HESI practice 5

A client with heart failure (HF) is receiving an IV infusion of 0.9% normal saline 250 ml at a keep-vein-open (KVO) rate of 40 ml/hour. The IV tubing has a minidrip chamber that delivers 60 microdrops/ml. The nurse should regulate the micro drop gravity IV infusion to deliver how many microdrops/minute? (Enter numeric value only.)

Answer 40 Rationale Use the formula, volume/time in minutes x drop factor. 40 ml / 60 minutes x 60 microdrops/minute = 40 microdrops/minute

When conducting a physical examination, the nurse is assessing a client's abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider what pathology? A. Aneurysm. B. Appendicitis. C. Tympany. D. Hernia.

Answer A. Aneurysm. Rationale The 7 Fs of abdominal distention focus on fat, flatus, fluid, feces, fetus or fetus growth, and fibroid cyst. However, none of these pulsate, indicating that and abdominal aneurysm is the most likely source of pulsation (A). (B) is associated with rebound pain at McBurney's point (localized in RLQ) or the periumbilical region. (C) is a percussed sound simulating a drum and reflects entrapped air over a large area of the abdomen. (D) is a bulge over an old operative scar in the umbilical or inguinal region that is apparent with increased intraabdominal pressure resulting from positional changes or the Valsalva maneuver.

An elderly female resident of a long-term care facility is experiencing frequent episodes of urinary incontinence. Which intervention is best for the nurse to implement with this client? A. Decrease time intervals between toileting assistance and encourage Kegel exercises. B. Apply disposable undergarments and change frequently to prevent skin breakdown. C. Offer emotional support and explain that urinary incontinence is a common occurrence among older women. D. Limit fluid intake during the evening meal and throughout the evening hours until bedtime.

Answer A. Decrease time intervals between toileting assistance and encourage Kegel exercises. Rationale Age-related changes to the urinary tract including hypertrophy and thickening of the bladder wall and muscle, often result in urinary incontinence. Frequent toileting assistance and Kegel exercises (A) are effective interventions. (B) manages the symptoms of incontinence, but does not address the actual case. (C) may be helpful, but will not decrease the incontinence. (D) may help prevent nighttime incontinence, but does not address daytime occurrences, nor does it address the underlying etiology.

A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement? A. Encourage the client to express her feelings regarding the upcoming procedure. B. Explain to the client that her behavior invades the rights of the nursing staff. C. Teach the client strategies to control her obsessive-compulsive behavior. D. Ask the client to explain why she is keeping a detailed record of her nursing care.

Answer A. Encourage the client to express her feelings regarding the upcoming procedure. Rationale The behaviors exhibited by a client with a personality disorder are maladaptive responses to anxiety, and may worsen during periods of high anxiety. Encouraging the client to act out her anxiety (A) is likely to reduce her anxiety. The client's behavior does not violate the rights of the nursing staff (B). Personality disorders are long-standing and cannot be resolved in an acute care environment (C). "Why" questions (D) are not helpful in responding to the clients anxiety.

The nurse is administering 18 units of Humulin N at 1630 to a client with Type 2 diabetes. Which intervention is most important for the nurse to implement? A. Ensure that the client eats the bedtime snack provided by dietary. B. Obtain the client's blood glucose level prior to eating dinner. C. Encourage the client to ambulate in the hall prior to going to sleep. D. Assess the clients serum potassium level prior to administering insulin.

Answer A. Ensure that the client eats the bedtime snack provided by dietary. Rationale Humulin N is an intermediate-acting insulin that peaks 6 to 8 hours after being administered, so the client must eat a bedtime snack to prevent late night hypoglycemia (A). (B and C) do not affect the Humulin N insulin administration. Potassium is monitored during diabetic ketoacidosis, but does not affect the administration of insulin (D).

An older male adult who has type 2 diabetes mellitus (DM) and a history of heart failure (HF) tells the home home home health nurse that his daughter brought him herbal melatonin to help him with his sleeping problems. What information should the nurse provide to the client? A. Explain that melatonin can interfere with the action of prescribed medications for DM and HF. B. Tell the daughter to check with the healthcare provider before providing herbal supplements. C. Remind the client that herbal medications are not regulated by the Food and Drug Administration. D. Melatonin can cause nightmares and decrease libido, and should not be used at his age.

Answer A. Explain that melatonin can interfere with the action of prescribed medications for DM and HF. Rationale Melatonin raises the blood sugar level and slows clotting mechanism, so it should not be taken with anticoagulants in use for chronic cardiac disease and diabetic medications (A). (B and C) are accurate, but this information is not as essential as (A). Nightmares and a decreased sex drive (D) are undesirable effects that may occur with use of melatonin, but these are not life-threatening problems.

An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (Tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose? A. LDH or LD, SGOT or ALT, SGPT or AST. B. White blood count, hemoglobin, hematocrit. C. BUN, creatinine, specific gravity. D. pH, PCO2, HCO3.

