HESI with Rationale 12 366 rn exit Hesi

The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.) A. Obtain blood glucose level. B. Verify the insulin prescription. C. Cleanse the selected site. D. Draw insulin into insulin syringe.

Answer 1. Obtain blood glucose level. 2. Verify the insulin prescription. 3. Draw insulin into insulin syringe. 4. Cleanse the selected site. Rationale The client should administer a sliding scale dose of insulin by first obtaining a blood glucose level to determine sliding scale insulin dose, then verifying the insulin prescription. Next, the insulin is drawn into the insulin syringe and the selected site cleansed.

A client who is having an allergic reaction receives a prescription for epinephrine 0.4 mg subcutaneously. The available vial is labeled, Epinephrine Injection, USP, 1:1000 (1 mg/ml) For Subcutaneous use only. How many ml should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Answer 0.4 Rationale Using the formula, D/H x Q 0.4 mg/ 1 mg x 1 ml = 0.4 ml

When conducting diet teaching for a client who is diagnosed with Crohn's Disease, which foods should the nurse encourage the client to eat? (Select all that apply.) A. Clams. B. Raisins. C. Buttermilk. D. Orange juice. E. Processed cheese.

Answer A. Clams. B. Raisins. Rationale (A and B) are correct. Crohn's Disease should be supplemented with additional iron in the diet. Foods that are high in iron content are some seafoods , such as clams (A), and a dark red fruits (B). (C, D, and E) are not iron rich sources.

When assessing a client, the nurse should establish which findings as objective? (Select all that apply.) A. Edema. B. Anxiety. C. Nausea. D. Diaphoresis. E. Hypertension. F. Urticaria.

Answer A. Edema. D. Diaphoresis. E. Hypertension. F. Urticaria. Rationale (A, D, E, and F) Our objective findings or signs that can be observed by another individual. (B and C) are subjective symptoms.

An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest indication that the client is experiencing increased intracranial pressure (ICP)? A. Lethargy. B. Decorticate posturing. C. Fixed dilated pupil. D. Clear drainage from the ear.

Answer A. Lethargy. Rationale Lethargy (A) is the earliest sign of ICP along with slowing of speech and response to verbal commands. The most important indicator of increased ICP is the client's level or responsiveness or consciousness. (B and C) are very late signs of ICP. (D) should be tested to determine if it is cerebrospinal fluid, but would not be an indication of increased ICP.

The nurse has completed the diet teaching of a male client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? A. A peanut butter sandwich with soda and cookies. B. A tunafish sandwich with chips and ice cream. C. A salad with three kinds of lettuce and fruit. D. Vegetable soup, crackers, and milk.

Answer B. A tunafish sandwich with chips and ice cream. Rationale (B) contains the highest amount of protein. Four ounces of tuna contains 11 g of protein, and ice cream 5 g of protein per cup. Chips are a fat with virtually no protein value. (A) contains 4 grams of protein per tablespoon. (C) contains only 1 gram of protein per 1 cup serving. (D) may have beef flavoring but it consist mostly of vegetables and would therefore be low in protein.

A client is admitted with the diagnosis of Wernicke's Syndrome. What assessment finding should the nurse use in planning the clients care? A. Right lower abdominal pain. B. Confusion. C. Peripheral neuropathy. D. Depression.

Answer B. Confusion. Rationale Wernicke's syndrome is related to thiamine deficiency in clients with alcohol dependency and is manifested by confusion (B), ataxia, and vision changes. (A, C, and D) May be complications of alcoholism but are not specific in Wernicke's syndrome.

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.

Answer B. Muffled heart sounds. Rationale Muffled heart sounds (B) may indicate fluid build-up in the pericardium and is life-threatening. (A, C, and D) are signs of end stage liver disease related to alcoholism but are not immediately life-threatening.

While caring for a client with a cervical spine injury, which assessment finding should the nurse report to the healthcare provider immediately? A. Heart rate 140 beats/minute. B. Respiratory rate 6 breaths/minute. C. Average urinary output 20 mL/hour. D. Sluggish pupillary response.

Answer B. Respiratory rate 6 breaths/minute. Rationale With a cervical spinal injury the respiratory status can quickly become compromised and require mechanical ventilation. A slowing respiratory rate (B) is a critical sign that the client is decompensating. (A, C, and D) are important but do not have the priority of (B).

A client who recently underwear 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.

Answer B. Teach tracheal suctioning techniques. Rationale Suctioning (B) helps to clear secretions and maintain an open airway, which is critical. Communication (A) is impaired and independence (C) is altered, but these are not life-threatening problems. Keep the tracheostomy site clean (D) helps prevent infection and should be taught prior to discharge, but this content does not have the priority of suctioning.

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. Force oral fluids. B. Request a nutrition consult. C. Administer prescribed antibiotics. D. Reapply a sterile non-adhesive dressing.

