HESI practice 5

Penicillin G procaine 240,000 units intramuscularly is prescribed for four-year-old child who has a streptococcal respiratory infection. The medication bio is labeled 1,200,000 units/2 ml. How many ml should the nurse administer?

0.4

The nurse plans to administer a bolus dose of IV Heparin based on the clients weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of heparin should the nurse administer?

9000

A client in the third trimester of pregnancy complaints of frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated, and she has an increased costal angle. Which intervention should the nurse implement? A. Ask a nurse with more experience to validate the costal angle finding B. Ask the health care provider to evaluate the client's respiratory status C. Examine the client for signs of tissue and anoxia, such as pallor D. Record the respiratory finding in the client's record as normal

C. Examine the client for signs of tissue and anoxia, such as pallor

A male client being treated for testicular cancer with chemotherapy has a decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement? A. Advise the client that the treatment is having a beneficial effect B. Instruct the client to obtain prostate specific antigen (PSA) testing C. Inform the client that his chemotherapy dose will probably be increased D. Discuss options for Hospice care with the client and family members

C. Inform the client that his chemotherapy dose will probably be increased

A mother brings her three-year old son to the emergency room and tells the nurse that he had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 degrees Fahrenheit. He is drooling in becoming increasingly more restless. What action should the nurse take first? A. Put a cold cloth on his head and administer acetaminophen B. Assist the child to lie down and examine his throat C. Notify the health care provider and obtain a tracheostomy tray D. Listen to the lung sounds and place him in a mist tent

C. Notify the health care provider and obtain a tracheostomy tray

A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor, and he often uses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement? A. Ask family to remain nearby, but in another room B. Encourage family to speak often with the client C. Teach family how to assist the client to a wheelchair D. Instruct family to offer client only soft bland foods

C. Teach family how to assist the client to a wheelchair

A client with his C7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor? a. An acutely distended bladder b. Profuse forehead diaphoresis c. Skeletal traction misalignment d. A severe pounding headache

a. An acutely distended bladder

A journalist asked the nurse working in the emergency department about the condition of the local politician recently admitted to the Medical Center following a publicly reported building fire. Which action should the nurse take? a. Direct the journalists to the agencies communication/ marketing department b. Document the official identification of the journalist before providing any information c. Obtain verbal consent from a family member before discussing the clients condition d. Provide only general information regarding the client's overall condition

a. Direct the journalists to the agencies communication/ marketing department

A client who is an avid hiker expresses concern about losing too much potassium while hiking. And teaching the client to prepare potassium rich snack mix, the nurse would encourage the client to include which items? a. Dried apricots b. Seedless raisins c. Lightly salted peanuts d. Dried bananas e. Dried apples

a. Dried apricots b. Seedless raisins d. Dried bananas

Four hours following surgical repair of a compound fracture of the right ulna, the nurse is unable to palpate the clients right radial pulse. Which action should the nurse take first? a. Elevate the clients right hand on one or two pillows b. Notify the health care provider of the finding immediately c. Measure the clients blood pressure and apical pulse rate d. Complete a neurovascular assessment of the right hand

a. Elevate the clients right hand on one or two pillows

An adolescent female with an eating disorder is admitted to the inpatient psychiatric unit. Which intervention should the nurse implement? a. Encourage the client to weigh herself daily at bed time b. Allow the client to select an arts and crafts activity c. Recommend exercise and recreation in the morning d. Put the client in charge of choosing snacks for the unit

a. Encourage the client to weigh herself daily at bed time

The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? a. Hold the Walker securely to prevent slipping when the client rises b. Applied gait belt to assist the client to rise out of the chair c. Instruct the client to use the arms of the chair for support d. Encourage the client to use the weaker leg with the walker when rising

a. Hold the walker securely to prevent slipping when the client rises

During the admission assessment, the nurse identifies multiple bruises at various stages of healing on a client recently diagnosed with aplastic anemia. Nurse reviews the client's serum laboratory values which reveal platelets 50,000mm^3, white blood cells 3000 mm^3, and red blood cells 2.5 million/mm^3. Which action should the nurse implement? Select all that apply. a. Implement contact precautions b. Monitor for signs of bleeding c. Provide a soft bristle toothbrush d. Initiate sepsis protocol e. Infuse blood products as prescribed

a. Implement contact precautions b. Monitor for signs of bleeding c. Provide a soft bristle toothbrush d. Initiate sepsis protocol e. Infuse blood products as prescribed

