HESI practice 4
An adolescent receives a prescription for an injection of S-matriptan succinate 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.)
Answer 0.33 mL Rationale Using ratio and proportion, 4 mg : X ml :: 6 mg : 0.5 ml 6X = 2.0 X = 0.33
The staff nurse is assigned to care of for clients on the dayshift. After receiving report, in what order should the nurse assess the assigned clients? (Arrange the nursing actions with the highest priority first, on top, and lowest priority last, on bottom.) A. An adult receiving patient controlled analgesia (PCA) whose spinal tumor causes pain and parenthesia. B. An adult with a leg infection who is scheduled to receive insulin before breakfast. C. And adolescent whose left foot was amputated last night after a tree fell on it. D. An older adult who had knee replacement and is scheduled for transfer to rehabilitation later today.
Answer 1. And adolescent whose left foot was amputated last night after a tree fell on it. 2. An adult receiving patient controlled analgesia (PCA) whose spinal tumor causes pain and parenthesia. 3. An adult with a leg infection who is scheduled to receive insulin before breakfast. 4. An older adult who had knee replacement and is scheduled for transfer to rehabilitation later today. Rationale The adolescent who his foot was amputated has a high risk for bleeding, so this client should be assessed first. Next the client with the PCA should be assessed, followed by the client who requires an injection of insulin before breakfast. The client who is scheduled for transfer to rehabilitation later in the day has the lowest priority.
Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom.) A. Document concerns and report them to the charge nurse. B. Submit a written report to the director of nursing. C. Talk to the physician as a group in a non-confrontational manner. D. Contact the hospital's chief of medical services. E. File a formal complaint with the state medical board.
Answer 1. Talk to the physician as a group in a non-confrontational manner. 2. Document concerns and report them to the charge nurse. 3. Submit a written report to the director of nursing. 4. Contact the hospital's chief of medical services. 5. File a formal complaint with the state medical board. Rational Nurses have both an ethical and legal responsibility to advocate for clients' physical and emotional safety. Talking with the physician in a non-confrontational manner is the first step in conflict resolution. If this is not effective, the organizational chain of ineffective, a formal complaint with the state medical board should be implemented.
The healthcare provider prescribes a maintenance dose of norepinephrine bitartrate at 4 mcg/minute for a client with septic shock. The pharmacy provides a solution containing 8 mg in 250 ml of D3W. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numerical value only. If rounding is required, rounded to the nearest tenth.)
Answer 7.5 Rationale First calculate the mcg/hour. 4 mcg/min x 60 min = 240 mcg/hour Convert the solution strength in mg to mcg. 8 mg x 1,000 mcg = 8,000 mcg Use the solution strength available to calculate the ml/hr. 8,000 mcg : 250 ml = 240 mcg : X ml 8,000X = 60,000 X = 7.5 ml/hour To infuse 4 mcg/minute, the infusion rate should be set at 7.5 ml/hour.
After teaching a male client with chronic kidney disease (CKD) about a therapeutic diet for his condition, the client is presented with a menu from which to choose foods to include in his meals for the next 24 hours. Selection of which menu of foods indicates that the teaching was effective? (Select all that apply.) A. A slice of whole-grain toast. B. Half cup of black beans. C. A ham and cheese sandwich. D. A bowl of cream of wheat. E. Two bananas.
Answer A. A slice of whole-grain toast. D. A bowl of cream of wheat. Rationale (A and D) are correct. Those with CKD have elevated serum potassium, sodium, and protein levels. Whole-grain toast (A) and cream of wheat (D) are low in potassium, sodium, and protein. Black beans (B) are high in protein. A ham and cheese sandwich (C) contains high levels of protein and sodium. Bananas (E) are high in potassium.
The nurse is verifying a blood transfusion for a client who is blood type is A positive. Which blood type is incompatible for this client? A. AB, Rh positive. B. O, Rh negative. C. A, Rh negative. D. O, Rh positive.
Answer A. AB, Rh positive. Rationale Red blood cells )RBCs) are typed according to the presence of an antigen, A, B, or D (Rh positive). An antigen antibody reaction occurs when the antibody found on a recipient's RBCs reacts to the donor RBCs and since (A) contains type B, it is incompatible with the client's blood type A blood. Blood type O is referred to as the universal donor, so the client could receive either (B and D). Rh negative (C) blood can be given to a client who is Rh positive but not to clients with Rh negative blood who will become sensitized by exposure to Rh positive blood products.
