Hesi Practice Questions 1

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? A "What are the voices saying?" B "Which medication works best?" C "When do you hear voices?" D "How do you cope with the voices?"

A "What are the voices saying?"

Which intervention Is most important for the nurse to include in the plan of Care for a client who is 12 hours post-thyroidectomy ? A Resume antithyroid drug therapy. B Prepare to administer radioactive iodine treatments. C Anticipate and monitor for hypothermia. D Maintain a semi-Fowler position.

A Resume antithyroid drug therapy.

While assisting a male client who has muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

Place a portable toilet next to the bed

A client diagnosed with bipolar disorder is going home on a week-end pass. Which suggestions should give the client's family to help them prepare for the visit? 1. Discuss the importance of continuing the usual at-home activities 2. Encourage the family to plan daily activities to keep the client busy 3. Have friends and family visit the client at a welcome party. 4. Instruct family to monitor the client's choice of television programs.

1. Discuss the importance of continuing the usual at-home activities

A patient who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breast are swollen, warm and tender on palpitation. Which instruction should the nurse provide?

Apply ice to the breast for comfort

a clent with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client's symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order? A. Orange juice B. Regular insulin C. NPH insulin D. Repeat blood sugar level

B. Regular insulin

An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? A. History of smoking over the past 6 months B. Sleep patterns during the previous few weeks C. Activity level prior to onset of symptoms D. Recent compliance with prescribed medications

D. Recent compliance with prescribed medications

During a visit to the planned parenthood clinic, a young woman tells the nurse that she is going to discontinue taking the oral contraceptives she has taken for three years because she wants to get pregnant. History indicates that her grandfather has adult onset diabetes and that she was treated for chlamydia six months ago, which factor in this client's history poses the greatest risk for this woman's pregnancy? A. Family history of adult onset diabetes. B. Treatment for chlamydia in the past year C. Client's age and previous sexual behavior D. Three year history of taking oral contraceptives

D. Three year history of taking oral contraceptives

The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?

Medication port

While attempting to stablish risk reduction strategies in a community, the nurse notes that the regional studies have indicated....persons with irreversible mental deficiencies due to hypothyroidism. The nurse should seek funding to implement which screening measure?

T4 levels in newborns

A client with hyperthyroidism is admitted to the postoperative after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse

Total calcium 5.0 mg/dl

Following a gun shot wound to the abdomen, a young adult male had an emergency bowel...Multiple blood products while in the operating room. His current blood pressure is 78/52...He is being mechanically ventilated, and his oxygen saturation is 87%. His laboratory values...Grams / dl (70 mmol / L SI), platelets 20,000 / mm 3 (20 x 10 9 / L (SI units), and white blood cells. Based on these assessments findings, which intervention, should the nurse implements first? a. Transfuse packed red blood cells b. Obtain blood and sputum cultures. c. Infuse 1000 ml normal saline d. Titrate oxygen to keep o2 saturation 90%

a. Transfuse packed red blood cells

35 years old female client has just been admitted to the post anesthesia recovery unit following a partial thyroidectomy. Which statement reflects the nurse's accurate understanding of the expected outcome for the client following this surgery? a- Supplemental hormonal therapy will probably be unnecessary b- The thyroid will regenerate to a normal size within a few years. c- The client will be restricted from eating seafood d- The remainder of the thyroid will be removed at a later date.

c- The client will be restricted from eating seafood

A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? a) Irrigate the indwelling urinary catheter. b) Prepare the client for external pacing. c) Obtain capillary blood glucose measurement. d) Titrate the dopamine infusion to raise the BP.

d) Titrate the dopamine infusion to raise the BP.

An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

1000, 1600, 2200, 0400

After receiving report, the nurse can most safely plan to assess which client last? A An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed. B An older client with a distended abdomen and no drainage from the nasogastric tube. C An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac D An adult client with a rectal tube draining clear, pale red liquid drainage.

A An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed.

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

A) Have the client vocalize the instructions provided

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

A) Keep the nails trimmed short

What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse? A. "When I get out of bed quickly, I feel a little dizzy." B. "The dressing over my incision feels like it is too tight C. "I'm most comfortable when the head of the bed is raised" D. "This IV infusion makes me urinate more often than usual"

A. "When I get out of bed quickly, I feel a little dizzy."

The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first? A. A client with congestive heart failure who reports a 3 pound weight gain in the last two days B. An immobile client with a stage 3 pressure ulcer on the coccyx who is having low back pain C. A client diagnosed with chronic obstructive pulmonary disease (COPD) who is short of breath D. A terminally ill older adult who has refused to eat or drink anything for the last 48 hours

A. A client with congestive heart failure who reports a 3 pound weight gain in the last two days

The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority? A. Assess for signs of fluid volume deficit B. Observe wound drainage characteristics C. Measure the level of acute pain D. Determine when the client last ate

A. Assess for signs of fluid volume deficit

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A. Culture for sensitive organisms B. Serum blood glucose (BG) level C. Creatinine level D. Serum albumin

A. Culture for sensitive organisms

The nurse is assessing a client who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the healthcare provider immediately? A. Diminished breath sounds over the trocar insertion site B. Equal bilateral chest expansion C. Scattered crackles unchanged from baseline D. Respiratory rate of 22 breaths/minute

A. Diminished breath sounds over the trocar insertion site

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include: sodium 129 mEq/L, glucose 54mg, and potassium 5.3 mEq/L. When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? A. Hydrocortisone B. Regular insulin C. Broad spectrum antibiotic D. Potassium chloride

A. Hydrocortisone

During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class, as seen in the video. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem? A. Infection B. Ineffective airway clearance C. Altered comfort D. Impaired gas exchange

A. Infection

The laboratory findings for a client with chronic kidney disease (CKD) include elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. Based on these findings, which action should the nurse implement? A. Provide high protein snacks B. Administer PRN oxygen C. Schedule frequent rest periods D. Monitor glucose levels q4 hours.

