HESI practice #1

For each client statement, click to highlight the statement(s) below that require follow up teaching by the nurse. "I am at high risk for post-traumatic-stress disorder because I have acute stress" "I can use holistic approaches like meditation to help my symptoms." "I can learn to manage my thoughts better through therapy." "Many people have the same response to a stressful situation as I am having" "This diagnosis means that I am crazy." "I will probably need to be on medication for the rest of my life."

-I am at high risk for post-traumatic-stress disorder because I have acute stress -This diagnosis means that I am crazy -I will probably need to be on medication for the rest of my life

A client who weighs 110 pounds receives a prescription for dalteparin 150 units/kg subcutaneously daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer?

0.3 mL

The healthcare provider prescribes 500 mL intravenous (IV) bolus of 0.9% normal saline to be infused over 30 minutes. How many mL/hour should the nurse set the infusion pump? (Enter numerical value only.)

1,000 mL

0900: Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts andmemories about the house collapsing all the time, and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly. Drag from the options to complete the sentence After listening to the client's symptoms, the nurse realizes that she likely has (separation anxiety, acute stress disorder, phobia, hallucinations) related to (undiagnosed mental health disorder, traumatic stress exposure, side effects of medication, overstimulation) Submit Answer

1. acute stress disorder 2. traumatic stress exposure

An infant who weighs 22 pounds receives a prescription for amoxicillin 20 mg/kg/day by mouth in divided doses every 8 hours. The bottle is labeled, "Amoxicillin for Oral Suspension, USP 250 mg per 5 mL." How many mL should the nurse administer with each dose? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)

1.3

A client who weighs 65 kg receives a prescription for lorazepam 44 mcg/kg intravenously to be administered 20 minutes before a scheduled procedure. The medication is available in 2 mg/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

1.4

A client is receiving a secondary infusion of erythromycin 1 grams in 100 mL dextrose 5% in water (DW) to be infused in 30 minutes. How many mL/hour should the nurse program the infusion pump?

200 mL

A client with a chlamydia infection receives a prescription for a single dose azithromycin 1 gram by mouth. The bottle is labeled "Azithromycin for Oral Suspension, USP 200 mg per 5 mL." How many mL should the nurse administer?

25 mL

The nurse is preparing to administer a suspension ampicillin labeled, 250 mg/5 mL, to a child with impetigo. The prescription is for 500 mg four times a day. How many mL should the child receive per day?

40 mL

A client receives a prescription for a fluid bolus of 0.9% sodium chloride, USP 200 mL to be infused in 30 minutes. How many mL/hr should the nurse program the infusion pump to deliver?

400 mL

The healthcare provider prescribes dopamine 2 mcg/kg/min intravenously (IV) for client who weighs 60 kg. The IV bag contains dopamine 200 mg in dextrose 5% in water (DW) 250 mL. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numerical value only.)

9 mL/hr

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)] A. Assess urine and stool for occult blood. B. Obtain client's temperature every 4 hours. C. Monitor for signs of activity intolerance D. Require visitors to wear respiratory masks.

A. Assess urine and stool for occult blood.

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.) A. Avoid prolonged standing or sitting. B. Continue wearing compression stockings. C. Cross legs at knee but not at ankle. D. Use recliner for long periods of sitting. E. Maintain the bed flat while sleeping. Submit Answer

A. Avoid prolonged standing or sitting. B. Continue wearing compression stockings. D. Use recliner for long periods of sitting.

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take? A. Call for an assistant. B. Respond to the code. C. Finish the procedure. D. Close the room door.

A. Call for an assistant.

Placed a cervical collar with the assistance of the physician. The child's pulse is 121 beats/minute, the airway is patent, and there are no signs of any bleeding. Review H and P, nurse's note, laboratory results, orders, and imaging studies. What complications should the nurse monitor for in the next 6 to 8 hours? Select all that apply. A. Cerebral edema B. Acute asphyxia C. Hypertension D. Respiratory distress E. Hyperthermia F. Subdural hemorrhage

A. Cerebral edema B. Acute asphyxia D. Respiratory distress F. Subdural hemorrhage

The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first? A. Check the client's level of consciousness. B. Determine the depth of the slashes. C. Estimate the amount of blood loss. D. Find the object used to cause the injuries.

A. Check the client's level of consciousness.

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective? A. Clients who incurred disease complications promptly received rehabilitation. B. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign. C. At-risk clients received an increased number of routine health screenings. D. Clients reported having new confidence in making healthy food choices.

A. Clients who incurred disease complications promptly received rehabilitation.

A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse? A. Coarse breath sounds. B. Rust colored sputum. C. Unexplained fatigue. D. Clubbed fingernails.

A. Coarse breath sounds.

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider? A. Complete blood count. B. Allergy test. C. Skin biopsy. D. Electromyography.

A. Complete blood count.

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s) made by the client should the nurse recognize as needing additional education? (Select all that apply.) A. Consume foods with saturated fats. B. Walk 30 minutes per day. C. Use a salt substitute. D. Keep a food diary. E. Eat more canned vegetables. F. Include oatmeal for breakfast.

A. Consume foods with saturated fats. E. Eat more canned vegetables.

The child is showing only minor signs of impact from the submersion injury and will likely be discharged in the morning. The nurse would like to give some education to the parents before discharge. What should the nurse include in pre-discharge education for this child's parents? Select all that apply. A. Contact information for community resources B. Information about pool safety C. A warning about potential charges for child neglect D. When to follow up with the child's pediatrician F. Assessment of the parent's coping skills

A. Contact information for community resources B. Information about pool safety D. When to follow up with the child's pediatrician F. Assessment of the parent's coping skills

The client is a 7-year-old with spastic cerebral palsy (CP) admitted to pre-op for heel cord lengthening. Child has cognitive and speech delays. Experiences absent seizures numerous times daily according to parent. Surgery went well for bilateral heel cords lengthening. The nurse is updating the plan of care. Select 5 findings that would require immediate action prior to the nurse administering this pain medication A. Correct dosage of medication B. Vital signs with SaO2 C. Pain report from parent D. Valid pain assessment tool E. Identify allergies F. Subjective pain assessment

A. Correct dosage of medication B. Vital signs with SaO2 C. Pain report from parent D. Valid pain assessment tool E. Identify allergies

The home health nurse is assessing an older client who lives alone. The client reports being troubled by constipation. Which additional information should the nurse obtain to formulate a plan of care? (Select all that apply.) A. Current prescribed and over-the-counter medications. B. Next scheduled visit with healthcare provider. C. Methods currently used to treat constipation. D. Daily food and fluid intake. E. Level of physical activity and exercise.