Answer A. LDH or LD, SGOT or ALT, SGPT or AST. Rationale All of these blood values should be monitored, but (A) it is most important for this particular client, because acetaminophen (Tylenol) is extremely hepatotoxic. (B) might be an indication of infection or bleeding, (C) of renal functioning, and (D) of gas exchange.

After 2 days treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child's urine output is 50 mL/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement? A. Perform a fingerstick glucose test. B. Obtain arterial blood gases. C. Increase the IV fluid flow rate. D. Review 24 hour intake and output.

Answer A. Perform a fingerstick glucose test. Rationale A fingerstick glucose test (A) is indicated to determine if a change in level of consciousness is related to a low glucose, which is a common finding with fluid and electrolyte loss and can be quickly corrected. Arterial blood gases (B) may be indicated to assess oxygenation, but first the glucose level should be assessed. The child's urine output is adequate, so increasing the IV fluid rate (C) is not indicated. Knowing the last 24 hour fluid volume totals (D) does not address the immediate problem.

An adult female who had bariatric surgery two weeks ago returns to the emergency department and is readmitted to the hospital because she is complaining of nausea, vomiting, abdominal cramps, and severe diarrhea. Which interventions should the nurse include in the plan of care? (Select all that apply.) A. Provide small, frequent meals. B. Separate fluids from meals. C. Offer high-carbohydrate foods. D. Plan meals with low fiber. E. Eliminate acidic food choices.

Answer A. Provide small, frequent meals. B. Separate fluids from meals. E. Eliminate acidic food choices. Rationale (A, B, and E) are correct. Eating large portions may stretch the gastric pouch (stomach), so small, frequent meals (A) should be provided. When solids and liquids are consumed at the same time (B), it causes the pouch to empty too quickly, so the client continues to feel hungry. Acidic foods (E) are harder to digest. The client's diet should consist of low carbohydrates (C) and high fiber (D).

While teaching a client how to perform a skill, the nurse determines that the client is experiencing sensory overload and is unable to learn effectively. Which action should the nurse implement? A. Reduce the stimuli in the area before continuing the teaching. B. Reassure the client that the skill is not difficult to learn. C. Demonstrate the skill, speaking slowly and using simple terms. D. Provide the client with step-by-step written instructions.

Answer A. Reduce the stimuli in the area before continuing the teaching. Rationale When a client experiences sensory overload, it is important for the nurse to reduce excessive stimuli in the environment (A) so that distractions are decreased and the client can focus on learning the skill. (B, C, and D) are useful teaching strategies, but are less helpful than (A) when the client is experiencing sensory overload.

To assess for the presence of egophony, what instruction should the nurse give the client who has a lung abscess? A. Repeat vocalizing the letter E while the thorax is auscultated. B. Breathe in and out while all lobes of both lungs are auscultated. C. Repeat the number 99 during a systematic auscultation of the thorax. D. Whisper "one, two, three" in a sequence during auscultation of the thorax.

Answer A. Repeat vocalizing the letter E while the thorax is auscultated. Rationale Egophony is an abnormally enhanced vocal resonance with a high pitched, bleating, nasal quality that occurs in areas of consolidation, pleural effusion, or abscess. To assess for egophony, the client should repeat the letter "E" while the nurse auscultates the thorax (A) and if a flat, nasal sound of "A" is heard through the stethoscope, it indicates the existence of egophony. To assess for brochophony, the client should repeat the number 99 while the nurse auscultates the thorax (C). Asking the client to breathe in and out while auscultating all lobes of both lungs (B) is used to assess breath sounds. To assess whispered pectoriloquy, the client whispers the number sequence "one, two, three" while the nurse auscultates the lung fields (D).

An adult male is admitted with partial thickness burns on both legs from a battery explosion. Morphine sulfate 4 mg IV q2 hours PRN is prescribed for pain. Since admission four hours ago, the client has been requesting pain medication every hour. What action should the nurse implement? A. Request an increase in the prescribed amount of morphine. B. Teach the client nonpharmacological pain management techniques. C. Post the time in the client's room when next pain medication due. D. Explain risk of narcotic addiction as evidence by his request.

Answer A. Request an increase in the prescribed amount of morphine. Rationale Burns require a larger than normal amounts of analgesic medication to treat pain, and morphine 4 mg IV q2 hours is a low-dose and should be increased (A) based on the clients weight, metabolism, and self assessed pain. Nonpharmacological interventions (B) and posting a sign to let the client know when his next medication dose is due (C) do not address the issue that the client needs a higher dose of morphine. Narcotic addiction (D) is not a concern this early after a burn.

Assessment findings for a client following a colectomy for familial polyposis include an ileostomy bag that contains a large amount of fecal liquid and an IV of Dextrose 5% in Lactated Ringer's infusing at a rate of 100 ml/hour. Which assessment is most important for the nurse to monitor? A. Serum electrolytes. B. Urinary output. C. Skin turgor. D. Peristomal skin integrity.

