HESI Practice Questions

which complication is a patient with cirrhosis at risk for?

Bleeding

which response would the nurse give to a client who has a transurethral resection of the prostate who experiences dribbling after the removal?

"Increase your fluid intake and urinate at regular intervals."

Nursing actions prior to paracentesis

1. empty the bladder 2. vital signs 3. measure abdominal circumference and weight 4. HOB up- high fowlers position

which diagnostic test is most important for the nurse to obtain rapidly when caring for a client who has just arrived in the emergency department with possible acute coronary syndrome?

12-lead electrocardiogram (ECG)

when a client develops bacterial meningitis, which action is the nurse's priority?

Administering prescribed antibiotics

which laboratory value will be important for the nurse to monitor to determine whether a client with chest pain has acute coronary syndrome?

Troponin T (cTnT)

which hypersensitivity reaction will occur in the client who mistakenly received ABO-incompatible blood from a donor?

Type II

the nurse is caring for a client with the clinical manifestations of hypotension associated with a diagnosis of Addisons disease. Which hormone can be impaired in tis production because of this disease?

aldosterone

how would the nurse describe heart failure to a client?

an inability of the heart to pump blood into proportion to metabolic needs

which priority nursing intervention would the nurse implement when caring for a client with pneumonia?

instruct client on breathing exercises and controlled coughing

which strategy would the nurse include in the client's plan of care regarding preventing the development of ureteral colic from renal calculi in the future?

instruct the client to drink at least 3 L of fluid daily

when providing care for a client with a body surface burn injury of 55%, which information would the nurse consider when planning the client's care?

is prone to poor healing because of hyper-metabolic state

which finding in a client with asthma exacerbation requires the most rapid action by the nurse

markedly decreased breath sounds

The nurse is caring for a client with a history of alcoholism and cirrhosis who is hospitalized with sever dyspnea as a result of ascites. an increase in which process most likely caused the ascites?

pressure in the portal vein

Which nursing intervention would be the highest priority in managing a patient with ruptured esophageal varices?

protect the airway

a client, admitted with a full-thickness burn 2 weeks ago, has lost an average of 1 lb of weight each day. Which dietary adjustment would the nurse recommend?

provide high-protein drinks

The nurse is caring for a patient with severe liver cirrhosis and imbalanced nutrition. Which nursing intervention would prevent malnutrition in this patient?

provide oral care before meals

which benign condition shows silver scaly plaques on the skin?

psoriasis

which consideration is the nurse's concern when responding to the request of a hospice client who has severe pain and asks for another dose of oxycodone?

reduce the client's pain

which health problem history would increase an older adult's risk for experiencing a cerebrovascular accident?

transient ischemic attacks

Which condition unrelated to cardiac disease is the major cause of right ventricular failure?

Chronic obstructive pulmonary disease (COPD)

which client in the emergency department would the nurse assess first?

Client with chest pressure and ST segment elevation on the electrocardiogram

which finding on an electrocardiogram for a client reporting chest pain indicates possible acute myocardial infarction?

Elevated ST segments

which adverse medication effect will a nurse monitor for in a client with cirrhosis of the liver who develops ascites and is prescribed spironolactone?

Hyperkalemia

A client is admitted to the hospital with a diagnosis of acute Guillain-Barre syndrome. Which assessment is the priority?

Respiratory exchange

which assessment finding indicates a need for the nurse to consult with the health care provider before administering the prescribed metoprolol to a client with stable angina?

Sinus bradycardia, rate 54 on monitor

which recommendations would the nurse include in a client's discharge instructions regarding a home skincare program for psoriasis?

"apply an alcohol free, moisturizing lotion several times a day."

which response by the nurse is best when the primary health care provider prescribes "bathroom privileges only" for a client with an exacerbation of heart failure and the client becomes irritable and asks why bed rest is needed?

"rest reduced the amount of work your heart has to do right now."

after the nurse has taught a client with asthma about use of a peak flow meter, which client statements indicate that the teaching has been effective?