Which conditions are most likely to respond to treatment with antihistamines? (Select all that apply.) A. Allergic rhinitis. B. Contact dermatitis. D. Otis media. D. Bronchitis. E. Myocarditis.
Answer A. Allergic rhinitis. B. Contact dermatitis. Rationale (A and B) are correct. Allergic rhinitis (A) and contact dermatitis (B) occur following direct contact with an irritant or allergen. Antihistamines are used to relieve symptoms associated with histamine release from mast cells in allergic reactions. Antihistamine therapy is not indicated for (C, D, and E) because they are nonallergic conditions.
A client with bleeding esophageal varices receives vasopressin (Pitressin) IV. What should the nurse monitor for during the IV infusion of this medication? A. Chest pain and dysrhythmia. B. Vasodilation of the extremities. C. Hypertension and tachycardia. D. Decreasing G.I. cramping and nausea.
Answer A. Chest pain and dysrhythmia. Rationale In large doses, vasopressin may produce increased blood pressure, coronary insufficiency, myocardial ischemia or infarction, and dysrhythmia (A). (B, C, and D) are not typically associated with the use of vasopressin.
Prior to insertion of an indwelling urinary catheter, what client information is most important for the nurse to obtain? A. Client allergies to antiseptic solutions. B. Previous history of urinary tract infections. C. Client's ability to increase fluid intake. D. Color, clarity, and odor of urine.
Answer A. Client allergies to antiseptic solutions. Rationale Knowledge of allergies prior to cleansing with a medication or solution (A) is the highest priority because it may prevent a possible allergic reaction. (A, B, and D) provide relevant information when planning client care, but (A) should be obtained first.
A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the healthcare provider before administering which of the client's prescribes medications? (Select all that apply.) A. Clopidogrel (Plavix), an antiplatelet agent, given orally. B. Methylprednisolone (solu-medrol), a corticosteroid, to be given IV. C. Nitroglycerin (nitro-dur), an antianginal, to be given transdermally. D. Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous. E. Furosemide (lasix), a loop diuretic, to be given intravenously.
Answer A. Clopidogrel (Plavix), an antiplatelet agent, given orally. B. Methylprednisolone (solu-medrol), a corticosteroid, to be given IV. D. Enoxaparin (lovenox), a low-molecular weight heparin to be given subcutaneous. Rationale (A, B, and D) are correct. The clients emesis has a coffee ground appearance, which is an indication of bleeding in the gastrointestinal tract. The nurse should consult with the healthcare provider before administering medications that increase risk for bleeding, including (A, B, and D). (C and E) are unlikely to increase the risk for bleeding.
A woman at 12-weeks gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should also discuss which issue about pregnancy at this initial visit? A. Cultural practices related to childbearing. B. Concerns about parenting. C. Knowledge about labor and delivery. D. Complications associated with childbirth.
Answer A. Cultural practices related to childbearing. Rationale To ensure culturally competent care, information that is specific to the client's cultural beliefs, practices, and family values (A) should be discussed to ensure client care is culturally sensitive. (B, C, and D) are not indicated for this gestational period and may increase the client's anxiety.
A male client was transferred yesterday from the emergency department to the telemetry unit because he had ST depression and resolved chest pain. When his EKG monitor alarms for ventricular tachycardia (VT), what action should the nurse take first? A. Determine the client's responsiveness and respirations. B. Bring the crash cart to the room to defibrillate the client. C. Immediately initiate chest compressions. D. Notify the emergency response team.
Answer A. Determine the client's responsiveness and respirations. Rationale Activities, such as brushing teeth, can mimic the waveform of VI, so first he client should be assessed (A) to determine if the alarm is accurate. The crash cart can be brought to the room by someone else and defibrillation (B) delivered as indicated by the client's rhythm. Based on as assessment of the client, CPR© as summoning the emergency response team (D) may be indicated.
An adult woman suffered burns to her face and chest resulting from a grease fire. On admission, airway protection with endotracheal intubation was required and a 2 liter bolus of normal normal saline was administered. Currently the normal saline is infusing at 250 ml/hour. The client's heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP) is 4 mm H2O. Which intervention should the nurse implement? A. Infuse an additional bolus of normal saline. B. Increase the oxygen delivered by the ventilator. C. Bring a tracheotomy tray to the bedside. D. Lower the head of the bed to a recumbent position.