Answer A. Serum electrolytes. Rationale The client is losing large amounts of fluids and electrolytes in the liquid feces from the ileum, so monitoring of the client's serum electrolytes (A) to evaluate the effectiveness of replacement by the present present infusion of Dextrose 5% in Lactated Ringer's is most important. Although the client's urinary output (B) may decrease due to ileostomy fluid loss, it is more important for the nurse to monitor the client's serum electrolytes. Poor skin turgor (C) occurs with dehydration, but the client's serum electrolyte levels are specific values that first indicate physiological changes. Skin integrity (D) should be evaluated when the ileostomy appliance is replaced.

When developing a plan of care for a client with Parkinson's disease (PD) at admission, the nurse assesses the client's mobility needs. Which findings indicate the need to plan interventions related to the client's mobility? (Select all that apply.) A. Shuffling, propulsive gait. B. Stooped posture. C. Masklike facial appearance. D. Orthostatic hypotension. E. Muscular rigidity.

Answer A. Shuffling, propulsive gait. D. Orthostatic hypotension. E. Muscular rigidity. Rationale The correct answers are (A, D, and E). A shuffling, propulsive gait (A) places the client at risk for injury and safety measures should be implemented. Orthostatic hypotension (D) results in dizziness when standing and safety measures are needed. Muscular rigidity (E) increases need for assistance when rising from a chair or bed and possibly with ambulation if freezing occurs. A stooped posture (B) and masklike facies (C) do not indicate the need for interventions to promote safe mobility.

During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aid and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe a PRN dose of an oral over-the-counter laxative for a client who is constipated. What instruction should the RN provide the unit clerk? A. Tell the healthcare provider the RN will return the phone call as soon as possible. B. Remain with this client and monitor the vital signs while the RN takes the call. C. Ask the healthcare provider to remain on "hold" until the RN can confirm the prescription. D. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.

Answer A. Tell the healthcare provider the RN will return the phone call as soon as possible. Rationale Verbal prescriptions must be taken by a licensed nurse, so the RN should instruct the clerk that the RN will return the phone call as soon as possible (A). The RN should remain with the unstable client (B), which is a higher priority than taking a prescription for a PRN laxative. (C) is not a prudent use of the healthcare provider's time. The responsibility for taking verbal or telephone prescriptions cannot be delegated to a unit clerk, certified medication aide, or unlicensed assistive personnel (D).

The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first? A. Usual bedtime and time of awakenings. B. Urinary frequency and episodes of nocturia. C. History of seasonal allergies and nasal congestion. D. Amount and type of caffeinated drinks before bedtime.

Answer A. Usual bedtime and time of awakenings. Rationale First, the nature of the sleep pattern disturbance (A) should be determined. Further information regarding (B, C, and D) can then be obtained.

In assigning client care to an RN and a licensed practical nurse (LPN), it is most important to assign which client to the RN? The client who A. is exhibiting signs of Addison's crisis after corticosteroids were discontinued. B. has diabetes and has an elevated serum glycosylated Hgb (Hgb A1C). C. is newly diagnosed with hypothyroidism and who is to receive the first dose of levothyroxine (Synthroid). D. is two days post-thyroidectomy and is unable to speak clearly due to laryngeal nerve damage.

Answer A. is exhibiting signs of Addison's crisis after corticosteroids were discontinued. Rationale Addison's crisis is a medical emergency requiring the expertise of the RN to assess the client and administer emergency intravenous fluids and medications(A). (B and C) require some simple client teaching, which is of less priority than (A), and can be completed by the LPN. (D) is more physiologically stable than (A).

The nurse inserts an IV catheter in the client's left arm. There is no infusion pump available, and the nurse notes that the infusion rate changes whenever the client moves the arm. What actions should the nurse take? (Select all that apply.) A. Restart the IV in the opposite extremity. B. Confirm that the IV cannula is secured in position. C. Restrain the arm so no movement is possible. D. Monitor the IV flow rate frequently. E. Increase the height of the infusing IV solution.

Answer B. Confirm that the IV cannula is secured in position. D. Monitor the IV flow rate frequently. Rationale Correct choices are (B and D). The IV cannula may bend and slow the infusion when the client moves the extremity, so securing the IV cannula (B) can adjust the angle of insertion, which may help to maintain the prescribed flow rate. The nurse should monitor the flow rate frequently to prevent excess fluid infusion (D). An unnecessary IV insertion (A) places the client at risk of infection. A changing rate of IV infusion is not an acceptable reason for the use of restraints (C). Adjusting the height of the IV solution (E) does not influence the flow rate of an IV that has positional problems.

When assessing a 24-year-old bodybuilder, the nurse is unable to palpate an apical impulse. What action should the nurse implement? A. Dim the lights in the examination room. B. Continue with the cardiac examination. C. Question the client about steroid use. D. Position the client in high Fowler's position.