Which long term outcome is most important for the nurse to include in the plan of care for an older adult client with chronic pyelonephritis? a. Maintains blood pressure within normal limits b. Managers activities of daily living independently c. Restrict fluid intake to 1 L/day d. Measures oral temperature daily

a. Maintains blood pressure within normal limits

A client with cancer complains of fever, chills, malaise, and headache following administration of a colony stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like symptoms? a. Monitor lab values for an increase in WBCs b. Administer anti emetics before, during, and after therapy c. Administer acetaminophen Q4H d. Monitor vital signs Q4H for 24 hours

a. Monitor lab values for an increase in wbcs ?

A mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? a. Position the infant on the stomach occasionally when awake and active b. Turn the infant on the left side braced against the crib when sleeping c. Prop the infant in a sitting position with a cushion when not sleeping d. Place a small pillow under the infants head while lying on the back

a. Position the infant on the stomach occasionally when awake and active

A successful businessman presents to the community Health Center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist the client in diminishing his anxiety? a. Reinforce the reality of his financial situation b. Direct him to drink a glass of red wine at bedtime c. Teach him to limit sugar and caffeine intake d. Encourage him to initiate daily rituals

a. Reinforce the reality of his financial situation

Which diet should the nurse recommend for a client who is in acute rental failure? a. High protein, low carbohydrate, low sodium, low potassium b. Low protein, high carbohydrate, low sodium, low potassium c. Low protein, high carbohydrate, low sodium, high potassium d. High protein, low carbohydrate, low sodium, high potassium

b. Low protein, high carbohydrate, low sodium, low potassium

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? a. Cornea are jaundiced b. Oral mucosa is cyanotic c. Face is flushed and diaphoretic d. Eyelids are matted and crusted

b. Oral mucosa is cyanotic

A client has a new prescription for the maximum recommended dosage of piperacillin/tazobactam for nosocomial pneumonia. The nurse should report which laboratory finding to the health care provider before administering the prescribed dose? a. Elevated white blood cell count b. Presence of gram-positive bacteria in the sputum c. Decrease creatinine clearance d. Elevated cholesterol and lipoproteins

b. Presence of gram-positive bacteria in the sputum

A client is admitted to the hospital with symptoms consistent with the right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse? a. Orientation to person in place only b. Unequal bilateral hand grip strengths c. Pupillary changes to ipsilateral dilation d. Left sided facial droop and dysphasia

b. Unequal bilateral hand grip strengths

Which daily dietary instruction should the nurse include when teaching a client how to reduce episodes of Raynaud's syndrome? a. Reduce saturated fat intake b. Increase calcium intake c. Eliminate caffeine intake d. Avoid hot beverages

c. Eliminate caffeine intake

A 7 year old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant? a. Chicken pox b. Mumps c. Sore throat d. Influenza

c. Sore throat

The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse take in response to the finding? a. Ask the client to describe recent alcohol use b. Keep the clients feet elevated when in bed c. Assess the clients muscle strength and tone d. Complete a thorough neurological assessment

d. Complete a thorough neurological assessment

A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The health care provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take? A. Initiate an Ethics Committee review of the case B. Place a DNR bracelet on the client's arm C. Ensure resuscitation equipment is available D. Ask the family to review options with the client

A. Initiate an Ethics Committee review of the case

A postoperative client has a large amount of serosanguineous drainage on the surgical dressing and the nurse notes that the operative report indicates the client has a Penrose drain near the incision. What intervention should the nurse implement when changing the clients dressing? A. Place sterile gauze dressings under the Penrose drain B. Apply sterile gloves before removing the soiled dressing C. Cover the Penrose drain with a saline moistened gauze D. Wear a face mask or shield during the dressing change