A. Provide high protein snacks

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? A. Report serum albumin and globulin levels B. Provide diet low in phosphorus C. Note signs of swelling and edema D. Monitor abdominal girth E. Increase oral fluid intake to 1,500 mL daily

A. Report serum albumin and globulin levels C. Note signs of swelling and edema D. Monitor abdominal girth

A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply) A.)Headache and tremors B.)Postural hypotension C.)Pallor and diaphoresis D.)Irregular heart beat E.)Plus 4 pitting edema

A.)Headache and tremors B.)Postural hypotension C.)Pallor and diaphoresis D.)Irregular heart beat

An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first? A Provide bedside equipment for transmission and protective precautions. B Culture sputum, urine, burn wound, and all intravenous access sites. C Implement central line-associated bloodstream infection (CLABSI) protocols. D Evaluate daily serum electrolytes and hydration status.

B Culture sputum, urine, burn wound, and all intravenous access sites.

An older adult with terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which intervention(s) should he nurse include in this client's plan of care? (Select all that apply). A Record the client's desire to live. B Teach client how to use guided imagery. C Instruct client and family to reconsider end of life choices. D Encourage family to bring the client old photographs. E Encourage family to visit frequently.

B Teach client how to use guided imagery. D Encourage family to bring the client old photographs. E Encourage family to visit frequently.

Oxygen at 5l/min per nasal cannula is being administered to a 10 year old child with pneumonia. When planning care for this child, what principle of oxygen administration should the nurse consider? A) Taking a sedative at bedtime slows respiratory rate, which decreases oxygen? B) Avoid administration of oxygen at high levels for extended periods. C) Increase oxygen rate during sleep to compensate for slower respiratory rate. D) Oxygen is less toxic when it is humidified with a hydration source.

B) Avoid administration of oxygen at high levels for extended periods.

In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and? A) Increased retention of albumin in the vascular system B) Decreased colloidal osmotic pressure in the capillaries C) Fluid shift from interstitial spaces into the vascular space D) Reduced tubular reabsorption of sodium and water

B) Decreased colloidal osmotic pressure in the capillaries

A male client with diabetes mellitus type 2, who is taking pioglitazone PO daily, reports to the nurse the recent onset of nausea, accompanied by dark-colored urine, and a yellowish cast to his skin. What instructions should the nurse provide? A. "You have become dehydrated from the nausea. You will need to rest and increase fluid intake" B. "you need to seek immediate medical assistance to evaluate the cause of these symptoms" C. A urine specimen will be needed to determine what kind of infection you have developed" D. use insulin per sliding scale until the nausea resolves, and then resume your oral medication

B. "you need to seek immediate medical assistance to evaluate the cause of these symptoms"

A male client suffering from depression has been taking an antidepressant medication for two days. He tells the nurse that he is smiling more and feeling better. Which response is best for the nurse to provide? A. Feeling hopeful is a good sign that your depression is improving. B. Antidepressants usually begin to improve your mood after 2 to 4 weeks C. Antidepressants can cause mild mood swings within several days D. Antidepressants can stabilize your mood within several days.

B. Antidepressants usually begin to improve your mood after 2 to 4 weeks

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

B. Begin chest compressions at 100/minute

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

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

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? A. Resume normal physical activity B. Give a dose of regular insulin as prescribed C. Measure urine output over the next 24 hours D. Drink electrolyte fluid replacements

B. Give a dose of regular insulin as prescribed

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)? A. Leukocytes, neutrophils, and thyroxine B. Serum potassium, calcium, and phosphorus C. Blood pressure, heart rate, and temperatue D. Erythrocytes, hemoglobin, and hematocrit

B. Serum potassium, calcium, and phosphorus

The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings, as seen in the video. Which action(s) should the charge nurse take? (Select all that apply) A Advise the nurse to use the plunger when giving medications. B Encourage the nurse to flush the tube with more water. C Confirm that the nurse determined the amount of gastric residual. D Instruct the nurse to administer each medication separately. E Add the liquid volumes when documenting fluid intake.

C Confirm that the nurse determined the amount of gastric residual. D Instruct the nurse to administer each medication separately. E Add the liquid volumes when documenting fluid intake.

An older client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition. The healthcare provider prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important for the nurse to include in client's plan of care? A Measure and record the client's urinary output every day. B Provide the client with teaching regarding a cardiac diet. C Obtain a blood pressure reading before client gets out of bed. D Obtain client's vital signs every 4 hours when awake.

C Obtain a blood pressure reading before client gets out of bed.