Answer B. Continue with the cardiac examination. Rationale An apical impulse, the point of maximal impulse (PMI), is not palpable in about 50% of adults, particularly in those who are obese or those with thick chest walls, such as body-builders, so a continuation of the exam (B) is the best course of action. (A, C, and D) are not indicated.

The nurse observes a practical nurse PN pouring warm water over the perennial area of a female client with frequent urinary incontinence while the client is positioned on a bedpan. What action should the nurse take? A. Recommend a complete bath to cleanse the perennial area more fully. B. Evaluate the effectiveness of this measure to stimulate client voiding. C. Instruct the PN that this technique promotes infection in elderly females. D. Suggest contacting the health care provider for a prescription for catheter insertion.

Answer B. Evaluate the effectiveness of this measure to stimulate client voiding. Rationale Pouring warm water over the perennial area can be an effective measure to stimulate voiding and reduce episodes of incontinence. The nurse should evaluate the effectiveness of this intervention by the PN (B). This is not a cleansing technique (A) and does not increase the risk of infection (C). Non-invasive measures to promote continents are more desirable than (D).

A female client, a retired schoolteacher, is it admitted for a breast biopsy. After being told that the biopsy was positive for cancer, she becomes dependent and asks her family for help with activities of daily living that she is physically capable of performing. Which interpretation of this client's behavior by the nurse is likely to be most accurate? A. Unacceptable, and limits should be set to encourage the client to maintain her independence. B. Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety. C. Should be accepted by staff as the first step the client must experience in the grieving process. D. Should be encouraged as representative of the client's nondestructive method of fear expression.

Answer B. Expected, as the client is attempting to reduce anxiety by regressing to a state of lesser anxiety. Rationale Regression to an earlier stage of development which was less stressful is an expected response to crises (B). (A) is hostile and unaccepting of the client's level of stress. (C) might be expected, but being dependent is a classic sign of regression. The behavior should be understood and accepted by the nurse, but encouraging it (D) is not therapeutic.

A client who participates in a health maintenance organization (HMO) needs a bone marrow transplant for treatment of breast cancer. The client tells the nurse that she is concerned that her HMO may deny her claim. What action by the nurse best addresses the client's need at this time? A. Have the client's health care provider write a letter to the HMO explaining the need for the transplant. B. Help the client place a call to the HMO to seek information about limitations of coverage. C. Encourage the client to call a lawyer so that a lawsuit can be filed against the HMO if necessary. D. Have the social worker call the state board of insurance to register a complaint against the HMO.

Answer B. Help the client place a call to the HMO to seek information about limitations of coverage. Rationale The client needs to contact her HMO first (B) to see if a transplant is a covered treatment option. If the transplant is not covered by the HMO, the client may be able to seek recourse as explained in the Patient's Bill of Rights published by the American Hospital Association. (A, C, and D) describe actions that are premature at this time.

A nurse performs a Tinetti assessment on an 82-year-old client and calculates a balance score of 12 and a gait score of 8. What do these results indicate? A. Expected results for an elderly adult. B. Increased risk for falling. C. Need for a walker to aid in ambulation. D. Likely onset of Parkinson's disease.

Answer B. Increased risk for falling. Rationale A score of 20 indicates an increased risk of falling (B). The Tinetti Balance and Gait Assessment tool is used to assess the risk of falling in older adults and has a possible combined score of 28. The lower the score the greater the risk of falling. A combined score of 19 or less indicates a high risk of falling. This is not an expected result for an elderly client (A). It does not assess the specific need for a walker (C), nor is it a diagnostic tool for Parkinson's (D).

In teaching a client with Parkinson's disease, which rationale for the prescription of levodopa-carbidopa (Sinemet) should the nurse include? A. Acts as an anti-seizure medication reducing the tremors caused by the disease. B. Increases the amount of dopamine needed for muscles to function correctly. C. Slows the scarring in the myelin sheath improving muscle tone and strength. D. Reduces the inflammatory process improving nerve transmission and function.

Answer B. Increases the amount of dopamine needed for muscles to function correctly. Rationale The symptoms of Parkinson's disease are caused by insufficient dopamine to maintain normal muscle function (B). Hand tremors, while typical of the disease, are not a result of (A or D). (C) describes the pathology of multiple sclerosis.

Which pathology occurs with an asthma condition? A. Chronic inflammation of the bronchi or bronchi and trachea caused by infection. B. Recurring spasms of the airways accompanied by edema and mucus production. C. Reduced surface area of the lungs caused by rupture or other damage to the alveoli. D. Acute inflammation in which lung airways become blocked with thick exudates.

Answer B. Recurring spasms of the airways accompanied by edema and mucus production. Rationale Asthma is characterized by recurring spasms of the airways accompanied by edema and mucus production (B). (A) describes acute bronchitis. (C) describes emphysema. (D) describes pneumonia.