Answer A. Infuse an additional bolus of normal saline. Rationale Burns require a massive amount of fluid resuscitation. A low CVP (normal 5 to 12 mm H2O) and low blood pressure indicates the need for additional IV fluids (A). The ventilator respirations may need to be increased, but there is no evidence to support increasing the oxygen (B). (C) is not necessary, and (D) is contraindicated.
During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement? (Select all that apply.) A. Instruct the client to keep the left leg straight. B. Keep the head of the bed at a 60 degree angle. C. Observe the insertion site for a hematoma. D. Manually flush the arterial sheath hourly. E. Circle first noted drainage on the dressing.
Answer A. Instruct the client to keep the left leg straight. C. Observe the insertion site for a hematoma. E. Circle first noted drainage on the dressing. Rationale (A, C, and E) on the correct responses. The clients leg should remain straight while the sheath not further occluded or the catheter kinked by bending the leg. The side should be observed for significant internal bleeding at the site. Circling the drainage (E) helps to monitor bleeding over flat, not (B), to avoid bending at hip which may kink sheath. Manual flushing of the sheath (D).
Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? A. Intravenous administration of thyroid hormones. B. Oral administration of hypnotic agents. C. Intravenous bolus of hydrocortisone. D. Subcutaneous administration of vitamin k.
Answer A. Intravenous administration of thyroid hormones. Rationale: The high mortality of myxedema coma requires immediate administration of IV thyroid hormones (A). (B) Is contraindicated, because eves small doses can cause profound somnolence lasting longer than expected. (C) Is administered to clients diagnosed with adrenal insufficiency (Addisonian crisis) and (D) to clients who have had an overdose of warfarin.
A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement? A. Measure vital signs. B. Auscultate breath sounds. C. Palpate the abdomen. D. Observe the skin for bruising.
Answer A. Measure vital signs. Rationale Abrupt withdrawal of an exogenous source of corticosteroid can precipitate adrenal insufficiency, hypoglycemia, hypokalemia, and circulatory collapse. It is most important for the nurse to assess for signs of impending shock. (B, C, and D) are other useful interventions but of less priority then (A).
An older female who ambulates with a quad-cane prefers to use a wheelchair because she is halting and unsteady gait at times. Which interventions should the nurse implement? (Select all that apply.) A. Move personal items within clients reach. B. Lower bed to the lowest possible position. C. Raise all bed rails when client is resting. D. Give directions to call for assistance. E. Assist client to the bathroom q 2 hours. F. Encourage the use of the wheelchair.
Answer A. Move personal items within clients reach. B. Lower bed to the lowest possible position. D. Give directions to call for assistance. E. Assist client to the bathroom q 2 hours. Rationale (A, B, D, and E) are correct. A client who needs assistive devices such as quad-cane, is at risk for falls. Precautions that should be implemented include ensuring that personal items are within reach (A), the bed is in the lowest position (B), and directions should be given to call for assistance (D) to minimize the risk for falls. Frequently assisting the client to the bathroom (E) helps ensure the client does not go to the bathroom by herself, thereby decreasing the possibility of falling. Raising all bed rails (C) may be unwarranted use of restraint while also presenting a barrier to the client's mobility. Encouraging use of a wheelchair (F) impairs the client's mobility.
The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? A. Muscle spasms of the back and neck. B. Rocks back and forth in the chair. C. Shuffling gait and stooped posture. D. Lip smacking and frequent eye blinking.
Answer A. Muscle spasms of the back and neck. Rationale An extra pyramidal symptom (EPS) characterized by abnormal muscle spasms of the neck (A) requires immediate intervention because it can cause difficulty swallowing and jeopardize the airway. Though (A, B and C) are also EPS caused by antipsychotic medications used to manage schizophrenia, (D) has the highest priority to insure client safety is (A).
An older woman who lives alone in a two-story home is admitted after falling while shopping. X-rays reveal a fractured left hip. With no immediate family in the area, the client is concerned about her pets. Which intervention should the nurse implement? A. Palpate and mark pedal pulses. B. Alert social worker of clients concerns. C. Assess ability to bear weight when standing. D. Evaluate pain using a standard pain scale. E. Support left leg with two pillows.