Upon the return of a client from surgery after an open reduction of a femur fracture, the nurse notes a small bloodstain on the cast and marks it. Four hours later the nurse observes that the stain has doubled in size. What is the best action for the nurse to take? A) Access the site by cutting a window in the cast B) Call the health care provider C) Outline the new spot then continue monitoring D) Record the findings in the client's record

C) Outline the new spot then continue monitoring

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply). A. A bedside commode is positioned near the bed B. A saline lock is present in the right forearm C. A full pitcher of water is on the bedside table D. The client is lying in a supine position in bed E. A low sodium diet tray was brought to the room

C. A full pitcher of water is on the bedside table D. The client is lying in a supine position in bed

The nurse is caring for a client who is admitted to the emergency center after a motor vehicle collision. The client begins to experience a decreased level of consciousness and the pupils do not respond equally to light. Which vital signs changes indicate the client is manifesting Cushing's triad? A. Blood pressure of 80/40 mmHg, weak heart rate of 40 beats/minute, Cheyne-Stokes respirations of 10 breaths/minute B. Blood pressure 180/120 mmHg, weak heart rate of 92 beats/minute, Kussmaul respirations of 18 breaths/minute C. Blood pressure of 180/80 mmHg, bounding heart rate of 50 beats/minute, respirations of 30 breaths/minute with apneic episodes D. Blood pressure of 90/60 mmHg, strong heart rate of 60 beats/minutes, eupneic respirations of 16 breaths/minute

C. Blood pressure of 180/80 mmHg, bounding heart rate of 50 beats/minute, respirations of 30 breaths/minute with apneic episodes

The parents of a 6 year old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? A. Provide a list of alternative activities that are less likely to cause the child to experience fatigue B. Explain that their child is too young to understand the risks associated with swimming C. Encourage the parents to allow the child to continue attending swimming lessons with supervision

C. Encourage the parents to allow the child to continue attending swimming lessons with supervision

In caring for a client with Cushing's Syndrome, which serum laboratory value is most important for the nurse to monitor? A. Creatinine B. Lactate C. Glucose D. Hemoglobin

C. Glucose

While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take? A. Start progressive mobilization B. Request a nutrition consult C. Request a wound culture and sensitivity D. Force oral fluids

C. Request a wound culture and sensitivity

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum sodium of 145 mEq/L (145 mmol/L SI) C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI) D. White blood cell count of of 12,000 mm3 (12 x 109/L SI)

C. Serum creatinine of 4.5 mg/dl (398 mcmol/L SI)

Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider? A A client is walking the halls at night rubbing his hands together. B A family member expresses concern about their relative "picking" at the NG tube. C A 16-year-old boy swung his fist at the nurse. D A disoriented client removed the mesh wrapped IV line for the second time.

D A disoriented client removed the mesh wrapped IV line for the second time.

The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize? A Leg elevation. B Pain management. C Ambulation teaching. D Neurovascular check

D Neurovascular check

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take? A Inform the mother that toilet training is slower for boys. B Refer the mother to a community parent education program. C Suggest that the mother consult a pediatric nephrologist. D Provide disposable training pants while calming the mother.

D Provide disposable training pants while calming the mother.

Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have had a pulmonary embolus. Which action should the nurse take first? A Bring the emergency crash cart to the bedside. B Prepare a continuous heparin infusion per protocol C Notify the healthcare provider. D Provide supplemental oxygen.

D Provide supplemental oxygen.

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the cent. Which action should the nurse take? A Remind the UP to apply a fitted respirator mask before entering the client's room. B Assign the UP to provide care for another client and assume full care of the client. C Instruct the UP to notify the nurse of any changes in the client's respiratory status. D Review the need for the UP to wear a face mask while in close contact with the client.

D Review the need for the UP to wear a face mask while in close contact with the client.

An adult client is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes two hours or longer to complete. The client worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? A. Phobia B. Addiction C. Obsession D. Compulsion

D. Compulsion

A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? A. Regular contractions occurring every 10 minutes B. Sterile vaginal exam revealing 3cm dilation C. Biophysical profile results showing oligohydramnios D. Fetal heart tones located in upper right quadrants

D. Fetal heart tones located in upper right quadrants

A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus?A. Mean arterial pressure (MAP) B. White blood cell count C. Blood culture D. Oxygen saturation

D. Oxygen saturation

During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? a. Keep a daily weight record b. Obtain weight at the same time every day c. Limit intake of dietary salt. d. Report weight gain of 2 pounds (0.9kg) in 24 hours

Report weight gain of 2 pounds (0.9kg) in 24 hours

Prior to obtaining a trapeze bar for a pt with limited mobility, which pt assessment is most important for the nurse to obtain?

Upper body muscle strength

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?