A. Place sterile gauze dressings under the Penrose drain

A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? A. Place the client in Trendelenburg B. Administer oxygen via face mask C. Notify the operating room team D. Administer a fluid bolus of 500 mL

A. Place the client in Trendelenburg

A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains a blood glucose 50 mg/dL, heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg. Which intervention is most important for the nurse to implement? A. Position client with head flat and feet elevated B. Suggest obtaining a medical alert bracelet to be always worn C. Encourage the client to eat low carbohydrate and high protein meals D. Reinforced the need to continue the outpatient clinic therapy

A. Position client with head flat and feet elevated

The nurse who is working on a post surgical intensive care unit receives report regarding the assigned clients for the upcoming shift. Which client should the nurses assess first? a. An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100 ml chest tube drainage b. A young adult who had an abdominoperineal resection 3 days ago and is currently complaining of chills c. An older adult who had a misstep to me two days ago and has 50 ml serosanguinous drainage in the Jackson Pratt drain d. A teenager who had a gunshot wound repair yesterday and has a quarter sized dark drainage on the dressing

a. An adult who has a collapsed lung related to a fall from ladder 8 hours ago and now has 100 ml chest tube drainage

The nurse notes that a client's legs become dusty red whenever the client is sitting with both feet dangling. Which follow up assessment should the nurse complete? a. Ankle brachial index b. Joint range of motion c. Calf diameter d. Skin elasticity

a. Ankle brachial index

The nurse is planning care for a 16 year old, who has juvenile idiopathic arthritis. The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Exercise in a swimming pool b. Splint affected joints during activity c. Perform passive range of motion exercises twice daily d. Begin a training program lifting weights and running

a. Exercise in a swimming pool

When performing postural drainage on a client with chronic obstructive pulmonary disease, which approach should the nurse use? a. Explain that the client may be placed in five positions b. Instruct the client to breathe shallow and fast c. Obtain arterial blood gases prior to the procedure d. Perform the drainage immediately after meals

a. Explain that the client may be placed in five positions

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites and a client with cirrhosis? a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubes c. Decreased renin angiotensin response related to an increase in renal blood flow d. Decrease portacaval pressure with greater collateral circulation

a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure

When is the best time for the nurse to assess a client for residual urine? a. Immediately after the client voids b. Just prior to the client voiding c. After draining the urinary catheter bag d. When the client's bladder is distended

a. Immediately after the client voids

While admitting a client to the surgical unit who had a pneumonectomy 4 hours ago, the call system alarm is initiated by a client in another room period which action should the nurse implement? a. Investigate the reason for the call bell alarm and then complete the admission assessment b. Tell the unit clerk to ask the client via the intercom what is needed c. Ask a coworker to respond to the client who's called bell is alarming d. Complete the post-operative admission assessment then investigate the call bell alarm

a. Investigate the reason for the call bell alarm and then complete the admission assessment

The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports that the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the client's clinical recovery? a. Lipase b. Creatinine c. Bilirubin d. Glucose

a. Lipase

A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain in a possible ectopic pregnancy. She tells the nurse that her pain is gone, but she is now experiencing a generalized abdominal aching. Her blood pressure has decreased in her pulse has increased over the past two hours. While waiting for the health care provider to arrive, which intravenous solution is best for the nurse to initiate? a. Normal saline at 20 ml/hr b. Lactated ringer's at 150 ml/hr c. D5W/ 0.45 NS at 125 ml/hr d. Dextrose 10% at 83 ml/hr

a. Normal saline at 20 ml/hr

The nurse finds a female client crying quietly in her room period what action should the nurse take first? a. Pull up a chair and sit beside the client b. Review the client's record before attempting to intervene c. Provide the client privacy and quietly close the door d. Ask the client why she is crying

a. Pull up a chair and sit beside the client

An older woman who lives alone talks with the clinic nurse about her fears of falling at home. Which intervention should the nurse suggest? Select all that apply. a. Recommend installing grab bars by toilets, bathtub, and shower b. Have the home health nurse assessed the home for fall risks c. Encourage exercise to improve balance and mobility d. We're an emergency response pendant at home e. Request that a family member move in with her

a. Recommend installing grab bars by toilets, bathtub, and shower b. Have the home health nurse assessed the home for fall risks