Answer A. Palpate and mark pedal pulses. B. Alert social worker of clients concerns. D. Evaluate pain using a standard pain scale. Rationale (A, B, and D) are correct. A change in the pulses (A) may indicate decreased circulation. The social worker (B) can address the client's concerns regarding her home and pets. Pain (D) should be assessed and treated. Bearing weight (C) and elevation on pillows (E) is contraindicated because the client should be on bed rest with traction applied to the left leg.
A client with HIV and pulmonary coccidioidomycosis is receiving amphotericin B. Which assessment finding should the nurse report to the healthcare provider? A. Urinary output of 25mL per hour. B. Hemoglobin level of 10 g/dl or 100 g/L (SI). C. Hyperactive bowel sounds. D. Oral temperature of 100.4° F (38 C).
Answer A. Urinary output of 25mL per hour. Rationale A major adverse effect of amphotericin B, an antifungal, is nephrotoxicity, so the nurse should monitor throughout therapy and report decreased urinary output (A). The client's hemoglobin is low due to fatigue and possible bleeding. Hyperactive bowel sounds (C) are related to the diarrhea, but nephrotoxicity is more important. (D) is an expected finding since the client clinically presents with this fungal lung infection (Coccidioides immitis).
An older female client with long term type 2 diabetes mellitus DM is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complications of DM, which assessment should the nurse obtain? (Select all that apply.) A. Visual acuity. B. Serum creatine and blood urea nitrogen (BUN). C. Signs of respiratory tract infection. D. Sensation in feet and legs. E. Skin condition of lower extremities.
Answer A. Visual acuity. B. Serum creatine and blood urea nitrogen (BUN). D. Sensation in feet and legs. E. Skin condition of lower extremities. Rationale (A, B, D, and E) are correct. Clients with diabetes mellitus are prone to macrovascular and microvascular complications, such as diabetic retinopathy, neuropathy, peripheral neuropathy, and peripheral vascular disease (PVD). Signs of visual changes (A), decreased renal function (B), peripheral neuropathy (D), PVD as exhibited by skin changes (E) should be assessed for changes consistent with long-term complications. While clients with DM are prone to infection, respiratory infections (C) are not a high-risk, long-term problem.
The nurse administers an antibiotic to a client with respiratory tract infection. To evaluate the medication's effectiveness, which laboratory values should the nurse monitor? (Select all that apply.) A. White blood cell (WBC) count. B. Red blood cell (RBC) count. C. Serum potassium. D. Urinalysis. E. Sputum culture and sensitivity. F. Blood urea nitrogen (BUN).
Answer A. White blood cell (WBC) count. E. Sputum culture and sensitivity. Rationale (A and E) are correct. Antibiotic agents are used to treat bacterial infections. An increase in the WBCs indicates infection so the WBC count (A) should be monitored. The sputum culture and sensitivity report (E) reflects microorganisms in the sputum and their sensitivity to antiinfective agents. Changes in (B, C, D, and F) do not show the effectiveness of antibiotic treatment.
The nurse is conducting health assessments. Which assessment finding increases a 56-year-old woman's risk for developing osteoporosis? A. Body mass index of (BMI) of 31. B. 20 pack-year history of cigarette smoking. C. Birth control pill usage until age 45. D. Diabetes mellitus in family history.
Answer B. 20 pack-year history of cigarette smoking. Rationale Cigarette smoking (2 packs/day x 310 years = 20 packs-year) (B) increases the risk of osteoporosis. (A) BMI of 30 or greater falls in the category of obesity which increase weight bearing that is protective against osteoporosis. (C) contain estrogens, and are also protective against development of osteoporosis. (D) is not related to the development of osteoporosis.
At 1130, the nurse assumes care of an adult with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client's electronic health record, which priority nursing action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the clients medical record.) A. Obtain antibiotic peak and trough levels. B. Administer insulin per sliding scale. C. Assess appearance of foot wound. D. Initiate hourly urine output measurements.