While assessing a clients blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. What action should the nurse implement next? A. Continue the blood pressure assessment until the last Korotkoff sound is heard. B. Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading. C. Reposition the stethoscope in the antecubital fossae over the palpable brachial pulse point. D. Inflate the cuff quickly to a higher mm of Hg reading than the previously auscultated systolic sound.

Answer B. Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading. Rationale Korotkoff sounds describe blood pressure from the first sound, which is a clear, rhythmic, tapping sound that corresponds with systolic blood pressure, to the fifth sound which is a disappearance of all sound and corresponds with the diastolic for a blood pressure. If the first Korotkoff sound is heard immediately after releasing the valve, it means that the cuff was not inflated high enough and all the air should be released and the cuff reinflated to a higher level. (A, C, and D) are incorrect actions, based on the information provided.

A postoperative client's respiratory rate decreased from 14/minute to 6/minute after administration of an opioid analgesic. Thirty minutes later, the clients respiratory rate decreases to 4/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of IV naloxone (Narcan). The charge nurse should counsel the nurse regarding which intervention? A. The initial administration of the analgesic. B. The decision regarding when to call the healthcare provider. C. The administration of naloxone (Narcan) via IV. D. The documentation of the client's respiratory rate.

Answer B. The decision regarding when to call the healthcare provider. Rationale The nurse should have called the healthcare provider when the respiratory rate decreased to 6/minute, rather than waiting 30 minutes when the rate was 4/minute. This delay increased the risk for respiratory failure (B). The charge nurse should initiate interventions such as completing an adverse occurrence report, and ensuring that the nurse receives guidance to prevent further poor decision making. (A, C, and D) were all appropriate interventions by the nurse and do not require further action by the charge nurse.

When using a Yankauer oral-tip catheter to suction a client's oropharynx, which action should the nurse take before inserting the catheter into the oropharynx? A. Ask the client to begin swallowing. B. Turn on the continuous suction device. C. Assess the nares for a deviated septum. D. Apply suction by occluding the port.

Answer B. Turn on the continuous suction device. Rationale The continuous suction device should be turned on (B) prior to inserting the Yankauer tip or tonsillar tip catheter into the client's mouth so that suction can be applied as soon as it is in place. (A) is an action implemented prior to nasogastric tube (NGT) placement. (C) should be assessed prior to insertion of a nasal suction catheter or NGT. Suction should not be applied while a catheter is inserted (D) because it can traumatize tissue and remove oxygen in the upper airways.

While changing the abdominal dressing of a client who had surgery three days ago, the nurse identifies a yellow drainage from separations in the incision line. After cleansing the wound with normal saline, what action should the nurse implement? A Leave the incision open to air. B. Apply a dry sterile dressing. C. Cover with a sterile non-adherent dressing. D. Place a transparent dressing over the wound.

Answer C. Cover with a sterile non-adherent dressing. Rationale Dehiscence of the outer incisional layers and postoperative infection are interrelated in causing delayed would healing. The nurse should apply a sterile non-adherent dressing (C) to the wound and notify the surgeon of the purulent drainage and separation. (A) increases risk of drying the tissues and the risk for nosocomial spread of pathogens. (B) can stick to the drainage and cause disruption of any granulation tissue when the dressing is removed. (D) is not indicated for surgical incisions.

The nurse teaches the client with diabetes mellitus that chronic hyperglycemia contributes to reduced wound healing. How should the nurse explain the changes caused by chronic hyperglycemia to the client? A. Reduces venous return. B. Causes tissue Adema. C. Damages the capillaries. D. Impairs muscle function.

Answer C. Damages the capillaries. Rationale Chronic hyperglycemia causes vascular changes that occur when advanced glycosylated end products (AGEs) accumulate and attach to cells in the walls of blood vessels and promote atherosclerosis. Damaged capillaries (C) cause decreased tissue perfusion and reduce the availability of needed nutrients for wound healing. (A, B, and D) are not pathophysiologic sequela to hyperglycemia.

Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which findings should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion? A. Stabilization of blood pressure ranges. B. Cessation of chest pain. C. Decreased frequency of episodes of VT. D. Reduced heart rate.

Answer C. Decreased frequency of episodes of VT. Rationale Lidocaine, a class Ib antiarrhythmic, reduces myocardial automaticity and decreases ventricular irritability, which often occurs after STEMI. A therapeutic response to lidocaine is a decrease in premature ventricular contractions (PVCs) and (VT). In the management of acute myocardial infarction (AMI), (A) is a therapeutic action for angiotension converting enzyme (ACE) inhibitors. (B) is a therapeutic action for timely administration of thrombolytics, and (C) is therapeutic actions for beta blockers.

The nurse learns and report that a client is stuporous. What assessment should the nurse perform to confirm this report? A. Assess for a positive Romberg sign. B. Check the pupillary response to light. C. Determine the response to stimuli. D. Observe for any facial asymmetry.