A. Current prescribed and over-the-counter medications. C. Methods currently used to treat constipation. D. Daily food and fluid intake. E. Level of physical activity and exercise.

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? A. Document in the client's record. B. Prepare the client for an echocardiogram. C. Notify the healthcare provider. D. Limit the client's fluids.

A. Document in the client's record.

The nurse is providing discharge teaching to a client who underwent a pneumonectomy. The client wants to resume social activities with family. How should the nurse respond? A. Encourage family gatherings to reduce feelings of isolation. B. Explain the need to avoid persons with respiratory infections. C. Reinforce the need to avoid social contact for several weeks. D. Recommend the use of a face mask during family events.

A. Encourage family gatherings to reduce feelings of isolation.

A client with a diagnosis of schizophrenia sits in the day room and fails to interact with the staff or peers. Which intervention is best for the nurse to implement with this client? A. Give the client a schedule of planned daily activities. B. Engage the client in a game of cards. C. Encourage the client to have lunch off the unit. D. Complete an assessment of social support.

A. Give the client a schedule of planned daily activities.

A client with a history of type 1 diabetes mellitus (DM) and asthma is readmitted to the unit for the third time in two months with a current fasting blood sugar (FBS) is 325 mg/dL (18 mmol/L). The client describes to the nurse of not understanding why the blood glucose level continues to be out of control. Which intervention(s) should the nurse implement? (Select all that apply.) A. Have the client demonstrate technique used to monitor blood glucose levels. B. Evaluate the client's asthma medications that can elevate the blood glucose. C. Ask the client if they want a different manufacturer's glucose monitoring device. D. Have the client describe a typical day at work, home, and social activities. E. Determine if the client is using a new insulin needle each administration. Submit Answer

A. Have the client demonstrate technique used to monitor blood glucose levels. B. Evaluate the client's asthma medications that can elevate the blood glucose. D. Have the client describe a typical day at work, home, and social activities. E. Determine if the client is using a new insulin needle each administration. Submit Answer

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care? A. Have the client vocalize the instructions provided. B. Provide written instructions for eye drop administration. C. Speak clearly and face the client for lip reading. D. Ensure that someone will stay with the client for 24 hours.

A. Have the client vocalize the instructions provided.

In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28% (0.28 volume fraction), a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? Reference Range: Hematocrit [37% to 47% (0.37 to 0.47 volume fraction)] A. Hematocrit of 28% (0.28 volume fraction). B. Heart rate of 92 beats per minute. C. Systolic murmur. D. Elevated thyroid hormone level.

A. Hematocrit of 28% (0.28 volume fraction).

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. Which intervention should the nurse implement first? A. Initiate a prescribed IV for parenteral fluid. B. Feed the infant 3 ounces of Isomil. C. Give the infant 5% dextrose in water orally. D. Insert a nasogastric tube for feeding.

A. Initiate a prescribed IV for parenteral fluid.

After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Prior to starting the urine collection, the nurse notes that the client's serum creatinine is 0.3 mg/dL (22.9 μmol/L). Which action should the nurse implement?Creatinine [Reference Range: 0.5 to 1.1 mg/dL (44 to 97 μmol/L)] A. Initiate the urine collection as prescribed. B. Evaluate the client's serum BUN level. C. Notify the healthcare provider of the results. D. Assess the client for signs of hypokalemia.

A. Initiate the urine collection as prescribed.

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.) A. Inspect skin for redness. B. Use a residual limb shrinker. C. Avoid range of motion exercises. D. Apply alcohol to the residual limb after bathing.

A. Inspect skin for redness. B. Use a residual limb shrinker.

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. Ask the mother to decrease the infant's intake of fruits for 24 hours. C. Encourage the mother to apply lotion with each diaper change. D. Tell the mother to cleanse with soap and water at each diaper change.

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

This is a healthy male infant who was the child of a diabetic mother. He was born vaginally at 39 weeks gestation. His parents report no health issues. He has 2 older siblings, a 4-year-old sister and a 6-year-old brother. Neither sibling has any health issues. The nurse at the 9-month visit reviews the child's height, weight, and feeding progression history. What should the nurse advise the parents concerning the child's nutrition? Select all that apply A. Juice should be avoided in infancy and early childhood B. The majority of the child's calories should be coming from the formula C. The parents can add raw fruit, cheese, or firmly cooked vegetables to the diet D. The child should probably be eating more times per day E. The parents should consider using a fluoride supplement F. The child can now convert to animal milk instead of formula

A. Juice should be avoided in infancy and early childhood C. The parents can add raw fruit, cheese, or firmly cooked vegetables to the diet D. The child should probably be eating more times per day

When should the nurse conduct an Allen's test? A. Just before arterial blood gasses are drawn peripherally. B. Prior to attempting a cardiac output calculation. C. To assess for presence of a deep vein thrombus in the leg. D. When pulmonary artery pressures are obtained.

A. Just before arterial blood gasses are drawn peripherally.

A client is admitted to the surgical intensive care unit following the removal of a large portion of the intestines due to a gunshot wound to the abdomen. The client begins to display signs of septic shock and a sepsis protocol is initiated. Which intervention is most important for the nurse to include in the plan of care? A. Maintain strict intake and output. B. Assess warmth of extremities. C. Keep head of bed raised 45 degrees. D. Monitor blood glucose level.

A. Maintain strict intake and output.

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter? A. Observe insertion site. B. Palpate flank area. C. Measure abdominal girth. D. Assess perineal area.

A. Observe insertion site.

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care? A. Observe the color of urine. B. Assess skin turgor. C. Measure body temperature. D. Check for pedal edema.

A. Observe the color of urine.

An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.) A. Obtain the client's tympanic temperature measurement. B. Review the client's current food and medication allergies. C. Ask if the client is experiencing any pain with urination. D. Encourage increasing the intake of high protein foods. E. Determine if the client has recently experienced a fall.

A. Obtain the client's tympanic temperature measurement. C. Ask if the client is experiencing any pain with urination. E. Determine if the client has recently experienced a fall.