A client is discussing feelings related to a recent loss with a nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior? a. Silence allows the client to reflect on what was said b. The nurse is respecting the client's loss c. The nurse is stating disapproval of the statement d. Silence is reflecting the client sadness

a. Silence allows the client to reflect on what was said

A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy tests and ultrasounds were negative, so an exploratory laparotomy was completed during the night. When coffee ground material is observed in the drainage from the nasal gastric tube, which intervention should the nurse implement? a. Verify correct placement of the nasogastric tube b. Perform gastroccult test on the nasogastric drainage c. Listen for evidence of diminished bowel sounds d. Irrigate the nasogastric tube with water until clear

a. Verify correct placement of the nasogastric tube

The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky pain, nausea, vomiting, and abdominal distention. Which pathophysiologic mechanism supports the client's clinical presentation? a. An incompetent lower esophageal sphincter b. A weakened diaphragm with high abdominal pressure c. Intestinal scar tissue buildup from a chronic condition d. History of having Helicobacter pylori infection

b. A weakened diaphragm with high abdominal pressure

A middle-aged client is returned from the intensive care unit to the surgical unit following a right pneumonectomy for cancer of the lung. The client has a patient-controlled analgesia pump and two right chest tubes which are clamped for the surgeon to release serosanguineous drainage. Which assessment finding requires immediate intervention by the nurse? a. Pain at the level of five on a scale of 1 to 10 with the use of PCA b. Absence of lung sounds on the operative side c. A high pitched, course sound over the trachea d. Request to see his family at his bedside immediately

b. Absence of lung sounds on the operative side

A client is being treated for hepatic failure. On examination, the client has awakened of 4.4 pounds in 24 hours and elevated pulse rate. Which intervention should the nurse include in the plan of care? a. Review arterial blood gases results b. Assess for dependent pitting edema c. Document abdominal girth d. Record usual eating patterns

b. Assess for dependent pitting edema

The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these underserved immunization groups? a. Reports describing influenza rates during times of greatest prevalence b. Designation of clinics conveniently located in target neighborhoods c. Legislative proposals that mandate influenza vaccinations for all d. Radio announcements about availability of the influenza vaccine

b. Designation of clinics conveniently located in target neighborhoods

A client tells the nurse that he is very nervous about the surgery he is scheduled to have in the morning. Which action should the nurse implement first? a. Provide the client with distractions to decrease his anxiety b. Explore the clients perception of the impending surgery c. Notify the health care provider of the client's expressed fears and anxiety d. Present the client with information about the surgical procedure

b. Explore the clients perception of the impending surgery

An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rails and wheezing. When assessing this client, which additional finding is the nurse likely to obtain? a. Jugular vein distention b. Fatigue c. Hepatomegaly d. Lower extremity edema

b. Fatigue

While assessing a client who had a laparotomy the previous day, the nurse notices that 300 mL of dark red fluid has drained from the nasogastric tube in the last hour. Which action should the nurse take first? a. Determine the client's vital signs b. Monitor urinary output hourly c. Notify the surgeon immediately d. Assess the client's level of pain

b. Monitor urinary output hourly

The nurse is caring for a child newly diagnosed with attention deficit hyperactive disorder (ADHD). The child's mother asked about information of the treatment options. Which information is most helpful for the nurse to provide? a. Emphasize the addictive nature of popular medications b. Offer effective time management strategies c. Explore the combination of medication and behavioral therapies d. Discuss dietary changes such as increasing protein intake

b. Offer effective time management strategies

After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of pacemaker, how should the nurse respond? a. Use simple terms to describe how the pacemaker functions b. Offer reassurance that the staff will monitor the pacemaker c. Reinforce that the pacemaker is a temporary measure d. Encourage discussion about the concerns and fears