Answer B. Administer insulin per sliding scale. Rationale A blood glucose level of 450 mg/dl or 25 mmol/L (SI) indicates significant hyperglycemia that requires immediate treatment with insulin (B) to prevent worsening of vital signs, as ketoacidosis (DKA) or hyperglycemic hyperosmolar nonketotic syndrome (HHNS) develop. Infection often contributes to the onset of DKA and HHS so (A and C) are important, but immediate control of the hyperglycemia is a higher priority. (D) is indicated in response to the onset of hypotension and should be implemented after (B).
A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? A. Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock. B. Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. C. Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzyme levels. D. Notify the healthcare provider of the clients increased chest pain and called for the defibrillator crash cart.
Answer B. Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. Rationale Administering morphine sulfate and increasing oxygen supply (B) are the priority interventions for symptoms of acute myocardial infarction, and should be supplemented with nitroglycerin and aspirin administration. (A) may result in fluid overload that the impaired myocardium cannot handle effectively. (C and D) are helpful interventions that should be implemented after (B) is implemented.
During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 minutes ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply.) A. Situation. B. Background. C. Assessment. D. Recommendation. E. Rationales.
Answer B. Background. C. Assessment. D. Recommendation. Rationale (B, C, and D) are correct. The current situation is reported regarding the client's nausea and pain (A). Based on SBAR communication, critical information about the client's clinical history (B), and assessment (C) such as pain scale or vital signs related to client's response to medication, are not included, nor are any recommendations for further follow-up (D). (E) is not a component of SBAR communication.
A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? A. Explain that it may take several weeks for the medication to be effective. B. Confirm the desired effect of the medication has been achieved. C. Notify the health care provider than a change may be needed. D. Evaluate when and how the medication is being administered to the client.
Answer B. Confirm the desired effect of the medication has been achieved. Rationale Trazodone (Desyrel), an atypical antidepressant, is prescribed for client with AD to improve mood and sleep (B). (A and C are not indicated since the desired effect has been achieved. If the medication was not effective, (D) is indicated to determine if the medication is being taken correctly.
A 15-year-old male is attending an after school, adolescent group session because he frequently loses his temper, argues with his teachers, and refuses to comply with classroom rules. During the group session, the adolescent repeatedly blames others regardless of the situation. To help modify the adolescent's behavior, what action should the nurse implement. A. Encourage the client to ventilate his feelings of anger. B. Describe the consequences of his behavior in concrete terms. C. Ignore blaming behavior and praise the client's appropriate behavior. D. Explain that blaming others limits his psychological growth.
Answer B. Describe the consequences of his behavior in concrete terms. Rationale To proactively manage this adolescent's oppositional behavior, the nurse should describe the consequences for specific, offensive behaviors (B). It is important for clients to verbalize feelings (A), but understanding the relationship between actions and consequences takes priority. Although providing positive feedback for appropriate behavior is a reinforcer that helps shape behavior and increase self-esteem, the blaming behavior should not be ignored (C). Explaining that the blaming behavior limits the clients psychological growth (D) is likely to elicit defensiveness.
A client with secondary adrenal cortical insufficiency is complaining of fatigue. Which laboratory test results support this finding? (Select all that apply.) A. High level of androgens. B. Low level of adrenocorticotropic hormone (ACTH). C. High level of antidiuretic hormone (ADH). D. Low level of cortisol. E. Low level of aldosterone.
Answer B. Low level of adrenocorticotropic hormone (ACTH). D. Low level of cortisol. Rationale (B and D) are correct. In secondary hormone imbalances, the pituitary gland produces less ACTH (B) to stimulate the adrenal cortex. Adrenal cortical insufficiency results in decreased secretion of the adrenal cortisol (D) and sex hormones, not (A). ADH (C) is secreted by the posterior pituitary and influences reabsorption of water in the renal tubules. Aldosterone is secreted by the adrenal cortex but is controlled by the renin-angiotensin-aldosterone axis, so (E) is incorrect.
A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restraints are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care? A. Understand pain management scale. B. Maintain effective breathing patterns. C. Absence of ventilator associated pneumonia. D. No injuries refer to soft restrains occur.
Answer B. Maintain effective breathing patterns. Rationale Basic airway management (B) is the priority. Pain management (A), risk of infection (C), and prevention of injury (D) do not have the same priority as (C).
The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. What should the nurse do next? A. Attach the tubing to the saline lock. B. Open the roller clamp on the tubing. C. Label the bag of IV solution. D. Flush the saline lock with saline.