The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider? A. Ortolani maneuver causing a click at the hip joint. B. Plumb line test indicates fetal position curvature. C. Babinski test that reveals fanning out of toes. D. Moro test precipitating a startle response.

A. Ortolani maneuver causing a click at the hip joint.

A 7-year-old female child admitted to pre-op for scheduled surgery. Focused assessment completed. Lung sounds are clear to auscultation (CTA), heart sounds clear with normal sinus rhythm, skin clear with no breakdown. Abdomen soft with bowel sounds heard in all 4 quadrants. A feeding tube is present on the abdomen Site is clean and clear. Consents for surgery signed by parent at preadmission visit. Peripheral IV (PIV) 22 gauge inserted in right forearm with assistance from another nurse. Cried throughout procedure. Comforted by parent and use of touch music. IV fluids at 75 mL/hr started. Client transported to operating room (OR) and The nurse is developing the plan of care for the child. To provide atraumatic care for this child post-operatively, what will be the priority? A. Pain assessments B. Antibiotics C. Occupational therapy D. Wound care E. Physical therapy

A. Pain assessments

An older adult client is admitted to the stroke unit after recovery from the acute phrase of an ischemic cerebral vascular accident (CVA). Which intervention(s) should the nurse include in the plan of care during convalescence and rehabilitation? (Select all that apply.) A. Place a bedside commode next to bed. B. Measure neurological vital signs every 4 hours. C. Suction oral cavity every 4 hours. D. Encourage family to participate in the client's care. E. Play classical music in room while client is Submit Answer

A. Place a bedside commode next to bed. B. Measure neurological vital signs every 4 hours. D. Encourage family to participate in the client's care.

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first? A. Reason for taking the aspirin. B. Dosage of ibuprofen taken. C. Presence of gastric pain. D. Amount of pain control.

A. Reason for taking the aspirin.

The nurse is caring for a client with the sexually transmitted infection (STI) genital herpes. The client reports having sex with multiple partners. Which response should the nurse provide A. Remain non-judgmental and assure the client of confidentiality. B. Provide counseling that most contraceptives protect against infection. C. Clarify that all STIs are transmitted through sexual intercourse. D. Inform the client that complications will not result from reinfection.

A. Remain non-judgmental and assure the client of confidentiality.

Six weeks after the birth of a child with Trisomy 21, the parents return to the prenatal clinic for a follow-up visit. They have spoken with a genetic counselor, but are still unsure about the risk of having another child with Trisomy 21. The couple brings literature from the counselor with them, and asks the nurse to explain it. Which action should the nurse take? A. Review the literature and answer any questions the nurse is able to answer. B. Determine their reasoning for seeking genetic counseling at this time. C. Tell the couple that it is best to call the counselor with their questions. D. Recommend a community support group for parents of children with Trisomy 21.

A. Review the literature and answer any questions the nurse is able to answer.

The nurse reviews the physician's orders for clonazepam and gives the medication as ordered. What nursing interventions are appropriate for the client starting clonazepam? Select all that apply. A. Screen for orthostatic hypotension B. Provide oral care at least twice a day C. Monitor calcium levels D. Assess mental status regularly E. Assist the client to the bathroom F. Have an opioid agonist at the bedside

A. Screen for orthostatic hypotension B. Provide oral care at least twice a day D. Assess mental status regularly E. Assist the client to the bathroom

1430 The parents are at the bedside and state that each parent thought the other parent was watching the child. They are not sure how long he was in the pool or how he might have fallen in. The temperature of the pool was cool as the temperature outside was about 64 °F (17.8 °C). Review H and P and nurse's notes. What are the first four actions that the nurse should take? A. Take the child's pulse B. Place a cervical collar on the client C. Look for any open wounds D. Call child protective services E. Determine if the child's airway is clear F. Start a peripheral intravenous line

A. Take the child's pulse B. Place a cervical collar on the client C. Look for any open wounds E. Determine if the child's airway is clear

This is an 11-month-old male with a 2-day history of fussiness, increased nasal secretions, and cough. The baby is 24.3 lb. (11 kg). He was born at 34 weeks gestation and spent several weeks in the neonatal intensive care unit for poor feeding. He is currently up to date on vaccinations and is meeting appropriate developmental milestones. The parents deny that he takes any medications at home. Review H and P and flow sheet. Select which assessment findings indicate that the baby has an increased fluid requirement. Select all that apply. A. Temperature 103 °F (39.4 °C) B. Blood pressure 89/51 mmHg C. Respiratory rate 55 breaths/min D. Copious, clear secretions from both nostrils F. Oxygen saturation 95% G. Wet diaper with 12 mL of urine H. Heart rate 159 bpm

A. Temperature 103 °F (39.4 °C) C. Respiratory rate 55 breaths/min D. Copious, clear secretions from both nostrils

The child is a 2-year-old who fell in a pool. He was retrieved from the pool by a family member but was not breathing. The family member started CPR and the ambulance brought him to the hospital. Review H and P. What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion? Select all that apply. A. The amount of time the child was submerged B. Temperature of water C. Whether or not anyone witnessed the fall into the pool D. Oxygen concentration of the ambient air E. The weight of the child Submit Answer

A. The amount of time the child was submerged C. Whether or not anyone witnessed the fall into the pool D. Oxygen concentration of the ambient air

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure? A. Tingling on tongue or lips. B. Episodes of shivering. C. Salty taste in the mouth. D. Difficulty breathing.

A. Tingling on tongue or lips.

The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. Which client with which change in status is best to assign to the PN? A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C). B. Myxedema coma whose blood pressure changed from 80/50 mm Hg to 70/40 mm Hg. C. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7. D. Subdural hematoma whose blood pressure changed from 150/80 mm Hg to 170/60 mm Hg.

A. Viral meningitis whose temperature changed from 101° F (38.3°C) to 102° F (38.9° C).

When performing suctioning for a client with a tracheostomy, which action should the nurse include? A. Wear protective goggles while performing the procedure. B. Apply a water soluble lubricant to the catheter. C. Instill 3 mL of normal saline before suctioning. D. Instruct the client to cough as the suction tip is removed.

A. Wear protective goggles while performing the procedure.

A client is being discharged home after being treated for heart failure (HF). Which instruction should the nurse include in this client's discharge teaching plan? A. Weigh every morning. B. Perform range of motion exercises. C. Limit fluid intake to 1,500 mL daily. D. Eat a high protein diet.