Answer C. Determine the response to stimuli. Rationale Descriptive terminology, such as stuporous, lethargic, comatose, and alert, is often used to describe a clients response to verbal, tactile, and painful stimuli (C), which is related to the clients level of consciousness. A positive Romberg sign (A) is assessed by asking the client to stand, which is unsafe for a stuporous client and does not confirm the clients level of consciousness. The people Larry response to light (B) and the lack of facial symmetry (D) May be altered as a result of neurologic compromise, but do not confirm the clients level of consciousness.

A client recently diagnosed with early stage Alzheimer's disease receives a prescription for acetylcholinesterase donepezil (Aricept). Which content should the nurse include in the medication teaching? A. Encourage the client to avoid foods high in vitamin K, such as green leafy vegetables. B. Explain that the psychiatrist has prescribed the maximum dose and will decrease it gradually. C. Discuss the fact that Aricept may slow the progression of the disease over the next year. D. Instruct the client to get monthly liver function studies to assess for liver failure.

Answer C. Discuss the fact that Aricept may slow the progression of the disease over the next year. Rationale There is no known medication that will cure Alzheimer's, but Aricept can delay the symptoms (C) for 6 to 12 months if prescribed in the early stages of the disease. (A) decreases the anticoagulant effects of warfarin (Coumadin), but has no effect on Aricept administration. The medication is prescribed at the lowest dose and gradually increased (B). (D) is not a side effect of Aricept.

An adult woman who has a history of hypothyroidism is admitted with facial swelling and hypothermia. The client is anxious and the initial nursing assessment indicates that she is oriented to person only. Which intervention should the nurse implement first? A. Assess abdomen for bowel sounds. B. Observe for visual hallucinations. C. Evaluate for tongue thickening. D. Auscultate bilateral breath sounds.

Answer C. Evaluate for tongue thickening. Rationale The client is presenting with symptoms of severe hypothyroidism, known as Myxedema. A characteristic of Myxedema is a thickening tongue (C) that can obstruct the airway, so this life-threatening symptom must be evaluated first, and mechanical ventilation provided if indicated. (A, B, and D) are important interventions, but do not have the priority of (C).

The nurse is planning a weight reduction teaching program to be implemented at a community health center. Which goal is best for clients who are approximately 15 percent over their ideal weight and wish to participate in the weight loss program? A. A three to five pound weight loss per week. B. Caloric intake between 800 and 1,000 kcal per day. C. Fat intake between 20 to 30 percent of total daily intake. D. Maintain a cholesterol level between 225 and 240 mg/dl.

Answer C. Fat intake between 20 to 30 percent of total daily intake. Rationale These clients should follow a moderate plan for weight reduction, which includes a fat intake of 20 to 30 percent of the daily caloric consumption (C). Recommended weight loss for an individual who is overweight, but not morbidly obese, is 1 to 2 pounds per week. Weight loss greater than that (A) is unrealistic and will lead to discouragement and failure. A caloric intake of 800 to 1,000 kcal per day (B) is excessively low. It is generally recommended that the total cholesterol level be maintained below 200 mg/dl (D).

When initiating a dopamine (Intropin) intravenous infusion for a hypotensive client, which intervention should the nurse include in the client's plan of care? A. Assess bilateral breath sounds. B. Perform neuro assessment every 2 hours. C. Monitor urinary output every hour. D. Observe pulmonary capillary wedge pressure (PCWP).

Answer C. Monitor urinary output every hour. Rationale Dopamine is used as a first choice vasopressor for a client who is hypotensive because it increases systemic vascular resistance and mean arterial pressure (MAP), which determines renal blood flow, glomerular filtration rate (GFR), and urine production. Urine output must be monitored at least hourly (C) to evaluate systemic pressure and renal perfusion. (A, B, and D) are not specifically affected by dopamine.

The nurse watches an unlicensed assistive personnel (UAP) bring soap, washcloths and towels, and a basin into the room of a male client who had a suprapubic catheter inserted earlier that day. What action should the nurse implement? A.Remind the UAP to provide warmth and privacy when washing and drying around the client's catheter. B. Advise the UAP that the client's dressing will need to be removed before cleaning around his catheter. C. Tell the UAP that the nurse will perform the client's catheter care after the UAP assists with his personal care. D. Encourage the UAP to offer the client the opportunity to perform his own catheter care independently.

Answer C. Tell the UAP that the nurse will perform the client's catheter care after the UAP assists with his personal care. Rationale Suprapubic catheters are inserted surgically, so initial catheter care involves removal of the dressing and inspection of the surgical site, which should be performed by the nurse (C) rather than the UAP (A and B). If the catheter will be in place after discharge, the nurse should teach the client how to care for the catheter (D) during discharge instructions.

Which client's laboratory value requires immediate intervention by a nurse? A. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams. B. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday. C. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value. D. A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000 yesterday.