b. Offer reassurance that the staff will monitor the pacemaker

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? a. Decreased abdominal girth b. Prothrombin time within normal limits c. Improved level of consciousness d. Clear, dark amber colored urine

b. Prothrombin time within normal limits

The mother of a 14-month-old tells the nurse that she feeds her child nothing but prepared toddler foods and feels they provide the best nutrition for her child but is concerned about the cost. How should the nurse respond? a. Advise the mother that these foods will only be needed until the growth spurt of the toddler years is complete b. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients c. Affirm that these prepared foods are the best way to ensure that the toddler gets all the needed nutrients d. Teach the mother how to develop a budget to allow her to continue to provide the needed prepared toddler foods

b. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow up action by the nurse? a. Remind the client that it is also important to switch to decaffeinated coffee and tea b. Review with the client the need to avoid foods that are rich in milk and cream c. Reinforced this teaching by asking the client to list dairy foods that he might select d. Suggest that the client also plan to eat frequent small meals to reduce discomfort

b. Review with the client the need to avoid foods that are rich in milk and cream

A client uses triamcinolone, corticosteroid ointment, to manage puritis caused by a chronic skin rash. The client calls the clinic nurse to report increased erythema with purulent exudate at the site. Which action should the nurse implement? a. Explain that the client needs to complete all prescribed doses of the medication b. Schedule an appointment for the client to see the health care provider c. Instruct the client to continue the ointment until all erythema is relieved d. Advise the client to apply plastic wrap over the ointment to promote healing

b. Schedule an appointment for the client to see the health care provider

Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? a. Serum electrolytes b. Serum liver enzymes c. Capillary blood glucose d. Complete blood count

b. Serum liver enzymes

After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral anti acids without relief period her vital signs are heart rate 122 beats/minute, respiration 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70 mmhg. The nurse obtains a 12-lead electrocardiogram. Which assessment finding is most crucial? a. Irregular pulse rate b. St elevation in three leads c. Complaint of radiating jaw pain d. Bile colored emesis

b. St elevation in three leads

A four-year-old girl returns to the pediatricians office for a post-operative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should the nurse consider normal for this age child? a. Draw a picture of self with facial features b. Talks to an imaginary friend c. Sits quietly in her mother's lap d. Ignores other children in the play area

b. Talks to an imaginary friend

The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side. What style shoes should the nurse recommend a client where when ambulating with her husband's assistance? a. Slip on rubber shower shoes b. Tennis shoes with Velcro c. Rubber soled slippers d. Leather soled loafers

b. Tennis shoes with Velcro

The nurslings at a client does not know the purpose of the antipsychotic medication ziprasidone. How should the nurse best explain the purpose of this medication? a. This medication helps people with schizophrenia b. This medication will help you think more clearly c. This is an anti-psychotic medication to calm you down d. An antipsychotic medication promotes socialization

b. This medication will help you think more clearly

An older client has been diagnosed with chronic venous insufficiency period to promote venous return, which action should the nurse encourage the client to take? a. Set-up the side of the bed for 15 minutes before standing b. Wear cotton socks and in closed toe shoes whenever outside c. Lights down in bed two times a day d. Drink 8 to 10 ounces of water a day

b. Wear cotton socks and in closed toe shoes whenever outside

The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A client... a. With pneumonia whose serum potassium level is 6.5 mg/dl b. With atrial fibrillation whose saline lock is infiltrated c. Who is receiving heparin infusion has developed hematuria d. With hypertension whose blood pressure is 230/118

b. With atrial fibrillation whose saline lock is infiltrated

A client who suspects she is pregnant tells the nurse she has peptic ulcer is being treated with misoprostol, a synthetic prostaglandin E drug. How should the nurse respond? a. You may have an increased chance of having preeclampsia b. You may be at a higher risk for having a spontaneous miscarriage c. This medication will have no effect on your unborn child d. You may experience postpartum hemorrhaging after delivery

b. You may be at a higher risk for having a spontaneous miscarriage

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment? a. "The fire is burning my skin away right now" b. "The voices are telling me to kill the next person I see" c. "The nurse at night is trying to poison me with pills" d. "The snakes on the wall are going to eat me"

c. "The nurse at night is trying to poison me with pills"