A. Weigh every morning.

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Weigh the client and report any weight gain. B. Reporting any client complaints of pain or discomfort. C. Evaluate the client for sleep disturbances. D. Note and report the client's food and liquid intake during meals and snacks. E. Assess the client for weakness and fatigue.

A. Weigh the client and report any weight gain. B. Reporting any client complaints of pain or discomfort. D. Note and report the client's food and liquid intake during meals and snacks.

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In which, order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and the least priority last or at the bottom.) A: Stop the Infusion. B: Assess vital signs C: Contact the healthcare provider. D: Initiate an adverse event report. E: Document reaction to the drug.

A: Stop the Infusion. B: Assess vital signs C: Contact the healthcare provider. D: Initiate an adverse event report. E: Document reaction to the drug.

In the trauma unit, vital signs ordered every 4 hours are taken at 0400, 0800, 1200, 1600, 2000, and 2400. Select the times that the nurse should do vital signs. Select all that apply. A. 0200 B. 1300 C. 1000 D. 1600 E. 1400 F. 0900 G. 0800 H. 0500 I. 1100 J. 1200

B. 1300 C. 1000 D. 1600 E. 1400 F. 0900 G. 0800

A primiparous woman presents in labor with the following labs: hemoglobin 10.9 g/dL (109 g/L), hematocrit 29% (0.29), hepatitis surface antigen positive, group B Streptococcus positive, and rubella non- immune. Which intervention should the nurse implement? Reference Range Hemaglobin [Reference Range:12-16 g/dL (120-160 g/L)] Hematrocrit [Reference Range:Pregnant female: 37% to 47% (0.37 to 0.47 volume fraction)] Hepatitis Surface Antigen [Reference Range: negative] Group B Streptococcus [Reference Range: negative] A. Transfuse two units packed red blood cells. B. Administer ampicillin 2 grams intravenously. C. Inject hepatitis B immune globulin 0.5 mL. D. Give measles, mumps, rubella vaccine 0.5 mL.

B. Administer ampicillin 2 grams intravenously.

The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel (UAP) providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. Which is the priority nursing action? A. Explain to the UAP that changes in a client's condition should be reported immediately B. Advise the UAP to stop providing care so the nurse can assess the client's condition. C. Ask the UAP to position the client so the oral medications can be administere D. Determine why the UAP did not notify the nurse of the change in the client's condition

B. Advise the UAP to stop providing care so the nurse can assess the client's condition.

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? A. An adult who is in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours. B. An older client who is receiving packed red blood cells on the third day postoperatively for colon resection. C. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery. D. An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.

B. An older client who is receiving packed red blood cells on the third day

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having had prior sexually transmitted infections. Which response should the nurse provide? A. Discuss that partners without similar symptoms may not be infected. B. Answer questions directly and correct any misinformation. C. Provide counseling that most contraceptives protect against infection. D. Notify that persons with STIs are reported to local health departments.

B. Answer questions directly and correct any misinformation.

A client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client's admission prescriptions include radiation therapy. Which action should the nurse implement? A. Notify the radiation department to withhold the treatments for now. B. Ask the client about his expected goals for this hospitalization. C. Determine if the client wishes to cancel further radiation treatments. D. Explain that palliative care measures can be provided at home.

B. Ask the client about his expected goals for this hospitalization.

One hour after arriving on the postoperative unit, a woman who received spinal anesthesia 5 hours ago is complaining of severe abdominal incisional pain. Her vital signs are: temperature 99° F (37.2° C), heart rate 110 beats/minute, respiratory rate 30 breaths/minute and blood pressure 160/90 mmHg. The client's skin is pale, and the surgical dressing is dry and Intact. Which intervention is most important for the nurse to Implement? A. Provide pillow for splinting. B. Assess the IV site for patency. C. Place in a high Fowler position. D. Administer an IV analgesic.

B. Assess the IV site for patency.

The healthcare provider prescribes 5% Dextrose Injection, USP with 20 units of regular insulin for a client with a serum potassium level of 6.0 mEq/L (6.0 mmol/L) and glucose level of 180 mg/dL (10.0 mmol/L). Which evaluation is most important for the nurse to include in this client's plan of care? Reference Range Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)] A. Evaluate glucose levels before and after meals. B. Assess the serum potassium level every 4 hours. C. Monitor and document strict intake and output. D. Obtain a 12-lead electrocardiogram daily.

B. Assess the serum potassium level every 4 hours.

Heart rate 159 bpm Blood pressure 89/51 mmHg Respiratory rate 55 breaths/min Oxygen saturation 95% on 2 L of oxygen via nasal cannula Temperature 103 °F (39.4 °C) Review H and P, nurse's note, laboratory result, and flow sheet. What information should the nurse collect as part of the focused assessment for dehydration in this child? Select all that apply. A. Level of consciousness B. Capillary refill C. Temperature D. Blood pressure F. Pupil size and reactiveness G. Skin turgor H. Heart rate

B. Capillary refill C. Temperature D. Blood pressure H. Heart rate

The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication? A. Blood pressure 130/80 mm Hg. B. Cervical spine stiffness. C. Dark yellow urine. D. Excessive perspiration.

B. Cervical spine stiffness.

When caring for a client with full-thickness burns to both lower extremities, which assessment finding(s) warrant immediate intervention by the nurse? (Select all that apply.) A. Sloughing tissue around wound edges. B. Change in the quality of the peripheral pulses. C. Weeping serosanguineous fluid from wounds. D. Loss of sensation to the left lower extremity. E. Complaint of increased pain and pressure.

B. Change in the quality of the peripheral pulses. D. Loss of sensation to the left lower extremity. E. Complaint of increased pain and pressure.

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.) A. Red blood cell count (RBC). B. Core body temperature. C. Swollen lymph nodes in the groin. D. Location of the initial intravenous (IV) site. E. White blood cell count (WBC).