-"readings in the green zone mean that my asthma is under control." -"If I get a reading in the red zone, then I need to use the quick refilled inhaler and have my family take me to the hospital." -"I should check the peak flow readings at least twice a day until my baseline is established."

Which foods would the nurse teach the client who has gout to avoid?

-Liver -Shellfish

which priority intervention would the nurse follow when caring for a client with malignant hyperthermia?

-administer 100% oxygen -prepare for endotracheal intubation -stop all inhalation anesthetic agents

Which hematologic symptoms might be noted in a patient with cirrhosis of the liver?

-anemia -leukopenia -thrombocytopenia

a client with acute kidney injury is moved into the diuretic phase after 1 week of therapy. During this phase, which clinical indicators would the nurse assess?

-dehydration -Hypovolemia

when assessing a client with right ventricular heart failure, the nurse would expect which finding?

-dependent edema -swollen hands and fingers -right upper quadrant discomfort

which assessment findings is consistent with a client diagnosis of right-sided heart failure?

-distended abdomen -dependent edema -decreased appetite

which clinical finding would the nurse anticipate for a client who had an exacerbation of multiple sclerosis?

-double vision -scanning speech

The nurse is performing a physical assessment of a client admitted to the hospital with a diagnosis of cirrhosis. The nurse expect to observe which skin conditions?

-ecchymoses -telangiectasia

the nurse is completing the health history of a client admitted to the hospital with osteoarthritis. Which joint would the nurse expect the client to report as having been involved first?

-hips -knees

which interventions would the nurse implement when caring for a client with syndrome of inappropriate antidiuretic hormone?

-provide frequent oral care -institute fall risk precautions -monitor for and report neurological changes

when providing care for a client with a burn injury in the resuscitation phase, the nurse notices the client is hoarse and produced audible breath sounds on exhalation. Which immediate action would the nurse take?

-provide oxygen immediately -notify the rapid response team

which clinical finding would the nurse expect to observe in a client with a diagnosis of psoriasis?

-scaly lesions -reddened papules

Cirrhosis signs and symptoms

-splenomegaly -esophageal varices -portal hypertensions

which rationale explains why the nurse also monitors a client with a history of gastroesophageal reflux disease (GERD) for clinical manifestations of heart disease

Esophageal pain may imitate the symptoms of a heart attack

which abnormal finding would the nurse monitor for during the oliguric phase of acute kidney injury?

Hyperkalemia

the nurse is caring for a client with a diagnosis fo acute pancreatitis and alcoholism. The client asks, "How does my drinking relate to my diagnosis?" which effect of alcohol would the nurse include when responding?

It increases enzyme secretion and pancreatic duct pressure that causes back flow of enzymes into the pancreas.

The nurse is teaching pursed-lip breathing to a client with chronic obstructive pulmonary disease (COPD). The client asks about the benefit of exercise. Which explanation would the nurse give?

Keeps airway open longer to decrease the work that goes into breathing

which nursing action would the nurse monitor during the initial recovery phase of a client returning to the post anesthesia care unit with a three-way indwelling catheter and a continuous bladder irrigation after a transurethral prostatectomy (TURP)?

Monitor for bright red blood in the urinary drainage bag

Which assessment would be the priority for the nurse to complete for the client who had Guillain-Barre syndrome with rapidly ascending paralysis?