Weight bearing exercise

The nurse is teaching a primigravida about preeclampsia. Which findings are indicators of preeclampsia and should be reported to the healthcare provider? a) Blurred Vision b) Headache c) Lack of appetite d) Urinary frequency e) Chills and fever f) Swollen hands

a) Blurred Vision b) Headache f) Swollen hands

An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take? a) Obtain a prescription for an anticholinergic medication b) Determine how many hours declined slept last night c) Administer the PRN prescription for severe anxiety d) Watch the thyroid cartilage move while the client swallows

a) Obtain a prescription for an anticholinergic medication

The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? a) Recommend weigh bearing physical activity b) Reduce intake of foods high in vitamin D c) Decrease intake of foods high in fat d) Minimize heavy lifting and bending.

a) Recommend weigh bearing physical activity

A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply) a) Topical corticosteroid. b) Topical scabicide. c) Topical alcohol rub. d) Transdermal analgesic. e) Oral antihistamine

a) Topical corticosteroid e) Oral antihistamine

A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? a) Altered consciousness within the first 24 hours after injury. b) Cushing reflex and cerebral edema after 24 hours c) Fever, nuchal rigidity and opisthotonos within hours d.) Headache and pupillary changes 48 hours after a head injury

a)altered consciousness

The nurse requests a meals tray for a client follows Mormon beliefs and who is on clear liquid diet following abdominal surgery. Which meal item should the nurse request for this client? (Select all that apply) a- Apple juice b- Chicken broth. c- Hot chocolate d- Orange juice e- Black coffee

a- Apple juice b- Chicken broth.

Following insertion of a LeVeen shunt in a client with cirrhosis of the liver, which assessment finding indicates to the nurse that the shunt is effective? a- Decreased abdominal girth b- Increased blood pressure c- Clear breath sounds d- Decrease serum albumin.

a- Decreased abdominal girth

The nurse is assessing a 4-year-old boy admitted to the hospital with the diagnosis of possible nephrotic syndrome. Which statement by the parents indicates a likely correlation to the child's diagnosis? a- I couldn't get my son's socks and shoes on this morning" b- My son has been on amoxicillin/clavulanate for 2 days for an ear infection c- My son has had a red rash over his entire body for the past 4 days. d- I couldn't get my son calm down and sleep last night.

a- I couldn't get my son's socks and shoes on this morning"

During a left femoral artery aortogram, the healthcare provider inserts an arterial sheath and initiate. Through the sheath to dissolve an occluded artery. Which interventions should the nurse implement? a- Instruct the client to keep the left leg straight b- Keep the head of bed at 60-degree angle. c- Observe the insertion site for a hematoma d- Manually flush the arterial sheath hourly e- Circle first noted drainage on the dressing

a- Instruct the client to keep the left leg straight c- Observe the insertion site for a hematoma e- Circle first noted drainage on the dressing

A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding... the client? a. Blood pressure 149/101 b. Irregular pulse rate of 80 c. Oral temperature is 98.9 F (37.1 C) d. Pain rated 7 on scale 1-10

a. Blood pressure 149/101

A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? a. Cardiac rhythm and heart rate. b. Daily intake of foods rich in potassium. c. Hourly urinary output d. Thirst ad skin turgor.

a. Cardiac rhythm and heart rate.

The nurse is assessing a patient with a closed head injury sustained in a MVA. Which finding indicates the lowest neurological functioning? a. Decerebrate posturing during position changes b. Withdrawal from painful stimuli c. Decorticate posturing during tracheal suctioning d. Localization of a tactile stimulus

a. Decerebrate posturing during position changes

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? Select all that apply. a. Flat affect b. Frequent drooling c. Frequent syncope d. Blurred vision e. Occasional nocturia

a. Flat affect c. Frequent syncope d. Blurred vision

A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? a. Level of consciousness b. Percussion of abdomen c. Serum electrolytes d. Blood glucose.

a. Level of consciousness

An older adult client is admitted to the stroke unit after recovering from the acute phrase of an ischemic cerebral vascular accident CVA. Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? SATA a. Measure neurological vital signs every four hours b. Play classical music in Rome while client is awake c. Encourage family to participate in the client's care d. Place a bedside commode next to the bed

a. Measure neurological vital signs every four hours c. Encourage family to participate in the client's care d. Place a bedside commode next to the bed

An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition? a. Multiple organ dysfunction syndrome (MODS) b. Disseminated intravascular coagulation (DIC) c. Chronic obstructive disease. d. Acquired immunodeficiency syndrome (AIDS)

a. Multiple organ dysfunction syndrome (MODS)

While caring for a client postoperative dressing the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor before reporting this finding to the health care provider the nurse should note which of the clients Laboratory values? a. Neutrophil field count b. Creatinine level c. Serum albumin d.Serum potassium and sodium levels

a. Neutrophil field count

The nurse notes an increase in serosanguinous drainage from the abdominal surgical wound from an obese client. What action should the nurse implement? a. Observe the wound for dehiscence b. Teach the client to splint the incision while coughing c. Assess the skin surrounding the wound for maceration d. Obtain a culture of the wound drainage.