B. Core body temperature. C. Swollen lymph nodes in the groin. E. White blood cell count (WBC).

The client is a 70-year-old female training for a triathlon. She was hit by a car while jogging and has an abrasion that is 25 cm by 12 cm on her right leg and a liver laceration. She underwent an exploratory laparotomy to repair the liver laceration and to search for other internal injuries. The client has no chronic medical conditions and is in good health. She takes a calcium and magnesium supplement daily. She denies smoking or drinking alcohol. What age-related factors may factor into this client's wound healing? Select all that apply. A. Insulin resistance B. Decreased epidermal turnover C. Pigmentation changes D. T-cell function decrease E. Polypharmacy F. Decreased subcutaneous padding

B. Decreased epidermal turnover D. T-cell function decrease F. Decreased subcutaneous padding

The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include? A. Select a 22 gauge 1 1/2 inch (3.8 cm) needle for the intramuscular injection. B. Divide the medication into two injections with volumes under 1 mL. C. Administer into the deltoid muscle while the parent holds the infant securely. D. Use a quick dart-like motion to inject into the dorsogluteal site.

B. Divide the medication into two injections with volumes under 1 mL.

A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available for use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement?Serum Albumin Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L) A. Recommend the use of support stockings to enhance venous return B. Ensure the client receives frequent small meals containing complete proteins C. Evaluate patency of the AV graft for resumption of hemodialysis D. Instruct the client to continue to follow the prescribed rigid fluid restriction amounts

B. Ensure the client receives frequent small meals containing complete proteins

The nurse discovers that an older 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. Frequency of laxative use for chronic constipation. C. Length and frequency of the client's tobacco use. D. Ingestion of shellfish or fish oil capsules daily.

B. Frequency of laxative use for chronic constipation.

Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer? A. Protect the site from getting wet during bathing. B. Gently pat the skin dry after rinsing with water. C. Frequently apply moisturizers to prevent dry skin. D. Use a sponge to debride the affected area.

B. Gently pat the skin dry after rinsing with water.

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL (1.94 mmol/L) is alert and diaphoretic. Which action should the charge nurse take? Reference Ranges Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)] A. Collect a blood sample for hemoglobin Alc. B. Give the client a glass of orange juice. C. Notify the healthcare provider. D. Assess client for polyuria and polyphagia.

B. Give the client a glass of orange juice.

While caring for a client after a small bowel resection, the nurse is informed that the client has a history of methicillin-resistant Staphylococcus aureus (MRSA). To reduce the risk of recurrence of the MRSA in the postoperative wound, which intervention is most important for the nurse to implement? A. Report any increase in the white blood cell count. B. Instruct the family to adhere to contact precautions. C. Change the surgical dressing readily when soiled. D. Wear a face mask while performing wound care.

B. Instruct the family to adhere to contact precautions.

A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority? A. Mark an outline of the "olive-shaped" mass in the right epigastric area. B. Maintain a continuous infusion of IV fluids per prescription. C. Monitor amount of intake and infant's response to feedings. D. Instruct parents regarding care of the incisional area.

B. Maintain a continuous infusion of IV fluids per prescription.

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.) A. Use standard precautions and wear a mask. B. Monitor the client's white blood cell count. C. Institute contact precautions for staff and visitors. D. Send wound drainage for culture and sensitivity. E. Explain the purpose of a low-bacteria diet.

B. Monitor the client's white blood cell count. C. Institute contact precautions for staff and visitors. D. Send wound drainage for culture and sensitivity. E. Explain th

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period? A. Obtain vital signs every 2 hours during hospitalization. B. Provide an eye shield to be worn while sleeping. C. Teach a family member to administer eye drops. D. Encourage deep breathing and coughing exercises.

B. Provide an eye shield to be worn while sleeping.

An older client is being admitted to a short-term rehabilitation facility after a long hospitalization. The nurse is performing a functional assessment with the client. Which action should the nurse implement? A. Encourage the client to lie as still as possible during the assessment. B. Question the client about the frequency of falls in recent months. C. Assist the client with values clarification about end-of-life care options. D. Ask the client how often episodes of sundowning are experienced.

B. Question the client about the frequency of falls in recent months.

A client who is having gastrointestinal (GI) difficulties is undergoing diagnostic procedures. The client asks the nurse about the difference between ulcerative colitis and Crohn's disease. Which information should the nurse offer? A. Anal abscess and fistula rarely occur in Crohn's disease. B. Rectal bleeding is a predominant symptom in ulcerative colitis. C. Constipation is more common in Crohn's disease. D. Colitis and Crohn's disease don't involve chronic inflammation of the gastrointestinal tract

B. Rectal bleeding is a predominant symptom in ulcerative colitis.

A client who has been taking allopurinol prophylactically comes into the clinic with reoccurring gout attack episodes in left ankle. The healthcare provider changes the prescription to febuxostat. Which instruction should the nurse include in the discharge teaching? A. Eat high protein foods to achieve ideal body weight. B. Report experiencing right upper quadrant discomfort. C. Use electric heating pad when pain is at its worse. D. Replace dietary table salt with salt substitutes.

B. Report experiencing right upper quadrant discomfort.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Vital signs include: heart rate 122 beats/minute, respiratory rate 28 breaths/minute, and blood pressure 170/90 mmHg. Which assessment finding warrants the most immediate intervention by the nurse? A. Bilateral diffuse wheezing. B. Shortness of breath on exertion. C. Temperature of 100.5 °F (38.1 °C). D. Yellow expectorated sputum.

B. Shortness of breath on exertion.

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.) A. Bends from the waist to pick trash off the floor. B. Widens stance while working near the sink. C. Locks knees while preparing food on the counter. D. Brings a heavy can close to body before lifting. E. Leans forward to pull a pan from a high shelf

B. Widens stance while working near the sink. D. Brings a heavy can close to body before lifting.

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options? A. Repeat information to the client. B. Write information on a whiteboard. C. Talk loudly into the affected ear. D. Speak directly facing the client.

B. Write information on a whiteboard.

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next? A. "When did these voices begin?" B. "Do you believe the voices are real?" C. "Are you planning to obey the voices?" D. "Have you taken any hallucinogens?"

C. "Are you planning to obey the voices?"

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide? A. "Does your child seem mentally slower than his peers also?" B. "Haven't you been feeding him according to recommended daily allowances for children?" C. "His smaller size is probably due to the heart disease." D. "You should not worry about the growth tables. They are only averages for children."

C. "His smaller size is probably due to the heart disease."

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful? A. "You didn't do anything wrong." B. "Is there any particular reason why you think this is your fault?" C. "This must be a very difficult time for you." D. "With surgery, your baby should have a full recovery."