Monitoring respiratory status

the nurse is caring for a client with Addison disease. Which dietary instruction would the nurse provide?

add extra salt to food

which nursing intervention is most important for supporting the success of the bowel training program for a client who sustained a cerebrovascular accident and is incontinent to feces?

adhere to a definite time for attempted evacuations

when a client who has a chest tube after a thoracotomy reports sharp chest pain at the chest tube and refuses to take deep breaths, which action by the nurse is best?

administer prescribed pain medications

which method would the nurse teach a client on a rehabilitation unit after a cerebrovascular accident with residual hemiparesis to achieve the goal of safe walking with a cane?

advance the cane and the affected extremity simultaneously.

which information would the nurse include in explaining glaucoma to a client?

an increase in the pressure within the eyeball

which information is needed to determine oxygen administration for a client with chronic obstructive pulmonary disease (COPD) and an oxygen saturation of 87%

arterial blood gases

a client is admitted to the hospital with chronic asthma. Which complication would the nurse monitor in this client

atelectasis

which assessment is the priority when a client with heart failure reports a 9-pound weight gain in the past 2 weeks?

auscultate breath sounds

which finding during a peritoneal dialysis would the nurse act on as a sign of infection?

cloudy return of dialysate

which medication would the health care provider prescribe to treat the actor attack of your and prevent future attacks?

colchicine

which treatment goal would the nurse emphasize when teaching a client with a diagnosis of open-angle glaucoma?

control intraocular pressure

which type of lung sounds would the nurse expect to hear when caring for a client with heart failure?

crackles

when the nurse is caring for a client who had an open cholecystectomy, which assessment finding most indicates the need for action by the nurse?

decreased breath sounds at lung bases

where is the blood pressure cuff placed on a client with a dialysis access fistula in the right arm?

on the left arm

The nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis?

serum lipase

which explanation would the nurse provide to a client about a transient ischemic attacks?

temporary episodes of neurological dysfunction

which behavior by a client who had a cerebrovascular accident beginning to eat lunch indicates the client may be experiencing left hemianopsia?

the client ignored the food on the left side of the tray when eating

which information would the nurse expect the client who has multiple sclerosis with hand tremors to report?

the tremors increase when I preform an activity

which response would the nurse provide a client when asked the purpose for using Buck traction before surgery

to immobilize the fracture

which intervention would the nurse anticipate providing teaching on when a client presents with extensive lesions caused by psoriasis?

topical application of steroids

which clinical manifestations would the nurse identify as an indicator suggesting a client had urinary retention and overflow after sustaining a cerebrovascular accident?

-frequent voiding -suprapubic distention

For any client with esophageal varices

-no nasogastric tube -no straining (bowel movements)

which finding would the nurse expect when assessing a client who is in an early stage of multiple sclerosis?

-nystagmus -scanning speech -intention tremors

when obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include?

-pain history, including location, intensity, and quality of pain -pain pattern, including precipitating and alleviating factors

which organ can be affected by Candida albicans?

-vagina -mouth -intestines

which instruction would the nurse include when teaching the client how to perform peritoneal dialysis and the importance of preventing peritonitis?

-wear a mask during the procedure -clean the catheter exit site every day -maintain meticulous aseptic technique -wash your hands before the exchange -store supplies in a clean and dry location

which cytokine would the nurse teach a client is treatment for multiple sclerosis

beta-interferon

which type of burn injury should be followed up by scheduling the client for an electrocardiogram?

electrical burn

which information would the nurse include in a teaching plan when teaching a client with diabetes about the advantages of using an insulin pump?

-it can improve A1c levels -clients may be able to exercise without eating more carbohydrates

which assessment findings indicates that a client has had a stroke?

-lopsided smile -unilateral vision -incoherent speech -unable to raise right arm -symptoms started 2 hours ago

Cirrhosis patient diet

-low protein= low ammonia -low sodium and low fluid -no alcohol

which assessment findings in a client with acute lymphoblastic leukemia receiving chemotherapy would alert the nurse to the possible development of thrombocytopenia?

-melena -hematuria -ecchymosis

which nursing intervention would be included in the treatment of an adolescent who is diagnosed with type 2 diabetes mellitus, had a body mass index of 30, and reports fatigue, frequent urination, and a tingling sensation in the feet?

-physical activity -dietary counseling -behavior modification

which methods qualify as alternative therapies for pain?

-prayer -hypnosis -aromatherapy -guided imagery

which clinical manifestation exhibited by a client taking levothyroxine for hypothyroidism for 3 months would cause the nurse to suspect that a decrease in dosage is needed?