Answer C. Administer prescribed antibiotics. Rationale A client who has a postoperative dressing with a red, swollen wound, moderate amount of yellow, green drainage, foul odor, and experiencing a MRSA infection poses a risk for transmission of a healthcare-associated infection (HAI). The most important action for the nurse to take is administer prescribed antibiotics (C). (A, B, and D) are not the priority with highly resistant infections, such as MRSA.

What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning? A. Working together can decrease the risk for back injury to the nurses. B. Using two or three people increases client safety. C. The technique is intended to maintain straight spinal alignment. D. Turning instead of pulling reduces the likelihood of skin damage.

Answer C. The technique is intended to maintain straight spinal alignment. Rationale The main rationale for use of the log-rolling technique is to maintain the client's spine in straight alignment (C). (A and B) described additional benefits to of log-rolling. Log-rolling involves the use of a palling motion (D).

The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.) A. Start chest compressions with assisted manual ventilations. B. Apply pads and prepare for transthoracic pacing. C. Administer epinephrine 0.01 mg/kg intraosseous (IO). D. Review the possible underlying causes for bradycardia

Answer 1. Start chest compressions with assisted manual ventilations. 2. Administer epinephrine 0.01 mg/kg intraosseous (IO). 3. Apply pads and prepare for transthoracic pacing. 4. Review the possible underlying causes for bradycardia. Rationale The American Heart Association guidelines recommend that the basic life support (BLS) algorithm should be initiated immediately in pediatric clients who are unresponsive or have a heart rate below 60 beats/minute and exhibit signs of poor perfusion. This child is manifesting poor perfusion as evidenced by a low blood pressure and poor oxygenation, so chest compressions and assisted manual ventilation should be provided first, followed by the administration of drug therapy for persistent bradycardia. Preparations with pad placement for transthoracic pacing should be implemented next, followed by the treatment indicated for the underlying cause of the child's bradycardia.

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first and least priority last or at the bottom.) A. Stop the infusion. B. Assess vital signs. C. Contact the healthcare provider. D. Initiate adverse event report. E. Document reaction to the drug.

Answer 1. Stop the infusion. 2. Assess vital signs. 3. Contact the healthcare provider. 4. Document reaction to the drug. 5. Initiate adverse event report. Rationale The client is exhibiting a drug reaction and quick action is required. When a drug reaction is suspected, first the infusion should be stopped. Then vital signs and airway compromise should be assessed and the findings reported to the healthcare provider. Documentation of the occurrence, including a description of the rash and details of the reaction should be completed after the healthcare provider is notified. Finally, and adverse drug reaction or adverse event report should be completed.

The nurse is interviewing a 18-year-old female client who was released 3 weeks ago following two months of treatment for anorexia nervosa. Which statement is characteristic of a young woman who has been successfully treated for anorexia nervosa? A. "My parents attempt to smother me, but I will not allow them to make my decisions." B. "If I don't get a college scholarship my parents will be very disappointed in me." C. "I know that I am fat and I plan to lose at least 10 more pounds." D. "I will not binge eat, vomit after I eat, or take laxatives or diuretics."

Answer A. "My parents attempt to smother me, but I will not allow them to make my decisions." Rationale The family of an adolescent with anorexia nervosa is often rigid and overprotective of the child and the client's reaction to their behavior is accepting and healthy (A). (B) might be made by a client with bulimia since they believe they are judged by their success. (C) would be expected on admission, but not after two months of treatment. (D) is related to clients with bulimia, not anorexia nervosa.

During a family group meeting, the client's daughter tells the group, "I hope I didn't cause mom to be depressed." Which response should the nurse provide? A. "You seem worried. What about your mom is bothering you?" B. "It is not unusual for children to feel guilty about a parent's illness." C. You seem concerned. Are you too suffering from depression?" D. "Why does the reason for your mom's important to you?"

Answer A. "You seem worried. What about your mom is bothering you?" Rationale To provide a therapeutic response, this teenager's feelings should be acknowledged, and the teen should be encouraged to disclose the reasons for her concerns (A). Although children sometimes feel guilty about a parent's illness (B), this information is not useful and negates the girl's feelings. (C) is jumping to an interpretation of the daughter's feelings, and it does not reflect the adolescent's concern for her parent. "Why" questions (D) are often interpreted as confrontational and should be avoided whenever possible.

Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? A. A 39-week primigravida with biophysical profile score of 5 out of 8. B. A 36-week multigravida with a prescription for serial blood pressures. C. A 38-week primigravida who reports contractions occurring every 10 minutes. D. A 41-week multigravida who is scheduled induction of labor today.

Answer A. A 39-week primigravida with biophysical profile score of 5 out of 8. Rationale The client with a biophysical profile (BPP) score of 5 out of 8 has the highest priority (A) because low scores result from fetal hypoxia and are an accurate indicator of impending fetal death. (B) should be assessed for preeclampsia. (C and D) do not have the priority of (A).