a. Observe the wound for dehiscence

When assessing the surgical dressing of a client who had an abdominal surgery the previous day, the nurse observes that a small amount of drainage present on the dressing and the wounds Hemovac suction device is empty with the plug open. How should the nurse respond? a. Recompress the wound suction device and secure the plug b. Notify the health care provider that the drain is not working c. Replace the dressing and remove the drainage device d. Repositioned the drainage device to keep the plug open

a. Recompress the wound suction device and secure the plug

A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? a. Reduced level of pain b. Full volume of pedal pulses c. Granulating tissue in foot ulcer d. Improved visual acuity

a. Reduced level of pain

While the nurse is conducting an admission assessment of a female client with bipolar disorder, the client suddenly begins to take off her clothes and throw them about the room. Which action should the nurse take first? a. State it is unacceptable to undress during interview b. Change to less anxiety promoting questions c. Leave the client's room so she can act out her anxiety d. Ignore the client's inappropriate behavior

a. State it is unacceptable to undress during interview

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which assessment finding warrants immediate intervention by the nurse? a. The client has asymmetrical chest wall expansion b. The clients complain of pain at the insertion site c. The client chest's x-ray indicates decreased pleural effusion d. The client's arterial blood gases are pH 7.35, PaO2 85, Pa CO2 35, HCO3 26

a. The client has asymmetrical chest wall expansion

The is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? a. decreased level of consciousness b. loss of bladder control c. altered sensation to stimuli d. emotional lability

a. decreased level of consciousness

Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to ambulate a client for the first time after a colon resection? a. have the client sit on the side of the bed before helping the client to walk b. if the client is dizzy ask the client to take some slow, deep breaths c. help the client to walk in the room as often as the client wishes d. when you help the client to walk, ask if any pain occurs

a. have the client sit on the side of the bed before helping the client to walk

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant emlerocco (VRE) infection. Which nursing interventions should the nurse include in a plan of care? (Select all that apply) a. monitor the client's white blood cell count b. send wound drainage for culture and sensitivity c. Use standard precaution wear of mask d. Explain the procedure of a low bacterial diet e. Institute contact precaution for staff and visitor.

a. monitor the client's white blood cell count b. send wound drainage for culture and sensitivity e. Institute contact precaution for staff and visitor.

When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority? a. risk for injury: hemorrhage b. risk for injury related to peripheral neuropathy c. altered nutrition: less than body requirements d. fluid volume excess: ascites

a. risk for injury: hemorrhage

A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take? a) Ask a chemotherapy-certified nurse to administer the Zofran b) Administer the Zofran after flushing the saline lock with saline c) Hold the scheduled dose of Zofran until the client awakens d) Awaken the client to assess the need for administration of the Zofran.

b) Administer the Zofran after flushing the saline lock with saline

The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching? a) Do not read without direct lighting for 6 weeks. b) Avoid straining at stool, bending, or lifting heavy objects. c) Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. d) Limit exposure to sunlight during the first 2 weeks when the cornea is healing.

b) Avoid straining at stool, bending, or lifting heavy objects.

The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? a) Neutralize hydrochloric (HCI) acid in the stomach b) Decreases the amount of HCL secretion by the parietal cells in the stomach c) Inhibit action of acetylcholine by blocking parasympathetic nerve endings. d) Destroys microorganisms causing stomach inflammation

b) Decreases the amount of HCL secretion by the parietal cells in the stomach

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.) a) Take an additional dose for signs of hyperglycemia b) Recognize signs and symptoms of hypoglycemia. c) Report persist polyuria to the healthcare provider. d) Use sliding scale insulin for finger stick glucose elevation. e) Take Glucophage with the morning and evening meal.

b) Recognize signs and symptoms of hypoglycemia. c) Report persist polyuria to the healthcare provider. e) Take Glucophage with the morning and evening meal.

A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider? a) Gastric output of 900 mL in the last 24 hours b) Serum potassium level of 3.1 mEq/L or mmol/L (SI) c) Increased blood urea nitrogen (BUN) d) 24-hour intake at the current infusion rate.

b) Serum potassium level of 3.1 mEq/L or mmol/L (SI)

A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM? a) Immune antibodies attack pancreatic beta cells resulting in no insulin b) The body cells develop resistance to the action of insulin. c) Body organs produce less insulin and more glucagon d) The liver produces excess glucose in response to excess glycotrophic hormones

b) The body cells develop resistance to the action of insulin.

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is a rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? a. Demonstrate how to help the client move more efficiently b. Affirm that the client should arise slowly from the chair c. Offer a PRN analgesic to reduce painful movement d. Tell the UAP to assist the client in moving more quickly

b. Affirm that the client should arise slowly from the chair

When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility? a. Digestive problems b. Amenorrhea c. Electrolyte imbalance d. blood disorder

b. Amenorrhea

A client with hemorrhoids asked for information about high fiber diet. Which breakfast menu items should the nurse suggest? Select all that apply. a. Scrambled eggs b. Bowl of oatmeal c. Raisin bran muffins d. Cup of raspberries e. Bacon slices

b. Bowl of oatmeal c. Raisin bran muffins d. Cup of raspberries

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? a. Continued development of the brain lesion determines the child's outcome b. Brain damage with CP is not progressive but it does have variable course c. CP is one of the most common permanent physical disability in children d. Severe motor dysfunction determines the extent of successful habilitation

b. Brain damage with CP is not progressive but it does have variable course

A client with Alzheimer's disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client's mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information? a. Explain that it may take several weeks for the medication to be effective b. Confirm the desired effect of the medication has been achieved. c. Notify the health care provider than a change may be needed. d. Evaluate when and how the medication is being administered to the client.

b. Confirm the desired effect of the medication has been achieved.