-tremors -heat intolerance

Which laboratory result will the nurse expect then caring for a client who presents to the emergency department with an ST-segement-elevation myocardial infarction (STEMI)?

elevated serum troponins I and T

which finding would the nurse expect to identify in a client who had osteoarthritis that would not be present in clients with rheumatoid arthritis?

heberden nodes

when taking the health history for a client admitted with heart failure, which assessment finding will the nurse expect the client to report?

uses several pillows at night to sleep

which statement would be made by the nurse when performing presurgical teaching for a client pending a transurethral resection of the prostate?

"An indwelling catheter is required for at least 1 day."

a client is admitted to the hospital with a tentative diagnosis of Guillain-Barre syndrome. Which question by the nurse will elicit information consistent with this diagnosis?

"Have you experienced an infection recently?"

which statement by the client would the nurse expect when assessing a client with a diagnosis of left ventricular failure?

"I have trouble breathing when I walk rapidly."

the nurse is teaching the client about dietary control of gout. Which statement made by the client indicates successful learning?

"I will avoid eating shellfish."

which response would the nurse give to a client with an acute kidney injury who has peritoneal dialysis (PD) prescribed and asks why the procedure is necessary?

"PD helps perform some of the work usually performed by your kidneys."

which response would the nurse provide to a client who asks about what to expect postoperatively before a transurethral resection of the prostate (TURP)?

"There will be a urinary catheter and a continuous bladder irrigation."

which information would the nurse include in response to a client's questioning a portion-restriced dietary change required for acute kidney injury?

"This diet supplies only essential amino acids, reducing the amount of metabolic waste products, thus decreasing stress on the kidneys."

which response will the nurse make to explain the discoloration when a client with venous insufficiency has a question about the brownies discoloration of the skin on the legs?

"there is a leakage of red blood cells (RBCs) through the vein wall."

which response would the nurse give a client with tuberculosis who asks about the communicability of the disease?

"untreated active tuberculosis is communicable."

which actions will the nurse take when caring for a client with a chest tube in place after a thoracotomy?

-administer prescribed analgesic medications. -check around chest tube insertion site for crepitus. -add fluid to the suction control chamber as needed. -check for air bubbling in the water-seal chamber

the nurse is taking care of a client who has chronic back pain. which nursing considerations would be made when determining the client's plan of care?

-ask the client about the acceptable level of pain -administer the pain medications regularly around the clock

which intervention would the nurse include in the plan of care of a client with end-stage renal disease who has a mature arteriovenous fistula?

-auscultate the fistula for presence of a bruit -palpate the site to identify the presence of a thrill -avoid drawing blood for the affected extremity

which clinical manifestation would the nurse expect the client to report when experiencing renal calculi?

-blood in the urine -frequency and urgency of urination

the nurse evaluates the condition of a client with burns of the upper body. Which assessment findings indicate potential respiratory obstruction?

-brassy cough -singed nasal hair -dark mucous membranes

which amount of tine is the maximum amount the nurse would permit an older adult with a cerebrovascular accident to remain in one position?

1 to 2 hours

which type of reaction is being experienced by a client who develops acute dyspnea, generalized urticaria, a heart rate of 128 beats/minute, and a blood pressure of 70/38 mm Hg while receiving a blood transfusion?

Anaphylactic

which assessment has the highest priority when providing care for a client with a burn in the emergent stage?

extent of the burn

which type of burn would the nurse suspect in a client admitted with a burn injury that has erythema and mild swelling?

first-degree burn

which intervention would the nurse implement for a client admitted for an exacerbation of asthma?

give prescribed medications to promote bronchiolar dilation

which disease would the nurse suspect in a 16-year-old client with a history of multiple sexual partners who is complaining of increased vaginal discharge, intermittent vaginal bleeding, excessive bleeding during menstruation, and pain in the lower abdomen?