The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat gout? a. "I need to take the prescribed amount of the drug to get rid of my gout" b. "I need to take this drug every day to keep from having any flare ups" c. "The pain and swelling can be controlled by taking this drug every day" d. "I should I take this drug when I have gout attacks to reduce symptoms"

c. "The pain and swelling can be controlled by taking this drug every day"

The charge nurse is making client assessments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years' experience, one nurse with 5 years' experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse? a. A client with Adult Respiratory Distress Syndrome who is on a ventilator b. A client in end-stage renal failure who is experiencing esophageal bleeding c. A client with chest tubes secondary to a stab wound to the chest d. A client with multisystem failure secondary to a motor vehicle collision

c. A client with chest tubes secondary to a stab wound to the chest

A client is receiving a continuous infusion of normal saline at 125 ml/hr post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. The urine output is 800 ml over the past 24 hours with a central venous pressure of 15 mmHg. The nurse notes respiratory crackles and bounding central pulses. Vital signs: temperature 101.2 degrees Fahrenheit, heart rate 96 beats/minute, respirations 24 breaths/minute, and blood pressure of 160/90 mmhg. Which intervention should the nurse implement first? a. Review last administration of IV pain medication b. Decrease IV fluids to keep vein open (KVO) rate c. Administer PRN dose of acetaminophen d. Calculate total intake and output for the last 24 hours

c. Administer PRN dose of acetaminophen

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 1 to 10 scale. Which intervention should the nurse implement? a. Give maximum dosage when score reaches 10 b. Educate client on signs and symptoms of narcotic dependency c. Administer opioid and non-opioid medication simultaneously d. Alternate IV and IM analgesic medications

c. Administer opioid and non-opioid medication simultaneously

A pediatric home care nurse schedules a visit to the home of a four-week-old newborn who had a low thyroxine and high thyroid stimulating hormone at birth and was diagnosed with congenital hypothyroidism or cretinism. Which instruction is most important for the nurse to provide the parents of this child? a. Monitor the infants daily intake and weekly weight b. Offer a low sodium formula between breastfeeding c. Administer supplemental thyroid hormone daily d. Stimulate the infant during feedings to ensure adequate intake

c. Administer supplemental thyroid hormone daily

The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for Clonidine 0.2 milligrams PO taken twice daily. Which action should the nurse take? a. Monitor for signs of bleeding or hemorrhage b. Compare daily electrolyte levels prior to each morning dose c. Advice to sit up slowly from a reclining position d. Administer the medication on an empty stomach

c. Advice to sit up slowly from a reclining position

Which assessment finding places a client at risk for problems associated with impaired skin integrity? a. Smooth nail texture b. Scattered macula on the face c. Capillary refill 5 seconds d. Absence of skin tenting

c. Capillary refill 5 seconds

Client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make? a. Evidence of spread of the disease to the kidneys b. Representative of a decline in the client's condition c. Confirmation of the autoimmune disease process d. Indication of the onset of joint degeneration

c. Confirmation of the autoimmune disease process

Following a traumatic delivery, and infant receives an initial Apgar score of three period which intervention is most important for the nurse to implement? a. Page of pediatrician stat b. Inform the parents of the infant's condition c. Continue resuscitative efforts d. Repeat the Apgar assessment in five minutes

c. Continue resuscitative efforts

A neonate who has a congenital adrenal hyperplasia presents with ambiguous genitalia. What is the primary nursing consideration one supporting the parents of a child with this anomaly? a. Offer information about ultrasonography and genotyping to determine sex assignment b. Explain that corrective surgical procedures consistent with sex assignment can be delayed c. Discuss the need for cortisol and aldosterone replacement therapy after discharge d. Support the parents in their decision to assign sex of their child according to their preference

c. Discuss the need for cortisol and aldosterone replacement therapy after discharge