Answer B. Open the roller clamp on the tubing. Rationale After connecting the IV tubing to the IV solution, the nurse needs to clear the air out of the tuning by first squeezing the drip chamber and then opening the roller clamp (B) to allow IV fluid to displace air out of the tubing. After the tubing is cleared of air, the saline lock can be flushed (D) and the tubing connected to the lock (A). (C) is indicated if additional medication is added to the IV solution.
A client with a medical diagnosis of ruptured cerebral aneurysm exhibits the symptoms: no eye opening; no sound vocalized; and flexion to pain (decorticate posturing). What score on the Glasgow Coma Scale should the nurse calculate for this client? A. 13. B. 9. C. 5. D. 3
Answer C. 5 Rationale This client receives a score of 5 (C) out of a possible 15 points on the Glasgow Coma Scale (1 point for eye, 1 point for verbal, 3 points for motor). (A and B) reflect higher eye-opening, verbal, or motor abilities than the assessment findings indicate. (D) does not reflect the 3 points given for motor ability (flexion to pain, or decorticate posturing).
The nurse is counseling a family whose 5-year-old daughter was killed by a hit and run driver. The 10-year-old daughter child tells the nurse that she should have been watching her sister better. After the nurse tells the child she did not cause the accident, which response is best for the nurse to provide? A. Explain to the child that the accident was the fault of the person driving. B. Inquire if the parents or others were watching when the accident occurred. C. Ask the child to share what could have been done to stop this from happening. D. Question the parents if the child had the duty to watch her sister often.
Answer C. Ask the child to share what could have been done to stop this from happening. Rationale Children not only feel sorrow but also guilt over the death of a sibling. Although the nurse emphasizes that the child did not cause the accident or death of her sister, the 10-year-old is feeling guilty. Exploring the child's feelings by asking the child what could have been done to prevent this tragic accident (C) is the first response to help the child and family cope with their grief and underlying guilt about the accident. (A and B) displace the reality of the accident and lay blame. (D) can cause the parents to feel guilty.
A female client is admitted to the hospital for evaluation of severe abdominal pain. Laparoscopy examination reveals multiple ovarian cysts and a total abdominal hysterectomy with bilateral salpingo-oophorectomy is scheduled for the next day. In providing care for this client the evening before surgery, what nursing action has the highest priority? A. Assess IV sites for administration of fluids. B. Administer a douche and an enema to the client. C. Ask the client about her thoughts or concerns. D. Discuss prevention of infection after surgery.
Answer C. Ask the client about her thoughts or concerns. Rationale Promoting a positive body image and decreasing anxiety related to impending surgery are important factors related to preoperative care (C). (A) is not as important. (B) may be prescribed preoperatively, but clients often choose to self-administer these procedures. (D) is most dependent on the medical and nursing care provided during and after surgery.
After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? A. Dark, rust-colored urine. B. Urine output 300 ml/hr. C. Blood pressure 170/98. D. Joint and muscle aches.
Answer C. Blood pressure 170/98. SLE can result in renal complications such as glomerulonephritis, which can cause a critically high blood pressure (C) that necessitates immediate intervention. Dark rust-colored urine (A), joint muscle aches (D), and increased urinary output (B) are symptoms of glomerulonephritis and should be treated once the blood pressure is under control.
A preeclamptic client who delivered 24 hours ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? A. Discontinue the magnesium sulfate immediately. B. Decrease the client's iv rate to 50 ml per hour. C. Continue with the plan of care for this client. D. Change the client's to NPO status.
Answer C. Continue with the plan of care for this client. Rationale The nurse should continue with the client's plan of care (C). Diuresis in 24 to 48 hours after birth is a sign of improvement in the preeclamptic client. As relaxation of arteriolar spasms occurs, kidney perfusion increases. With improved perfusion, fluid is drawn into the intravascular bed from the interstitial tissue and then cleared by the kidneys. (A, B, and D) are not indicated at this time.
A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome? A. Lorazepam (Ativan). B. Famotidine (Pepcid). C. Thiamine (Vitamin B1). D. Atenolol (Tenormin).
Answer C. Thiamine (Vitamin B1). Rationale Thiamine replacement (C) is critical in preventing the onset of Wernickes encephalopathy, an acute triad of confusion, ataxia, and abnormal extraocular movements, such as nystagmus related to excessive alcohol abuse. Other medications are not indicated. (A) is a benzodiazepine used in the treatment of alcohol withdrawal. (B) is an H2 antagonist prescribed for the client's gastric distress. (D) is a beta blocker which is prescribed for hypertension which commonly occurs with long term alcohol ingestion.