gonorrhea

which laboratory result would the nurse check to evaluate a client's fluid loss from extensive burns?

hematocrit

which clinical indictor is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma?

impairment of peripheral vision

for a client admitted to the hospital with partial- and full-thickness burns of the chest and face obtained while attempting to extinguish a brush fire, which concern would the nurse establish as a priority?

inadequate gas exchanged caused by smoke inhalation

which explanation would the nurse give to a client with a diagnosis of myocardial infarction who asks the nurse, "What is causing the pain I am having"?

inadequate oxygenation of the myocardium

a client is returned to the surgical unit after an abdominal cholecystectomy. Which is the main reason why the nurse would assess for clinical indicators of respiratory complications?

incision is in close proximity to the client's diaphragm

which is the first sign that would assist the nurse in suspecting malignant hyperthermia in a client?

increased expired carbon dioxide

when a client is diagnosed with pneumonia, which finding would the nurse expect when assessing the chest?

increased tactile (vocal) fremitus

which intervention would prevent urinary stasis and formation of renal calculi in an immobile client?

increasing oral fluid intake to 2 to 3 L/day

a client has been diagnosed with cholelithiasis. Which fact about the condition would the nurse recall when assessing this client for risk factors?

individuals who are obese are more prone to this condition than those are are thin

which action would the nurse include in the pan of care for a client admitted with peritonitis secondary to a ruptured appendix?

inserting a nasogastric tube

a 15-year-old adolescent is found to have type 1 diabetes. which would the nurse include when teaching the adolescent about type 1 diabetes?

it has a more rapid onset than does type 2 diabetes

a client with a femoral fracture and osteomyelitis is immobilized for 3 weeks. Which rationale explains the nurse's plan to assess for the development of renal calculi?

lack of weight bearing activity promotes bone demineralization

a client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. Which would the nurse consider when formulating a response?

less thyroid tissue is available to supply thyroid hormone after surgery

which goal would the nurse establish when providing care for a client recovering from a transurethral resection of the prostate (TURP)?

maintain patency of the indwelling catheter

which type of rehabilitation is an essential component to a client's recovery from Guillain-Barre syndrome?

physical therapy

A patient with cirrhosis and esophageal varices is vomiting, and the nurse notes hematemesis. Which action should the nurse take first?

place the client in side lying position

which action indicates the need for additional teaching when the nurse is educating a client on the use of heat and cold for osteoarthritis pain?

places ice pack on skin

which procedure would the nurse expect as a treatment option for a client newly diagnosed with Guillain-Barre syndrome?

plasmapheresis

Which finding would help confirm the nurse's suspicion that a client may have meningitis after surgery for a brain tumor?

positive kernig sign

which manifestation in a client who has syndrome of inappropriate antidiuretic hormone would the nurse expect to find upon assessment?

retention of water

which description would the nurse expect the client to use to characterize the pain when admitted to the coronary care unit with a diagnosis of ST segment elevation myocardial infarction?

severe, intense chest pain

Which action will the nurse take during administration of blood products to ensure the client's safety?

stay with the client during the first 15 minutes of infusion

which action is the nurses priority the the nurse notices the client receiving a blood transfusion is having an acute hemolytic reaction?

stop the blood transfusion immediately

which action would the nurse perform first when assessing if an intravenous (IV) infusion of a vesicant has extravasated?

stop the infusion

which complication will it prevent administering a histamine H2 antagonist to a client who has extensive burns?

stress ulcer

which action would be used to decrease risk for postoperative respiratory complications in an older client with decreased vital capacity?

teach the client coughing and deep-breathing exercises

which action would the home health nurse take when caring for a client with a pink and moist left leg venous stasis ulcer?

clean the wound with normal saline and apply prescribed hydrocolloid dressings weekly.

which client who sustained injuries in an accidental fire would be provided with immediate care based on priority

client with burns to the head

which area is most important for the nurse to assess for fluid balance in a client with full-thickness burns of the anterior trunk and thigh when monitoring fluid balance during the first 2 to 3 days after the burn?