Answer D. A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000 yesterday. Rationale Clients undergoing chemotherapy (D) are at particular risk for neutropenia. The healthcare provider must be notified of the downward trend and precautions must be taken. Clients with neutropenia (an absolute count of neutrophils less than 2,000) are prone to infections and those with agranulocytosis (an absolute count less than 500 may) have a rapid progression to fatal sepsis. (A) is currently being treated with the transfusion. (B) often experiences elevated glucose levels, and sliding scale coverage does not usually occur until the level reaches 200mg/dl. (C) is an expected finding with hepatitis, which is why the client is jaundiced.

Which client is most likely candidate for parenteral nutrition (PN)? A. An older client who is having a laparoscopic cholecystectomy. B. A client diagnosed with diabetic ketoacidosis. C. An obese female who is on a medically supervised starvation diet. D. A young adult with an acute exacerbation of Crohn's disease.

Answer D. A young adult with an acute exacerbation of Crohn's disease. Rationale PN is indicated for those clients who are unable to ingest food or orally or by tube (Crohn's disease) (D), for those whose intake is insufficient to maintain an anabolic state (severe burns or AIDS), for those who refuse to ingest adequate nutrients (anorexia nervosa), for those who should not be fed orally or by tube (acute pancreatitis), or for those who need sustained pre/postoperative nutritional support (following bowel surgery). Age and sex are not related to the need for TPN. (A, B, and C) are not candidates for PN.

Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit? A. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank. B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension. C. A practical nurse (PN) is assigned to transport a postoperative client to the rehabilitation unit. D. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.

Answer D. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction. Rationale Checking a client for fecal impaction (D) may cause a vagal response, leading to severe bradycardia. This action should be performed by the nurse, rather than a UAP, so the charge nurse should immediately change this assignment. A graduate nurse can obtain and administer blood products (A), but may need supervision with the administration. (B and C) do not require immediate follow up by the charge nurse.

Which type of leukemia can be successfully treated by chemotherapy resulting in suppression, but not complete remission? A. Acute lymphoblastic leukemia (ALL). B. Acute myelogenous leukemia (AML). C. Hairy cell leukemia. D. Chronic lymphocytic leukemia (CLL).

Answer D. Chronic lymphocytic leukemia (CLL). Rationale Chronic forms of leukemia such as CLL (D), do not have remission completely established, but can be suppressed for several years. Acute forms of leukemia such as (A and B) respond well to chemotherapeutic agents, often resulting in complete remission in 70% to 90% of clients, as indicated by elimination of leukemic blasts from the bone marrow. (C) is a rare, chronic type of leukemia that responds well to treatment, unlike other types of chronic leukemias, with remission rates of 58% to 85% documented following low-dose interferon-alfa and chlorodeoxyadenosine administration.

The nurse notes that a client has a new prescription for 20 mEq of potassium chloride (KCL) to be administered IV push STAT. The client's IV site is slightly inflamed but is not tender and has a blood flashback. What action should the nurse take? A. Fax the prescription to the pharmacy for immediate delivery of the medication. B. Obtain a liter of normal sailing with 20 mEq of KCl from the supply cart. C. Withhold the prescribed medication until a new IV is inserted. D. Contact the healthcare provider to clarify the prescription.

Answer D. Contact the healthcare provider to clarify the prescription. Rationale Intravenous administration of undiluted KCl can cause life-threatening dysrhythmias, so the nurse must contact the healthcare provider to clarify the prescription (D). (A and C) may result in the administration of a fatal dose of medication. Although 20 mEq of KCl diluted in a liter of normal saline solution is a safe dilution for administration, the nurse cannot prescribe medications (B) and must contact the healthcare provider changing the prescription.

The nurse is caring for a group of clients on a surgical unit. What action should the nurse implement first? A. Assess a client who needs to be transferred to a long-term care facility. B. Direct to family members of a client in the operating room to the waiting area. C. Obtain vital signs on an assigned client and record on the graphic sheet. D. Determine if the client scheduled for surgery is prepared to go to the operating room.

Answer D. Determine if the client scheduled for surgery is prepared to go to the operating room. Rationale Because the client who is scheduled for surgery should be ready when the OR calls, the nurse should determine if the preoperative check list has been completed (D). Consent forms should be signed and witnessed, and the client should have completed all necessary preparations. (A) can be assessed after completing (D). (B and C) can be delegated to the unlicensed assistive personnel UAP.

In reviewing the dietary teaching for a young adult female with hyperthyroidism, the nurse learns that the client has increased her intake of protein and calories. What action should the nurse take? A. Instruct the client to also increase her daily intake of dietary fiber. B. Advise the client to include aerobic exercise along with dietary changes. C. Emphasize the need to reduce caloric intake, rather than increasing it. D. Encourage the client to continue these changes in her dietary plan.