C. "This must be a very difficult time for you."

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next? A. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. B. Secure client consent for coronary angiography and percutaneous coronary intervention. C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing. D. Place an indwelling urinary catheter and institute strict intake and output measurements.

C. Administer four 81 mg aspirin tablets providing instructions to chew before swallowing.

A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement? A. Offer additional blankets and a warm drink. B. Note the client's most recent hemoglobin level. C. Administer prescribed dose of levothyroxine. D. Assess for presence of non-pitting edema.

C. Administer prescribed dose of levothyroxine.

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? A. Furosemide. B. Aspirin, low dose. C. Allopurinol. D. Enalapril.

C. Allopurinol.

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care? A. Engage the client in regularly scheduled activities during the day. B. Offer the client frequent reassurance that he/she will be safe. C. Arrange the client's environment so the client can move about freely. D. Assign a UAP to provide the client with total personal care.

C. Arrange the client's environment so the client can move about freely.

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective? A. New screening protocols were developed, validated, and implemented. B. Clients who incurred disease complications promptly received rehabilitation. C. Average client scores improved on specific risk factor knowledge tests. D. More than half at risk clients were diagnosed early in the disease process

C. Average client scores improved on specific risk factor knowledge tests.

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective? A. New screening protocols were developed, validated, and implemented. B. Clients who incurred disease complications promptly received rehabilitation. C. Average client scores improved on specific risk factor knowledge tests. D. More than half of at-risk clients were diagnosed early in their disease process.

C. Average client scores improved on specific risk factor knowledge tests.

A client has received a prescription for orlistat for weight and nutrition management. In addition to the medication, the client plans to take a multivitamin. Which teaching should the nurse provide? A. Multivitamins are contraindicated during treatment with weight-control medications such as orlistat. B. As a nutritional supplement, orlistat already contains all the recommended daily vitamins and minerals. C. Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness. D. Following a well-balanced diet is a much healthier approach to good nutrition than depending on a multivitamin.

C. Be sure to take the multivitamin and the medication at least two hours apart for best absorption and effectiveness.

Which instruction should the nurse delegate to an unlicensed assistive personnel (UAP)? A. Call the pharmacy to obtain a client's next antibiotic dose. B. Observe a client's gait to determine the need for assistance. C. Bring a sterile chest drainage unit from central supply to the unit. D. Evaluate a client's urinary catheter for proper drainage.

C. Bring a sterile chest drainage unit from central supply to the unit.

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? A. Drank a glass of water in the past 2 hours. B. Reports left chest wall pain prior to admission. C. Experiences facial swelling after eating crab. D. Verbalizes a fear of being in a confined space.

C. Experiences facial swelling after eating crab.

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress? A. Left lateral position. B. Reverse Trendelenburg. C. High-Fowler's position. D. Supine

C. High-Fowler's position.

The nurse is planning to administer two medications to a client at 0900. Which property of the drugs, if shared by both drugs, indicates a need to closely monitor the client for drug toxicity? A. Low bioavailability. B. Short half life. C. Highly protein bound. D. High therapeutic index.

C. Highly protein bound.

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 (129 mmol/L), glucose 54 mg/dl (2.97 mmol/L) and potassium 5.3 mEq/L (5.3 mmol/L). When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? Reference Ranges Sodium [Reference Range: Adult 136 to 145 mEq/L (136 to 145 mmol/L) Glucose (Reference Range: 0 to 50 years: 74 to 106 mg/dl. (4.1 to 5.9 mmol/L)) Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L) A. Broad spectrum antibiotic. B. Regular insulin. C. Hydrocortisone. D. Potassium chloride.

C. Hydrocortisone.

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority? A. Disturbed Body Image. B. Interrupted Family Processes. C. Imbalanced Nutrition: less than body requirements. D. Noncompliance with treatment regimen.

C. Imbalanced Nutrition: less than body requirements.

The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication? A. Self-care deficit. B. Activity intolerance. C. Impaired gas exchange. D. Ineffective airway clearance.

C. Impaired gas exchange.

An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide? A. Tell the client to discuss the medication side effects with the healthcare provider. B. Tell the client that the medication's side effects will most likely dissipate over time. C. Inform the client that gradual tapering must be used to discontinue the medication. D. Remind the client that feeling better is the therapeutic effect of the medication.

C. Inform the client that gradual tapering must be used to discontinue the medication.

A client whose hyperthyroidism has not been responsive to medications is admitted for evaluation. During the admission assessment the client reports to the nurse of a sudden onset of feeling apprehensive and nurse notes the client is restless and very warm to touch. Which action should the nurse implement next? A. Access laboratory results to confirm a thyroid crisis. B. Obtain a complete set of vital signs. C. Initiate intravenous access. D. Encourage relaxation and slow deep breathing.

C. Initiate intravenous access.

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)? A. Evaluate and update plans of care for clients. B. Verify the readiness of clients for discharge. C. Insert urinary catheters for uncomplicated clients. D. Receive a postoperative client and conduct the assessment.

C. Insert urinary catheters for uncomplicated clients.

An unlicensed assistive personnel (UAP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take? A. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. B. Advise the UAP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care. C. Instruct the DAP that a standard face mask is sufficient to be able to provide care for the assigned client. D. Before changing assignments, determine which staff members have fitted particulate filter masks.

C. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication? A. Assess pupillary response to light hourly. B. Initiate seizure precautions. C. Measure urinary output every hour. D. Monitor serum potassium frequently.

C. Measure urinary output every hour.

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement? A. Use firmness and direct the client to sit for awhile. B. Suggest to the client that he take a walk. C. Move the client to a quiet place on the unit. D. Encourage the client to use the punching bag

C. Move the client to a quiet place on the unit.

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? A. Palpate all peripheral pulse points for volume and strength. B. Monitor the amount of drainage from the client's incision. C. Observe both lower extremities for redness and swelling. D. Evaluate the client's ability to use an incentive spirometer.

C. Observe both lower extremities for redness and swelling.

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include? A. Limit calories on days unable to exercise. B. Monitor blood glucose levels daily. C. Regular exercise with medical approval. D. Monthly appointments with the dietitian.

