg/dL (19.4 mmol/L)
Take the prescribed insulin dose even if he/she is unable to eat
The nurse provides home care instructions to a client after a scleral buckling procedure. What should the nurse tell the client? To maintain strict bedrest for 48 hours To expect bloody drainage on the eye dressing That vision will be perfectly clear immediately after surgery That redness and swelling of the eyelids and conjunctiva are expected
That redness and swelling of the eyelids and conjunctiva are expected
During a client's yearly eye examination, the nurse checks the intraocular pressure. The nurse notes that the pressure in the right eye is 12 mm Hg and 19 mm Hg in the left. What does the nurse tell the client? That he has glaucoma in the left eye That he has glaucoma in the right eye That the intraocular pressure in both eyes is normal That he needs to increase his fluid intake, because the pressure in the right eye is low
That the intraocular pressure in both eyes is normal
A client with a leg fracture who has been placed in skeletal traction is transported to the orthopedic unit after surgery. Which finding would indicate the need to contact the orthopedic specialist? The traction knots are intact. The traction weights are hanging freely. The clamps on the traction frame are tight. The traction ropes are unable to move over the pulleys.
The traction ropes are unable to move over the pulleys.
A mother calls the clinic and tells the nurse that her newborn's umbilical cord site looks red and swollen. What should the nurse tell the mother? That this is a normal occurrence To bring the newborn to the clinic To increase the number of cord site cleanings each day To place an ice pack on the cord for 10 minutes three times a day
To bring the newborn to the clinic
A client has undergone creation of an Indiana pouch for urine diversion after cystectomy, and the nurse provides instructions about reservoir catheterization. What does the nurse tell the client? To plan to drain the reservoir every 2 to 3 hours initially That if mucus drains from the reservoir the primary health care provider should be contacted That sometimes force is needed to insert the catheter into the reservoir To obtain 26F catheters from the medical supply store for the irrigations
To plan to drain the reservoir every 2 to 3 hours initially
The nurse is conducting an assessment of a client with mild preeclampsia. Which sign/symptom indicates improvement in the client's condition? Complaint of headache Trace protein in the urine Blood pressure 148/94 mm Hg Blood urea nitrogen (BUN) of 40 mg/dL (14.2 mmol/L)
Trace protein in the urine
The nurse is teaching a client who is experiencing homonymous hemianopsia after a brain attack (stroke) about measures to overcome the deficit. What does the nurse tell the client to do? Wear eyeglasses 24 hours a day Wear a patch on the affected eye Turn the head to scan the lost visual field Keep all objects in the impaired field of vision
Turn the head to scan the lost visual field
The nurse is having dinner at a restaurant when a man sitting at the next table collapses and falls to the floor. The nurse yells for help and quickly assesses the client, noting that the client is not breathing and does not have a pulse. The nurse initiates cardiopulmonary resuscitation (CPR) immediately, and the restaurant manager rushes to the scene with an automatic external defibrillator (AED). What should the nurse do next? Use the AED Stop the resuscitation efforts Perform CPR until emergency medical services arrives Check for a pulse for 30 seconds before continuing CPR
Use the AED
The nurse answers the call bell of a client who has been fitted with an internal cervical radiation implant, and the client states that she thinks that the implant has fallen out. The nurse checks the client and sees the implant lying in the bed. Which action should the nurse take first? Calling the primary health care provider Reinserting the implant into the client's vagina Picking up the implant with gloved hands and placing it in sterile water Using long-handled forceps to place the implant in a lead container
Using long-handled forceps to place the implant in a lead container
The nurse is reading the medical record of a pregnant client in the second trimester with a diagnosis of abruptio placentae. Which clinical manifestation of the disorder does the nurse expect to see documented? Uterine tenderness Lack of uterine activity Painless vaginal bleeding Constipation
Uterine tenderness
The nurse develops a nursing care plan for a client with a sealed radiation implant. Which stipulation does the nurse include in the plan? Visitors must be limited to one half-hour per day. Visitors must remain at least 2 feet (61 cm) from the client. A dosimeter badge must be placed on the client's bedside stand. The client may be maintained in a semiprivate room as long as the client uses a commode.
Visitors must be limited to one half-hour per day.
The nurse is caring for a client who is being treated for congestive heart failure related to excessive fluid volume. Which assessment finding causes the nurse to determine that the client's condition has improved? Dyspnea 1+ edema in the legs Moist crackles in the lower lobes of the lungs Weight loss of 4 lb (1.8 kg) in 24 hours
Weight loss of 4 lb (1.8 kg) in 24 hours
The emergency department nurse is caring for a client with acute pancreatitis who will be admitted to the hospital. Into which position that will ease the abdominal pain does the nurse assist the client? Prone Supine with the legs straight With the knees drawn up to the chest Side-lying with the head of the bed flat
With the knees drawn up to the chest
A client who experienced a brain attack (stroke) exhibits right-sided unilateral neglect. Where does the nurse caring for this client plan to place the client's personal care items? Within the client's reach on the left side Within the client's reach on the right side Just out of the client's reach on the left side Just out of the client's reach on the right side
Within the client's reach on the right side