urinary output every hour

Which finding in a client who has been admitted with myocardial infarction is most important to communicate to the health care provider?

urine output 15 mL/hr

which topic would the nurse include when teaching a client who is being treated for active tuberculosis and has a productive cough?

use of disposable tissues when coughing

What topic would the nurse plan to include in teaching a client with a new diagnosis of asthma

use of peak flow meter

the nurse is caring for a client with cholelithiasis. Which. clinical manifestation would the nurse expect if the client develops obstructive jaundice?

yellow sclera

a client with Guillain-Barre syndrome has been hospitalized for 3 days. Which assessment data would the nurse plan to monitor frequently for this client?

ascending weakness

which action would the nurse take to prevent postoperative respiratory complications after abdominal surgery?

assist with incentive spirometry

diagnosed with chronic obstructive pulmonary disease (COPD), a 50-year-old client's clinical data after treatment is: heart rate of 100 beats/min, blood pressure of 138/82 mm Hg, respiratory rate of 32 breaths/min, tympanic temperature of 98.2 degrees Fahrenheit, and an oxygen saturation of 80%. Which vital sign obtained by the nurse indicated a positive outcome.

-respiratory rate 14 breaths/min -blood pressure: 110/70 mm Hg -Oxygen saturation: 92%

A client stains a fractured right femur after an automobile accident and is admitted to the hospital's emergency department. Which assessment would the nurse make?

-take the client's pedal pulse in the affected extremity -instruct the client to wiggle toes of the right foot -ask the client if numbest or tingling is present in the right foot

which foods would the nurse teach a client to avoid when diagnosed with calcium oxalate renal calculi?

-tea -spinach -rhubarb

which action would the nurse include in the plan of care for a client who is being treated for a sexually transmitted infection and reports fever and irregular bleeding?

-the use of analgesics -abdominal palpation -complete blood count -culture of the cervical canal -administration of antibiotics as prescribed -teaching about the negative effects of douching

Cirrhosis bleeding risk

-use soft toothbrush -electric razor -monitor blood in stools

a client reports neck stiffness, severe headache, and a decreased level of consciousness. Which condition would the nurse suspect?

Bacterial meningitis

which prescription by the health care provider would the nurse question when caring for a client who is hospitalized for an acute myocardial infarction?

Rectal suppository as needed for constipation

for a client diagnoses with acquired immunodeficiency syndrome (AIDS), the nurse identifies white patchy plaques on the mucosa of the client's oral cavity. The nurse recognizes the findings most likely represents which opportunistic infection?

Candida albicans

the nurse is caring for a client hospitalized with syndrome of inappropriate antidiuretic hormone. Which action performed by the nurse may result in a positive outcome of treatment.

Changing the position of the client frequently

while receiving a blood transfusion, a client develops flank pain, chills, and fever. Which type of transfusion reaction would the nurse conclude that the client is experiencing?

Hemolytic

During an assessment of a patient, the nurse finds asterixis, twitching of the extremities, and notices that the patient is displaying inappropriate behavior and disorientation. Which condition does the nurse suspect?

Hepatic encephalopathy

which symptom would the nurse monitor for a client with Addisons disease?

Hypoglycemia

Latulose

Monitor for hypokalemia

How do you know albumin IV is effective?

Vital signs remain within normal limits

a 50-year-old client has difficulty communicating because of expressive aphasia after a cerebrovascular accident. When the nurse inquired about the client's feelings the spouse responded. Which communication strategy would the nurse use to address this behavior?

acknowledge the spouse, but look at the client for a response.

after a client with multiple fracture of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action?

administer oxygen

which clinical manifestation is associated with a diagnosis of tuberculosis?

anorexia, hemoptysis, and night sweats

The nurse is teaching positioning techniques to a client who developed degenerative joint disease of the vertebral column. In addition to suggesting that the client keep the spine straight and cross the arm over the chest, which instruction would the nurse provide?

bend the top knee to the side to which the client is turning

a client has a platelet count of 49,000/mL. the nurse would instruct the client to avoid which activity

blowing the nose

which explanation would the nurse include when teaching a client with her failure about the reason for a low-sodium diet?

decreased fluid retention

which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator?

demonstrates use of a metered-dose inhaler

which action would the nurse take when a client with chronic venous insufficiency has ankle edema?

elevate the legs

which metabolic manifestations are likely to be observed in a client with hypothyroidism?