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? a. Sed rate (ESR) b. Hemoglobin c. Calcium d. Osmolality

b. Hemoglobin

An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? a. Hygiene-self-care deficit b. Imbalance nutrition c. Disturbed sleep pattern d. Self-neglect

b. Imbalance nutrition

A client with the history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain. Vital signs are: temperature 102 F (38.9 C), heart rate 138 beats/Min, BP 80/60 mmHg. Which intervention should the nurse implement FIRST? a. Cover client with cooling blanket b. Infuse intravenous fluid bolus c. Obtain an analgesic prescription d. Administer PRN oral antipyretic

b. Infuse intravenous fluid bolus

A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action? a. Administer naloxone (Narcan) per PNR protocol b. Initiate seizure precautions c. Obtain a serum drug screen d. Instruct the family about withdrawal symptoms.

b. Initiate seizure precautions

A client with cirrhosis of the liver having numerous, liquid, incontinent stools, and continues to be confused. After reviewing the clients laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is most important for the client to receive? a. IV Human albumin b. Lactulose c. Furosemide d. Loperamide

b. Lactulose

A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Pain scale rating at 9 on a 0-10 scale b. Last menstrual period was 7 weeks ago c. Reports white curdy vaginal discharge d. History of irritable bowel syndrome IBS

b. Last menstrual period was 7 weeks ago

A client who had an emergency appendectomy is being mechanically ventilated, and soft wrist restrain are in place to prevent self extubation. Which outcome is most important for the nurse to include in the client's plan of care? a. Understand pain management scale b. Maintain effective breathing patterns c. Absence of ventilator associated pneumonia d. No injuries refer to soft restrains occur

b. Maintain effective breathing patterns

A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply) a. Check urine for ketones b. Measure blood glucose c. Monitor vital signs d. Assessed level of consciousness e. Obtain culture of wound

b. Measure blood glucose c. Monitor vital signs d. Assessed level of consciousness

A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? a. Jaundice skin tone b. Muffled heart sounds c. Pitting peripheral edema d. Bilateral scleral edema

b. Muffled heart sounds

An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? a. Observe neck for jugular vein distention b. Notify healthcare provider to prepare for pericardiocentesis c. Asses for paradoxical blood pressure d. Monitor oxygen saturation (Sp02) via continuous pulse oximetry

b. Notify healthcare provider to prepare for pericardiocentesis

A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? a. Determine client's level current blood alcohol level. b. Observe for changes in level of consciousness. c. Involve the client's family in healthcare decisions. d. Provide grief counseling for client and his family.

b. Observe for changes in level of consciousness.

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? a. Replace the IV site with a smaller gauge. b. Redress the abdominal incision c. Leave the lights on in the room at night. d. Apply soft bilateral wrist restraints.

b. Redress the abdominal incision

An older adult client with systematic inflammatory response syndrome SIRS has a temperature of 101.8 Fahrenheit heart rate of 110 beats/ minutes and respiratory rate of 24 breaths/ minutes which additional finding is most important to report to the healthcare provider? a. capillary glucose reading b. Serum creatinine of 2.0mg/dL c. Blood pressure of 130/88 mmHg d. Hemoglobin of 12 g/dL

b. Serum creatinine of 2.0 mg/dL

A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Blood alcohol level of 0.09% b. Serum lithium level of 1.6 mEq/L or mmol/l (SI) c. Six hours of sleep in the past three days. d. Weight loss of 10 pounds (4.5 kg) in past month.

b. Serum lithium level of 1.6 mEq/L or mmol/l (SI)

A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care? a. Elevate lower extremities while out of bed b. Teach family proper range of motion exercises. c. Maintain proper body alignment when in bed d. Encourage diaphragmatic breathing exercises.

b. Teach family proper range of motion exercises.

A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? a. Explain how to use communication tools. b. Teach tracheal suctioning techniques c. Encourage self-care and independence. d. Demonstrate how to clean tracheostomy site.

b. Teach tracheal suctioning techniques

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a. Evaluate the client for sleep disturbances b. Weigh the client and report any weight gain. c. Report any client complaint of pain or discomfort. d. Assess the client for weakness and fatigue e. Note and report the client's food and liquid intake during meals and snacks.

b. Weigh the client and report any weight gain. c. Report any client complaint of pain or discomfort. e. Note and report the client's food and liquid intake during meals and snacks.

The nurse is assigned to a client with parkinson disease. Which findings would the nurse anticipate? a. non intention tremors and urgency with voiding b. echolalia and a shuffling gait c. muscle spasms and a bent over posture d. intention tremor and jerky movement of the elbows

b. echolalia and a shuffling gait

The nurse is caring for a client with status epileptics. The most important nursing assessment of this client is a. intravenous drip rat b. level of consciousness c. pulse and respiration d. injuries to the extremities

b. level of consciousness

After receiving report, the nurse can most safely plan to assess which client last? The client with... a) A rectal tube draining clear, pale red liquid drainage b) A distended abdomen and no drainage from the nasogastric tube c) No postoperative drainage in the Jackson-Pratt drain with the bulb compressed d) Dark red drainage on a postoperative dressing, but no drainage in the Hemovac®.

c) No postoperative drainage in the Jackson-Pratt drain with the bulb compressed

The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin SHOCK... medication? a) Dilute the Dextrose in one liter of 0.9% Normal Saline solution. b) Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml. c) Push the undiluted Dextrose slowly through the currently infusion IV. d) Ask the pharmacist to add the Dextrose to a TPN solution.

c) Push the undiluted Dextrose slowly through the currently infusion IV.