C. Regular exercise with medical approval.

A female client is taking alendronate, a bisphosphonate, for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond? A. Determine how the client is administering the medication. B. Advise the client to gargle with warm salt water twice daily. C. Report the client's jaw pain to the healthcare provider. D. Confirm that this is a common symptom of osteoporosis.

C. Report the client's jaw pain to the healthcare provider.

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain? A. Physical soothing. B. Verbal reassurance. C. Simultaneous injections. D. Supine positioning.

C. Simultaneous injections.

The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child? A. Side-lying with the head slightly elevated. B. Standing with the head leaning backward. C. Sitting up and leaning forward. D. Supine with the legs raised.

C. Sitting up and leaning forward.

The nurse is assessing an older client who is having difficulty remembering events from earlier in the day and concentrating on the questions being asked. A family member shares that the client's home was recently sold and the client has just moved in with them. Which nursing response best promotes effective communication with the family? A. If the dementia is a result of Alzheimer's disease, it is often reversible even in the late stages. B. The client is exhibiting symptoms of dementia and because of age, it may be permanent. C. The client's delirium may be due to depression and is possibly reversible. D. Delirium is often a sign of underlying mental illness and institutionalization is often necessary.

C. The client's delirium may be due to depression and is possibly reversible

An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological intervention should the nurse implement? A. Clarify reality with the client about delusional thoughts. B. Reduce the client's interaction with others during day. C. Use distraction and therapeutic communication skills. D. Awaken the client for reality checks every 4 hours at night.

C. Use distraction and therapeutic communication skills.

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 health care provider? A. Yellow-tinged sputum B. Nausea and headache C. Watery diarrhea D. Increased fatigue

C. Watery diarrhea

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective? A. A salad with three kinds of lettuce and fruit. B. Vegetable soup, crackers, and milk. C. A peanut butter sandwich with soda and cookies. D. A tuna fish sandwich with chips and ice cream.

D. A tuna fish sandwich with chips and ice cream.

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

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

A client tells the nurse about jogging every day with the hope of losing weight and sleeping better. The client states that it takes hours to fall asleep at night and is experiencing fatigue and sleepiness throughout the day. Which action should the nurse implement? A. Advise the client that lifestyle changes often takes several weeks to be effective. B. Encourage the client to exercise every day to eliminate bedtime wakefulness. C. Determine the amount of weight the client has lost since increasing activity. D. Ask the client for a description of the exercise schedule that is being followed.

D. Ask the client for a description of the exercise schedule that is being followed.

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first? A. Provide a printed health care assessment form. B. Defer the health history until the client is less anxious. C. Ask the family member to answer the questions. D. Assess the surroundings for noise and distractions.

D. Assess the surroundings for noise and distractions.

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement? A. Observe for swelling at the fracture site. B. Analyze the cardiac rhythm in another lead. C. Obtain a 12-lead electrocardiogram. D. Begin chest compressions at 100/minute.

D. Begin chest compressions at 100/minute.

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? A. Diapering will be provided since hospitalization is stressful to preschoolers. B. A retraining program will need to be initiated when the child returns home. C. A potty chair should be brought from home so he can maintain his toileting skills. D. Children usually resume their toileting behaviors when they leave the hospital.

D. Children usually resume their toileting behaviors when they leave the hospital.

0900 The pts pain is 2/10. Pt requests sleeping meds for night. She has horrible thoughts and memories about the house collapsing and that it keeps her from sleeping "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." 1100 Noted that the client is using fantasy, isolation, and suppression as defense mechanisms. Notified the. Start clonazepam 0.25 mg PO every 12 hours The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration. What other treatments might be helpful for this client? Select all that apply. A. Phototherapy B. Administration of lithium C. Consciousness-raising D. Cognitive behavioral therapy E. Animal therapy F. Electroconvulsive therapy

D. Cognitive behavioral therapy E. Animal therapy

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important? A. Determine when the client last had pain medication. B. Offer to assist the client to the restroom to void. C. Review postoperative instructions with the client. D. Confirm that the client has been NPO since midnight.

D. Confirm that the client has been NPO since midnight.

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement? A. Arrange for unlicensed assistive personnel to assist the PN during the procedure. B. Acknowledge that the PN has positioned the client safely and correctly. C. Assume care of the client and assign the PN to the care of a different client. D. Demonstrate to the PN how to position the client more effectively for the procedure.

D. Demonstrate to the PN how to position the client more effectively for the procedure.

A client with persistent low back pain has received a prescription for an electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? A. Remove electrodes and observe for skin redness. B. Decrease the strength of the electrical signals. C. Check the amount of gel coating on the electrodes. D. Determine if the sensation feels uncomfortable.

D. Determine if the sensation feels uncomfortable.

The nurse-manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern? A. Potential changes in employee benefits. B. Changes in job descriptions. C. New management's expectations. D. Employees' job security.

D. Employees' job security.

When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement? A. Review transcutaneous bilirubin levels with a bilirubinometer. B. Observe and palpate newborn's breast tissue for enlargement. C. Assess for signs of fluid retention and bilateral pedal edema. D. Explain to the mother that the finding is due to increased androgen.

D. Explain to the mother that the finding is due to increased androgen.

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement? A. Refer the parents to the chaplain to provide grief counseling. B. Tell the parents that blaming each other will not change the situation C. Assure the parents that a terminal diagnosis is inevitable. D. Explain to the parents that anger is a common response to grief.

D. Explain to the parents that anger is a common response to grief.

Blood Pressure - mmHG- 80/60 Sodium 130 mEq Potassium 2.5 mEq The nurse inserts a urinary catheter and obtains a scant amount of dark amber output. 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. Initiate continuous dopamine infusion at 2 mcg/kg/minute. B. Administer promethazine 25 mg slow intravenous (IV) push every 4 hours. C. Begin potassium chloride 10 mEq over 1 hour per secondary infusion. D. Give a bolus of 0.9% sodium chloride 1,000 ml over 30 minutes

D. Give a bolus of 0.9% sodium chloride 1,000 ml over 30 minutes

An older client with a history of heart failure and admitted to the medical unit after falling at home and has become increasingly confused. The client's spouse is designated as the client's power of attorney. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first? A. Currently prescribed medications. B. Fall at home as reason for admission. C. Client's healthcare power of attorney. D. Increasing confusion of the client.