Answer D. Encourage the client to continue these changes in her dietary plan. Rationale Basal metabolic rate increases in hyperthyroidism, so to prevent excessive weight loss and tissue breakdown, the client should be encouraged to continue with a dietary plan that increases intake of calories and protein (D). Balancing rest and energy expenditure to minimize fatigue is recommended instead of (B). (A) may increase diarrhea associated with hyperthyroidism. Sustaining normal weight is the expected goal of increased caloric intake (C).

A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and loud wile the nurse talks to his spouse. What intervention is best for the nurse to implement at this time? A. Walk with the client to the cafeteria and stay as he eats lunch. B. Encourage the spouse to eat lunch with the client. C. Request a full tray from the dietary department. D. Move to a quiet area and provide peanut butter with crackers.

Answer D. Move to a quiet area and provide peanut butter with crackers. Rationale Both inadequate nutrition and inadequate sleep patterns plague clients with bipolar disorder and contribute to agitation, hostility, and aggressiveness. Using a calm, confident manner, the client should be moved to a quiet area (D) to decrease environmental stimuli and limit involvement with the spouse while nutritional needs, such as "finger foods", should be provided. (A, B, and C) are less effective when the client is unable to sit long enough to eat.

The nurse is planning to assess the client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has bilateral below-the-knee amputations and radial pulses that are weak and thready. What action should the nurse take? A. Document that an accurate oxygen saturation reading cannot be obtained. B. Elevate the client's hands for five minutes prior to obtaining a reading from the finger. C. Increase the oxygen based on the client's breathing patterns and lung sounds. D. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading.

Answer D. Place the oximeter clip on the earlobe to obtain the oxygen saturation reading. Rationale Pulse oximeter clips can be attached to the earlobe to obtain an accurate measurement of oxygen saturation(D). (A) is incorrect, since the earlobe can be used. (B) will diminish the pulse volume even more. (C) is not necessary, since an accurate saturation level can be obtained.

A client at 32-weeks gestation is admitted with moderate intensity contractions every 5 minutes and the healthcare provider prescribes terbutaline (Brethine). Prior to initiating this treatment regimen, which assessment data is most important for the nurse to obtain? A. Breath sounds. B. Capillary blood glucose. C. White blood cell count. D. Resting pulse rate.

Answer D. Resting pulse rate. Rationale Brethine, a beta-adrenergic agonist, relaxes smooth muscles, inhibits uterine activity, and causes other beta-adrenergic receptor side effects, such as tachycardia, dysrhythmias, tremors, fetal tachycardia, and hypoxia. Determining the client's resting heart rate (D) prior to the administration of Brethine provides data to evaluate the client's systemic response to the drug. (A, B, and C) should also be assessed, but the client's cardiac baseline is the most important assessment related to tocolytic therapy.

Legal experts recommend that healthcare institutions take all steps possible to reduce the increasing incidence and high costs of medical malpractice suits. Which remedy provides the earliest intervention for negligent injuries caused by healthcare providers that might deter legal disputes? A. Arbitration. B. Mediation. C. Disciplinary action. D. Risk management.

Answer D. Risk management. Rationale The earliest form of intervention is the prevention of injury and subsequent lawsuits, accomplished by enacting risk management (D) in the organization. Alternate dispute resolutions (ARDs) are used to settle healthcare disagreements quickly and cost effectively. They are preferred over the use of the legal system whenever possible. (A) is the next step in resolving disputes, but it is used less frequently in medical malpractice. (B) is an option for resolution after a suit has been filed. (C) attempts to point out behavioral deficiencies and prevent reoccurrences, but is not as early and intervention as a (D).

When providing care for an unconscious client who has seizures, which nursing intervention is most essential? A. Keep the room at a comfortable temperature. B. Ensure oral suction is available. C. Maintain the client in a semi Fowler's position. D. Provide frequent mouth care.

Answer B. Ensure oral suction is available. Rationale Maintaining a patent airway is a priority for an unconscious client who is at risk for seizures, so oral suction equipment should be available (B) for suctioning the mouth, pharynx, and trachea to prevent aspiration of possible vomitus or oral secretions. (A, C, and D) are all important interventions but not critical. Keeping the room temperature comfortable (A) helps reduce variant environmental stressors that may trigger seizures. If the unconscious client is receiving tube feeding, a semi Fowler's position should be maintained (C). Unconscious clients are often mouth breathers, which causes saliva to dry and adhere to the mouth and tooth surfaces, so frequent mouth care (D) is essential but not critical.

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first? A. Ask the client if he took any pain medication at home. B. Observe for nonverbal signs to measure pain intensity. C. Use a standard pain assessment questionnaire and scale. D. Collect a urine sample and strain for granules or calculi.

Answer C. Use a standard pain assessment questionnaire and scale. Rationale Renal calculi can precipitate sudden, severe flank or lower abdominal pain. A standard pain assessment (C) that includes location, duration, quality, intensity, aggravating and relieving factors should be used to determine the characteristics of the client's pain. Once the presenting picture of pain is assessed, other factors should be considered, such as medication use (A), non-verbal signs (B), and urine straining (C) results.