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan? A. Keep an antidote available in the event of hemorrhage. B. Continue obtaining scheduled laboratory bleeding tests. C. Eliminate spinach another green vegetables in the diet. D. Avoid use of nonsteroidal anti-inflammatory drugs (NSAID).
Answer D. Avoid use of nonsteroidal anti-inflammatory drugs (NSAID). Rationale Dabigatran, a direct reversible thrombin inhibitor, is prescribed to reduce the risk of stroke in clients with atrial fibrillation. The risk of bleeding and gastrointestinal events can be significant and the concomitant use of NSAIDs (D) and other anticoagulants should be avoided. There is no antidote for dabigatran (A). Although dabigatran does not require INR monitoring (B), any indicator of bleeding should be evaluated with hemoglobin and hematocrit tests. (C) is not indicated.
A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client? A. Cheddar cheese and crackers. B. Carrot and celery sticks. C. Beef bologna sausage slices. D. Dry roasted almonds.
Answer D. Dry roasted almonds. Rational Alcoholism promotes inadequate food intake and gastrointestinal loss of magnesium. Hypomagnesuim (less than 1.5 mEq/L or 0.75 mmol/L SI) can lead to cardiac dysrhythmias. Foods rich in magnesium include green leafy vegetables and nuts and seeds (D). (A, B, and C) are snacks that provide much lower amounts of magnesium per serving.
A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide? A. Plans to move into the dormitory need to be postponed for at least a semester. B. These early signs of an infection may require medical treatment with antibiotics. C. These are common side effects of the vaccines and will resolve in a few days. D. Immunizations can trigger a relapse of the disease, so get plenty of extra rest.
Answer D. Immunizations can trigger a relapse of the disease, so get plenty of extra rest. Rationale Numerous triggers, including immunization, can cause an exacerbation, or relapse, of multiple sclerosis. During a relapse, the client with multiple sclerosis needs additional rest (D) to combat the extreme fatigue and other debilitating symptoms that occur. Instructing the client to postpone plans for a semester (A) is premature until it is determined how long the symptoms will last. Fatigue and visual problems are not typically early symptoms of an infectious process (B) or common side effects of vaccination (C).
471. A male infant born at 28-weeks gestation at an outlying hospital is being prepared for transport to a respiration are 92 breaths/minute and his heart rate is 156 beats/minute. Which drug is the transport administration to this infant? A. Give ampicillin 25 mg/kg slow IV push. B. Deliver 1:10,000 epinephrine 0.1 ml/kg per endotracheal tube. C. Administer digoxin 20 mcg/kg IV. D. Instill beractant 100 mg/kg in endotracheal tube.
Answer D. Instill beractant 100 mg/kg in endotracheal tube. Rationale RDS (respiratory distress syndrome) results primarily from immature lungs and lack of surfactant mixture that coats the alveoli and prevents their collapse at the end of respiration. Beractant be given per enditracheal tube 15 minutes to 8 hours after birth. (A) is indicated if sepsis is suspected in this premature infant. Although (B) is indicated in cardiac arrest, the risk of respiratory distress rate is within normal limits, so (C) is not needed.
A client with chronic obstructive lung disease who is receiving oxygen at 1.5 liters/minute by nasal cannula, is currently short of breath. What action should the nurse take? A. Increase oxygen to 3 liters/minute. B. Have the client breathe into a paper bag. C. Ask the client to take short, rapid breaths. D. Instruct the client in pursed lip breathing.
Answer D. Instruct the client in pursed lip breathing. Rationale Pursed-lip breathing (D) keeps the alveoli open by maintaining positive pressure in the thoracic cavity. Increasing the oxygen level (A) decreases the hypercarbia drive to breathe. (B and C) are not indicated.
The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next? A. Remove the catheter and insert into urethral opening. B. Observe for urine flow and then inflate the balloon. C. Insert the catheter further and observe for discomfort. D. Leave the catheter in place and obtain a sterile catheter.
Answer D. Leave the catheter in place and obtain a sterile catheter. Rationale The catheter is in the vaginal opening.