D. Increasing confusion of the client.

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take? A. Secure chest tube to the stretcher for transport. B. Administer PRN pain medication prior to transport. C. Mark the amount of chest drainage on the container. D. Keep chest tube container below the site of insertion.

D. Keep chest tube container below the site of insertion.

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? A. Apply baby lotion to the skin twice daily. B. Bathe the child daily with bath oil. C. Allow the child to wear only 100% cotton clothing. D. Keep the nails trimmed short.

D. Keep the nails trimmed short.

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately? A. Dullness bilaterally on percussion. B. Serosanguinous drainage from the chest tube. C. Diminished breath sounds in the left lower lobe. D. Mediastinal shift to the right.

D. Mediastinal shift to the right.

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea? A. Buttered whole wheat toast and coffee. B. Sausage, poached eggs, and milk. C. Granola, strawberries, and tea. D. Oatmeal, banana, and herbal tea.

D. Oatmeal, banana, and herbal tea.

After having a pulmonary angiogram, a client is diagnosed with a pulmonary embolism (PE). Which intervention is most important for the nurse to include in the client's plan of care? A. Administer IV opioids as needed for pain. B. Teach how to use incentive spirometry. C. Monitor for confusion and restlessness. D. Observe for signs of increased bleeding.

D. Observe for signs of increased bleeding.

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who reports a pounding headache. Which action should the nurse take? A. Elevate head of bed no higher than 30 degrees. B. Affirm blood glucose is below 160 mg/dL (8.88 mmol/L) C. Check for a stat intravenous diuretic prescription. D. Obtain a manual blood pressure measurement.

D. Obtain a manual blood pressure measurement.

A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? A. No specific nursing action is required. B. Collect a clean catch urine specimen. C. Instruct the client to empty the bladder. D. Obtain vital signs and breath sounds.

D. Obtain vital signs and breath sounds.

A male client reports to the on-call clinic nurse that he took two tablets of 10 mg lisinopril by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any chest pain at the moment or recently. Which action should the nurse take? A. Instruct the client to increase his intake of oral fluids until the skin flushing is relieved. B. Advise the client to place one nitroglycerin tablet under his tongue as a precaution. C. Tell the client to have someone bring him to an emergency department immediately. D. Reassure the client that facial flushing is a common side effect of the medication.

D. Reassure the client that facial flushing is a common side effect of the medication.

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement? A. Encourage the use of ice on the areola. B. Teach about the use of a breast pump. C. Offer supplemental formula feedings. D. Recommend using a breast shield.

D. Recommend using a breast shield.

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implementfirst? A. Administer a prescribed PRN dose of hydralazine. B. Assess the client's blood pressures every 15 minutes. C. Teach the client to recognize the symptoms of dysreflexia. D. Relieve any kinks or obstruction in the client's Foley tubing.

D. Relieve any kinks or obstruction in the client's Foley tubing.

A female client is admitted with complaints of abdominal pain, loss of appetite, and a weight loss of 25 pounds (11 kg) in the last four months. During the admission assessment, the client tells the nurse that she has no interest in playing cards with her friends anymore and feels worthless most days. Which nursing problem should the nurse address first? A. Anxiety as evidenced by abdominal complaints secondary to depression. B. Imbalanced nutrition as evidenced by 25 pound (11 kg) weight loss in four months. C. Chronic low self-esteem as evidenced by feelings of worthlessness. D. Risk for self-directed violence as evidenced by feelings of hopelessness.

D. Risk for self-directed violence as evidenced by feelings of hopelessness.

A client with diabetes insipidus (DI) has an average urinary output of 500 ml. of dilute urine every hour for the last 4 hours. Which laboratory test is most important for the nurse to monitor? A. White blood cell count. B. Capillary glucose. C. Urine specific gravity. D. Serum sodium.

D. Serum sodium.

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing severe side effects since taking the drug. Which side effect should the nurse report to the healthcare provider? A. Dizziness reported after initial dose. B. A change in the sleep-wake cycle. C. Mild sedation. D. Somnambulism.

D. Somnambulism.

A client receives a prescription for itraconazole. Which information provided by the client requires additional instruction by the nurse? A. Report any difficulty with breathing. B. Monitor for changes in stool color. C. Avoid the consumption of grapefruit juice. D. Take the medication with antacids.

D. Take the medication with antacids.

A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her? A. The diaphragm should be inserted 2 to 4 hours before intercourse. B. The most effective form of contraception is a diaphragm. C. Vaseline lubricant can be used when inserting the diaphragm. D. The diaphragm must be refitted after childbirth.

D. The diaphragm must be refitted after childbirth.

The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. Which explanation should the nurse offer? A. The rash is due to distended oil glands that will resolve in a few weeks. B. This rash is characteristic of a medication reaction. C. The healthcare provider is being notified about the rash. D. This is a common newborn rash that will resolve after several days.

D. This is a common newborn rash that will resolve after several days.

While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Hematocrit. B. Platelet count. C. Creatinine level. D. White blood cell (WBC) count.

D. White blood cell (WBC) count.

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother? A. Administer a half dose now. B. Give another dose. C. Mix the next dose with food. D. Withhold this dose.

D. Withhold this dose.

The nurse is reviewing nurses' notes to determine if there are any variations. Click to highlight the findings that would indicate the client has developed a complication related to pregnancy. Client is at 28 weeks. She has been receiving prenatal care since 8 weeks' gestation. Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl. (9.1 mmol/L) Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).

Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dl. (9.1 mmol/L) Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).

Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both. Respiratory Distress Cerebral Edema -Course breath sounds -Decreased level of consciousness -Seizure activity -Irritability -Bradycardia

RESPIRATORY DISTRESS: -Course breath sounds -Irritability CEREBRAL EDEMA: -Decreased level of consciousness -Seizure activity -Irritability -Bradycardia

Client Statements below. Options Understanding No Understanding -I should have taken some allergy medications before going on the hike. -I should have eaten a snack halfway through the hike. -My friend smoked cigarettes during the hike. -I have been very stressed out lately and should work on stress management. -I should have taken an extra dose of Fluticasone- Salmeterol.

UNDERSTANDING: -I should have taken some allergy medications before going on the hike -My friend smoked cigarettes during the hike -I have been very stressed out lately and should work on stress management NO UNDERSTANDING: -I should have eaten a snack halfway through the hike. -I should have taken an extra dose of Fluticasone- Salmeterol