-intolerance to cold -decreased body temperature

A nurse is assisting with a paracentesis for a patient with ascites caused by cirrhosis. Which action should the nurse take first?

have the patient empty their bladder

A client is hospitalized with a diagnosis of acute pancreatitis. The plan of care is focused on the goals of maintaining nutrition, promoting rest, maintaining fluids and electrolyte, and decreasing anxiety. Which interventions would the nurse implement?

-administer anaglesics -teach relaxation exercises -monitor cardiac rate and rhythm

for which clinical indicator would the nurse monitor when caring for a client with cholelithiasis and obstructive jaundice?

-dark urine -yellow skin -clay-colored stool

which action would the nurse take to prevent knee deformities in a client who has an exacerbation of arthritis?

-encourage motion of the joint -maintain joints in functional alignment when resting

A client is taught how to recognize signs of a hypoglycemic reaction. Which symptoms identified by the client indicate to the nurse that the teaching was effective?

-fatigue -weakness -nervousness -increased perspiration

peritonitis develops in a client who has surgery for a ruptured appendix. which clinical findings related to peritonitis should the nurse expect the client to exhibit?

-fever -abdominal muscle rigidity

a client develops peritonitis and sepsis after the surgical repair of a ruptured diverticulum. Which signs would the nurse expect when assessing the client?

-fever -tachypnea -abdominal rigidity

when a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia

having suction available during meals

which intervention would the nurse implement after determining that a client, who sustained a cerebrovascular accident (CVA), needs assistance with eating for optimum nutrition?

encourage the client to participate in the feeding process

a client with chronic obstructive pulmonary disease (COPD) exacerbation is receiving oxygen at 2 L/minute per nasal cannula and has an oxygen saturation of 88%. Which action would the nurse anticipate taking next?

Increasing oxygen flow rate to 3 L/minute

A client has closed fractures of the right femur and tibia with multiple soft-tissue contusions. Which action would the nurse plan to take?

Perform a neuromuscular assessment of the extremity

which information will the nurse share with a client who sustained a burn and asks, "What is the difference between by full-thickness and deep partial-thickness burns?"

full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve only part of the dermis

the nurse provides education for a client with cirrhosis of the liver who has prolonged prothrombin time and a low platelet count. A regular diet is prescribed. Which instruction would the nurse include in the teaching?

Report sings of bleeding no matter how slight

which action would the nurse take next after the nurse immediately stops the infusion of a client demonstrating signs and symptoms of a transfusion reaction

hang a bag of normal saline with new tubing

which objective has the highest priority and directs the nursing interventions for a client that is 5 feet 8 inches tall (173cm) and weights 220 lb (99.8 kg) who has a ureteral colic, blood in the urine, and a blood pressure of 150/90 mm Hg?

decreased pain

which action would the nurse implement regarding the public health implications of a 16-year-old adolescent diagnosed with gonorrhea?

identifying and locating the client's sexual contacts

when providing care for a client during the first few hours after admission to the burn unit with full-thickness burns of the trunk and head, which goal is the nurse's priority during the emergent phase of this injury?

managing fluid loss

which pain relief medication would the nurse expect to find in the plan of care of a client with a myocardial infarction admitted to the cardiac intensive care unit?

morphine

which action would the nurse implement in a male client who reports an inability to voice after undergoing a cystoscopy and biopsy of the prostate gland due to dysuria, nocturne, and difficulty starting a urinary stream?

palpate above the pubic symphysis