A client at 30-weeks gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 0.25 mg is given subcutaneously. Based on which findings should the nurse withhold the next dose of this drug? A. Maternal blood pressure of 90/60. B. Fetal heart rate of 170 beats per minute for 15 minutes. D. Maternal pulse rate of 162 beats per minute. E. Serum potassium of 2.8 mg/dl.
Answer D. Maternal pulse rate of 162 beats per minute. Rationale The nurse should check the maternal pulse prior to administering the beta sympathomimetic drug terbutaline, and notify the healthcare provider before administration of the drug if the pulse is over 140 beats per minute (C). (A) is within normal limits because peripheral vasodilation accompanies pregnancy and causes the BP to decrease. (B) is a normal response of the fetus to maternal use of terbutaline, but should be reported if above 180. (D) is not an abnormal findings due to the shift of potassium to intracellular spaces that can occur with this medication.
Medical asepsis requires that the nurse include what handwashing technique? A. Hold hands higher than the elbows and scrub vigorously. B. Use hot water to ensure that pathogens are killed. C. Use a circular motion washing from clean to dirty areas. D. Rinse soap off, keeping hands and forearms lower than elbows.
Answer D. Rinse soap off, keeping hands and forearms lower than elbows. Rationale Hands and forearms should be kept lower than elbows during handwashing (D) because water should flow from the least to most contaminated areas, and the hands are considered the most contaminated part. (A, B, and C) are incorrect techniques.
A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client's right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax? A. Continuous bubbling in the water seal chamber. B. Decrease bright red blood drainage. C. Tachypnea and difficulty breathing. D. Tracheal deviation toward the left lung.
Answer D. Tracheal deviation toward the left lung. Rationale Tracheal deviation toward the unaffected left lung (D) with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax. Bubbling (A) in the water seal chamber indicates that there is a loose connection in the chest drainage system. A decrease in the amount of drainage (B) occurs with an obstruction of a displaced chest tube. Tachypnea with difficulty breathing (C) are early signs of respiratory distress, which can result from a variety of causes, including a pneumothorax.
The nurse is preparing dose # 7 of an IV piggyback infusion of tobramycin for a 73-year-old client first degree burns is infected Pseudomonas aeruginosa. Which assessment data warrants further intervention by the nurse? A. Peak and through levels has not been drawn since the tobramycin was started. B. Today's lab report indicates a white blood cell count of 13,000 cells/mm3. C. A serum creatinine level of 1.0 mg/dl is documented on yesterday's flowsheet. D. The culture growth from the burn areas is sensitive to aminoglycosides
Answer A. Peak and through levels has not been drawn since the tobramycin was started. Rationale Serum peak and trough levels (A) should be drawn periodically during IV aminoglycoside therapy to determine if the tobramycin level is at the therapeutic or toxic range, which can cause nephrotoxicity and ototoxicity. (B) infection is an expected finding. (C) is within normal limits. Nebcin is the desired antibiotic for the culture growth (D) to warrant further action.
The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.) A. Don sterile gloves and prepare to sterile field. B. Open the sterile catheter kit close to the client's perineum. C. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus D. Cleanse the urinary meatus using the solution, swabs, and forceps provided.
Answer: ODCP 1. Open the sterile catheter kit close to the client's perineum. 2. Don sterile gloves and prepare to sterile field. 3. Cleanse the urinary meatus using the solution, swabs, and forceps provided. 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus. Rationale First the kit should be open near the clients to minimize the risk of contamination during the collection of the sterile specimen. Once the kit is opened, sterile gloves should be donned to prepare the sterile field. Then the clients' meatus should be cleansed, and the catheter inserted while to distal end of the catheter drains urine into the sterile specimen cup or receptacle.
The nurse assesses a child in 90-90 traction. Where should did nurse assess for signs of compartment syndrome?
Rationale Compartment syndrome is the result of swelling and subsequent reduction in circulation to the area distal to the compartment. This can be a complication of traumatic injury and cast administration, so it is important to assess circulation distal to the casted prolonged capillary refill.
The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image).
The second panel is placed to the left of the apex of the heart to allow the most effective passage of an electric shock throughout the heart, sufficient to depolarize the myocardial cells. Subsequent repolarization allows the SA node to recapture it's role as the pacemaker of the heart.