During the admission assessment of a terminally ill client, the client expresses being agnostic. Which is the best nursing action in response to this statement? a. Invite the client to a healing service for people of all religions b. Provide information about the hours and location of the Chapel c. Document the statement in the client spiritual assessment d. Offer to contact the spiritual advisor at the client's choice

c. Document the statement in the client spiritual assessment

The mother of an infant born with hypospadias is concerned because she has been told that her child cannot be circumcised according to her Jewish faith tradition. Which response is best for the nurse to provide? a. Your faith is important, but correcting this problem is priority for your old son b. Circumcising the penis now may contribute to frequent urinary infections c. During the surgery part of the foreskin is used to repair the meatus d. I understand your concern. Would you like to talk to the pediatrician?

c. During the surgery part of the foreskin is used to repair the meatus

The client with which type of wound is most likely to need immediate intervention by the nurse? a. Ulceration b. Contusion c. Laceration d. Abrasion

c. Laceration

A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the nurse perform first? a. Inspect the perineum for lacerations b. Collect specimen for hemoglobin and hematocrit c. Massage the fundus and give oxytocic agent d. Place the infant to breast for bonding

c. Massage the fundus and give oxytocic agent

A client with heart failure reports increased of shortness of breath. The nurse administered furosemide 20 mg intravenously 60 minutes ago. Which action is most important for the nurse to implement? a. Auscultate the lung fields b. Review serum potassium c. Measure urine output d. Administer albuterol via nebulizer

c. Measure urine output

A client with chronic kidney disease on peritoneal dialysis exhibits redness, tenderness, and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings? a. Atelectasis b. Exit site infection c. Peritonitis d. Outflow obstruction

c. Peritonitis

After placing a 36-week gestation newborn in and isolette and drying the infant with several blankets, what should the nurse implement next? a. Administer the vitamin K injection b. Remove the wet blankets and linens from the isolette c. Place erythromycin ophthalmic ointment in both eyes d. Open the isolate door to assess the infants' vital signs

c. Place erythromycin ophthalmic ointment in both eyes

A client's tumor measures 2 centimeters before and after receiving a course of radiotherapy. What physiological mechanism renders this response to radiation therapy for cancers? a. Cellular anchorage that is necessary for cancer cell growth is removed b. Cell growth is disrupted during the resting phase of the cell cycle c. Production of ionizing energy damages DNA, hence, stops replication d. Reduction of contact inhibition results in cell death by phagocytosis

c. Production of ionizing energy damages DNA, hence, stops replication

While adding water to the chest tube drainage system, the nurse knocks over the container causing the blood to spill into the adjacent chamber. Which action should the nurse take? a. Increase suction to 30 centimeters b. Assess tubing for fluctuation with respirations c. Replace chest tube drainage system d. Mark drainage in both chambers

c. Replace chest tube drainage system

A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement? a. Withhold next scheduled dose of levothyroxine b. Request a PRN sedative hypnotic to help with insomnia c. Review the most recent thyroid function test results d. Encourage increased exercise and activity during the day

c. Review the most recent thyroid function test results

Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? a. Ensure that the drainage bag is attached to the bed frame b. Ensure continued sterility of the specimen container c. Securely fasten the clamp on the drainage bag d. Label the container with the clients identifiers

c. Securely fasten the clamp on the drainage bag

The nurse is assessing the mood of the depressed male client. When asked how he feels, the client looks down and states, "I don't know! I just can't think." Which activity should the nurse suggest that this client perform? a. Complete a written self-esteem assessment b. Review the client handbook about unit therapies c. Set daily goals in the community meeting d. Read, "The Depression Recovery Book"

c. Set daily goals in the community meeting

The nurse is educating a client in end stage renal failure who requires dialysis three times a week. Which information is important for the nurse to include about the clients daily diet? a. The intake of protein should be increased to stimulate the kidneys nephrons function b. The intake of protein should be increased due to its loss through the filter membrane c. The protein intake should be decreased to prevent nitrogenous waste buildup d. The intake of protein should be decreased due to the progressively failing function of the kidney

c. The protein intake should be decreased to prevent nitrogenous waste buildup ?