A client is admitted with an epidural hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? a) Slow increasing intracranial pressure (ICP) b) Decerebrate posturing c) Rapid onset of decreased level of consciousness. d) Coup contrecoup signs

c) Rapid onset of decreased level of consciousness

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? a) Ask the UAP to take the blood pressure in the other arm b) Tell the UAP to use a different sphygmomanometer. c) Review the client's serum calcium level d) Administer PRN antianxiety medication.

c) Review the client's serum calcium level

A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the health care provider? a) Serum ph of 7.45 b) Shift intake of 640 ml IV fluids plus 30 ml PO ice chips c) Serum potassium of 3.0 mg/dl d) Gastric output of 100 ml in the last 8 hours

c) Serum potassium of 3.0 mg/dl

The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs? a- Stares straight ahead without blinking b- Face does not convey any emotion c- Cries frequently during the interview d- Uses a monotone when speaking

c- Cries frequently during the interview

The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? a- Fruity breath odor b- Polyphagia c- Diaphoresis d- Polydipsia

c- Diaphoresis

The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? a. An adult female who has been depressed for the past several months and denies suicidal ideations. b. A middle-age male who is in a depressive phase of bipolar disease and is receiving Lithium. c. A young male with schizophrenia who said voices are telling him to kill his psychiatrist. d. An elderly male who tells the staff and other clients that he is superman and he can fly

c. A young male with schizophrenia who said voices are telling him to kill his psychiatrist.

A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement? a. Encourage the client to be calm and relax for a little while b. Assist the client to identify stimuli that precipitates the activity. c. Allow time for the behavior and then redirect the client to other activities. d. Teach the client thought stopping techniques and ways to refocus.

c. Allow time for the behavior and then redirect the client to other activities.

The nurse is administering albuterol to a child with asthma. Which of the following assessments by the nurse indicate the need for an adjustment of the medication? a. Lethargy and fatigue b. Edema is the lower extremities c. Apical pulse of 112 d. Temperature of 101 degrees Fahrenheit

c. Apical pulse of 112

A postpartum client who is breast feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client? a. Take a prescribed analgesic and expose breast to air b. Place warm packs on both of the breast c. Avoid stimulation of the breast and wear a tight bra d. Express a small amount of breast milk by hand

c. Avoid stimulation of the breast and wear a tight bra

In assessing a client with diabetes mellitus type 1, the nurse notes that the client's respirations have changed from 16 with normal depth to 32 and deep, and the client has become lethargic. What assessment data should the nurse obtain next? a. Arterial blood gases b. Core body temperature c. Blood glucose d. Oxygen saturation

c. Blood glucose

What action should the school nurse implement to provide secondary prevention to a school-age children? a. Collaborate with a science teacher to prepare a health lesson b. Prepare a presentation on how to prevent the spread of lice c. Initiate a hearing and vision screening program for first-graders d. Observe a person with type 1 diabetes self-administer a dose of insulin

c. Initiate a hearing and vision screening program for first-graders

The nurse is caring for a client after a thoracentesis that drained 50 ml of clear fluid from the left lung. Which assessment finding should the nurse report to the health care provider immediately? a. Serosanguinous drainage from the chest tube b. Dullness bilaterally on progression c. Mediastinal shift to the right d. Diminished breath sounds in the left lower lobe

c. Mediastinal shift to the right

An adult patient with a broken femur is transferred to the med surg unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the patient reports muscle spasm and pain at the fracture site. While waiting for the patient to be transported to surgery, which action should the nurse implement? a. Reduce weight on traction b. Administer PRN dose of muscle relaxant c. Observe for signs of DVT d. Check patient's most recent electrolyte values

c. Observe for signs of DVT

A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi-Fowler position with his arms at his sides. What action should the nurse implement? a. Reposition the client in a side-lying position and support his abdomen with pillows. b. Elevate the client's feet on a pillow while keeping the head of the bed elevated. c. Raise the head of the bed to a Fowler's position and support his arms with a pillow d. Place the client in a shock position and monitor his vital signs at frequent intervals

c. Raise the head of the bed to a Fowler's position and support his arms with a pillow

A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective? a. The nurse note that no pills remain in the prescription bottle. b. The client serum Depakote level is 125 mcg/ml c. The family reports a great reduction in client's maniac behavior d. The client denies any occurrence of suicidal ideation.

c. The family reports a great reduction in client's maniac behavior

While caring for a child with Reye's Syndrome, the nurse should give which action the highest priority? a. monitor intake and output b. provide good skin care c. assess level of consciousness d. assist with range of motion

c. assess level of consciousness

The nurse is caring for a post- surgical client at risk for developing deep vein thrombosis, Which intervention is an effective preventive measure? a. place pillows under the knees b. use elastic stockings continuously c. encourage range of motion and ambulation d. massage the legs twice daily

c. encourage range of motion and ambulation

The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? a) A 34-year -old admitted today after an emergency appendendectomy who has a peripheral intravenous catheter and a Foley catheter. b) A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race. c) A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter. d) An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied

d) An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied

The nurse who works in labor and delivery is reassigned to the cardiac care unit for the day because of a low census in labor and delivery. Which assignments is best for the nurse to give this nurse? a) Transfer a client to another unit b) Monitor the central telemetry c) Perform the admission d) Assist cardiac nurses with their assignments

d) Assist cardiac nurses with their assignments

The charge nurse in a critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? a) Pulmonary embolus with an intravenous heparin infusion and new onset hematuria b) Myocardial infarction with sinus bradycardia and multiple ectopic beats c) Adult respiratory distress syndrome with pulse oximetry of 85% saturation. d) Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

d) Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation

When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? a) Perform the drainage immediately after meals b) Instruct the client to breath shallow and fast c) Obtain arterial blood gases (ABG's) prior to procedure d) Explain that the client may be placed in five positions

d) Explain that the client may be placed in five positions

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

d) Measure urinary output every hour

A client with a fractured femur has been in Russell's traction for 24 hours. Which nursing action is the priority? a) Check the skin on the sacrum for skin breakdown b) Auscultate the lungs for atelectasis c) Inspect the pin sites for signs for infection d) Perform a neurovascular check for circulation

d) Perform a neurovascular checks for circulation

An adult male who fell from a roof and fractures his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse? a) Onset of mild confusion b) Pain score 8 out of 10 c) Pale, diaphoretic skin d) Weak palpable distal pulses

d) Weak palpable distal pulses

A male client who fell off a roof have right and left femur fractures and crushing injuries to both ankles. He is supine with bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hours. When asked to evaluate his pin on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has received morphine 2mg IV hourly. His vital signs are heart rate 130 beats/minute, respiration 32 breathes/minute, blood pressure 180/90 mmHg. Which interventions is most important for the nurse to implement? a) Request the healthcare provider to consider a different analgesic b) Evaluate the traction for amount of tension applied to each extremity c) Determine if client is experiencing cumulative effects of the total dosage d) Assess the extremities for signs of compartment syndrome q2 hours

d) assess the extremities for signs of compartment syndrome q2 hours

The nurse is caring for a 16 year old client with a femur fracture 14 hours after surgery. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 degrees Fahrenheit, complaints of feeling anxious and oxygen saturation levels of 88%. IN immediately notifying the provider of these findings, the nurse recognizes the client is at risk for a) compartment syndrome b) atelectasis c) myocardial infraction d) fatty embolism

d) fatty embolism

A 300 ml unit of packed red blood cells is prescribed for a client with heart failure who has 3+ pitting adima, shortness of breath with any activity, and crackles in both lung bases. What rate should the nurse administer the blood?a. 50 ml/hour b. 150 ml/hour c. 300 ml/hour d. 75 ml/hour

d. 75 ml/hour

A nurse working on an endocrine unit should see which client first? a. An adolescent male with diabetes who is arguing about his insulin dose b. An older client with Addison's disease whose current blood sugar level is 62mg/dl (3.44 mmol/l). c. An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour. d. A client taking corticosteroids who has become disoriented in the last two hours

d. A client taking corticosteroids who has become disoriented in the last two hours

A 15 y/o boy was diagnosed with type 1 diabetes. He tells the nurse that he's having difficulty adhering to his meal plans when he is with his friends. What nursing intervention is best for the nurse to implement? a. Recommend he avoid fast food restaurants until he is familiar with his prescribed diet b. Advise him to take his own food with him when going to restaurants with his friends c. Encourage him to find activities with his friends that don't involve eating d. Assist him in identifying popular fast foods that are within his meal plan for diabetes

d. Assist him in identifying popular fast foods that are within his meal plan for diabetes

An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? a. Spironolactone b. Potassium c. Ampicillin sodium parental d. Digoxin.

d. Digoxin.

The nurse is preparing an adult with Addison's disease for self-management. Which information should the nurse include in the client's instructions? a. Importance of recording daily weights b. Adherence to a high fiber low fat diet c. Need to check temperature daily d. Events requiring steroid dosage adjustments

d. Events requiring steroid dosage adjustments

A male client with cirrhosis and severe ascites, who is scheduled for a paracentesis tells the nurse that he is in pain and feel short of breath, so he wants to reschedule the procedure. How should the nurse respond? a. Advise the client that the procedure will help diagnose the cause of his symptoms b. Encourage the client to verbalize his fears about the outcome of the procedure c. Offer to notify the health care provider of his desire to reschedule the procedure d. Explain to the client that the paracentesis will provide relief from his discomfort

d. Explain to the client that the paracentesis will provide relief from his discomfort

During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? a. An increased thirst with frequent urination b. Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI) c. Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI) d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI).

An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? a. Urine ketones b. Urine albumin c. Serum protein d. Serum potassium

d. Serum potassium

Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client a. Have partner screened for human immunodeficiency virus b. Report a sudden onset arthralgia to the healthcare provider c. Decrease intake of high-fat-foods, caffeine, and alcohol d. Use two forms of contraception while taking this drug.

d. Use two forms of contraception while taking this drug.

A client with postpartum depression who is admitted to the behavioral health unit, refuses to leave her room or eat meals. In addition to maintaining physical safety, which short-term goal should the nurse include in the plan of care? a. sleeps at least 6 hours per night b. consumes 3 meals and 1500 mL of fluid per day c. engages in one client to client interaction daily d. attends one group activity per day

d. attends one group activity per day