The nurse plans to administer a low dose prescription for dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to dopamine? a. Pupil response b. Heart sounds c. Urinary output d. Temperature

c. Urinary output

Following a lumbar puncture, the client voices several concerns. Which concern indicates that the nurse that the client is experiencing a complication of the procedure? a. "I Feel sick to my stomach and I'm going to throw up" b. "I'm having pain in my lower back when I move my legs" c. "My throat hurts badly when I swallow and when I talk" d. "I have a headache that gets worse when I sit up"

d. "I have a headache that gets worse when I sit up"

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which healthcare measure is most important for the nurse to recommend to these clients? a. Ensure supplemental oxygen and respiratory medications are available at all times b. Use nasal or cough tissues followed by hand washing at all times c. Get annual flu and pneumococcal vaccine polyvalent vaccines d. Avoid large crowded areas during the colder months of the year

d. Avoid large crowded areas during the colder months of the year

The nurse seeks to alter or provision of a state nurse practice act regarding nurse client ratios, which the nurse believes to be unsafe. What action is most likely to impact a ruling by the State Board of nursing? a. Notify the states forward about the matter anonymously b. File a grievance at the Medical Center where the nurses employed c. Send a letter of concern to the American Nurses Association d. Consult with the appropriate state legislative representative

d. Consult with the appropriate state legislative representative

As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids based on which pathophysiological process? a. Removing gastric secretions and to relieve abdominal distention b. Reducing hydrochloric acid secretion c. Restoring and maintaining a positive fluid balance d. Decreasing the formation and secretion of pancreatic enzymes

d. Decreasing the formation and secretion of pancreatic enzymes

A client who is admitted with diabetic ketoacidosis is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases are: ph 7.50; paco2 30 mmhg; HCO3 24 meq/L. Which assessment finding warrants immediate intervention by the nurse? a. Muscle stiffness b. Abdominal pain c. Mental stupor d. Fruity breath

d. Fruity breath

A client arrives in the emergency department with a deep, full thickness burn all over the interior surface of both upper legs. Which priority intervention should the nurse implement? a. Start IV antibiotics b. Administer tetanus immunization c. Give IV analgesia d. Give an IV bolus of normal saline

d. Give an IV bolus of normal saline

The nurse is reviewing a client's urinalysis results and identifies a specific gravity of 1.035. Which action should the nurse implement based on this finding? a. Explain that the urine finding is normal b. Recommend the use of salt with meals c. Tell the client to report reduced urine output less than 1000 ml/day d. Instruct client to increase oral fluids to a minimum of 2400 ml/day

d. Instruct client to increase oral fluids to a minimum of 2400 ml/day

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which instruction is most important for the nurse to provide this client? a. Wear prescription glasses b. Eat a diet high in carotene c. Avoid frequent eye pressure measurements d. Maintain prescribed eyedrop regimen

d. Maintain prescribed eyedrop regimen

Two days after admission for a fractured wrist from a fall while intoxicated, a mail client with a history of mental illness and alcohol abuse becomes anxious, agitated, and diaphoretic. His vital signs are temperature of 99.6 degrees Fahrenheit, heart rate 112 beats, respiration 26 breaths, and blood pressure 190 / 108. He tells the nurse that bugs are crawling in his bet. Which prescription should the nurse administer? a. Buspirone b. Codeine c. Chlordiazepoxide d. Risperidone

d. Risperidone

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

d. Tell the healthcare provider the nurse will return the phone call as soon as possible

The nurse observes an elderly male client walking aimlessly in the hallway and staring straight ahead blankly. How should the nurse enter computer documentation of this finding? a. Demonstrates signs of early dementia b. Appears confused and depressed c. Ambulatory and disoriented to place d. Wandering behavior with flat affect

d. Wandering behavior with flat affect