The healthcare provider prescribed oxycodone/aspirin 1 tab PO every 4 hours as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the prescription should the nurse question? A. Aspirin content. B. Dose. C. Risk for addiction. D. Route.

Answer A. Aspirin content. Rationale Aspirin containing compounds are (A) contraindicated for clients with polycystic kidney disease because of the risk for bleeding. This is the recommended dose (B) and PO is the correct route administration (D). Addiction (C) is not the main concern regarding this prescription.

The nurse working in a critical care unit is assigned the care of two clients, one with pneumonia who is being mechanically ventilated and the other who had a thoracotomy yesterday and is complaining of incisional pain. What should the nurse to first? A. Assess the level of consciousness and vital signs for both clients. B. Complete a head to toe assessment of the client with pneumonia. C. Change the surgical dressing to observe the appearance of the incision. D. Review the plan of care and the medications that are due for both clients.

Answer A. Assess the level of consciousness and vital signs for both clients. Rationale Assessing the level of consciousness and vital signs for both clients (A) provides a quick measurement of priority need. Before a complete assessment (B) is done on one client, the nurse should at least do a quick assessment of the other client. Changing the dressing and observing the incision (C) may be indicated, but only after both clients are quickly assessed. Reviewing the plan of care and medications due for administration (D) should wait until the nurse has evaluated both clients for any urgent clinical needs.

A postpartum client who is bottlefeeding develops breast engorgement. What is the best recommendation for the nurse to provide this client? A. Avoid stimulation of the breasts and wear a tight bra. B. Express a small amount of breastmilk by hand. C. Take a prescribed analgesic and expose breasts to air. D. Place warm packs on both of the breasts.

Answer A. Avoid stimulation of the breasts and wear a tight bra. Rationale Compressing the milk sinuses by wearing a tight-fitting bra and preventing breast stimulation (A) decreases prolactin secretion and milk production. (B) stimulates an increase in milk production, although it will provide temporary relief. (C) is an intervention used for sore nipples, not engorgement. (D) increases vasodilation and engorgement.

A client who returns from surgery after the removal of a malignant thyroid tumor has a serum calcium level of 4.5 mg/dL or 1.125 mmol-L (SI). Which findings require immediate action by the nurse? (Select all that apply.) A. Carpopedal spasms with inflation of the blood pressure cuff. B. Spasm of the cheek and mouth when the facial nerve is tapped. C. Low serum thyroglobulin (Tg) level. D. Decreased gastrointestinal peristalsis. E. Changes in platelet closure time (PCT).

Answer A. Carpopedal spasms with inflation of the blood pressure cuff. B. Spasm of the cheek and mouth when the facial nerve is tapped. Rationale (A and B) are correct. In well-differentiated thyroid cancers, it is important that as much thyroid tissue as possible is removed. Extensive tissue removal often includes parathyroid glands, so that postoperatively radioactive iodine can target metastatic thyroid cells. The presence of a positive Trousseau (A) and Chvostek signs (B) after thyroid and parathyroid surgery indicate life-threatening tetany that is precipitated by hypocalcemia (normal serum calcium 9.0 to 10.5 mg/dL or 2.25 to 2.625 mmol/L). Tg (C), a tumor marker of thyroid tumor volume, should be low or undetectable after surgical or radioactive treatment. (D) is not uncommon after general anesthesia. PCT (E) differentiates platelet function influenced by aspirin.

A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? A. Cleanse the foot with soap and water and apply an antibiotic ointment. B. Provide teaching about the need for a tetanus booster within the next 72 hours. C. Have the mother check the child's temperature q4h for the next 24 hours. D. Transfer the child to the emergency department to receive a gamma globulin injection.

Answer A. Cleanse the foot with soap and water and apply an antibiotic ointment. Rationale The nurse should cleanse the wound first (A), and implement (B) next. (C and D) are not indicated in this situation.

During an assessment by the home health nurse of an older man who lives alone, the client reports that he is troubled by constipation. To formulate a plan of care, what additional information should the nurse obtain? (Select all that apply.) A. Daily food and fluid intake. B. Current prescribed and over-the-counter medications. C. Next scheduled visit with healthcare provider. D. Level of physical activity and exercise. E. Methods currently used to treat constipation.

Answer A. Daily food and fluid intake. B. Current prescribed and over-the-counter medications. D. Level of physical activity and exercise. E. Methods currently used to treat constipation. Rationale (A, B, D, and E) are correct. Older adults have a high risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduced motility. Obtaining a diet history (A) is crucial since low fluid intake is common in the elderly, and the client's diet may be low in fiber, especially since he lives alone and is likely to prepare his own meals. Medications (B) may include diuretics which increase urine output, or have constipation as a common adverse response. Decreased activity (D) may contribute to decreased GI motility. Many older adults use enemas (A) for constipation, so this information should be considered when developing a plan of care. Next scheduled visit with the healthcare provider (C) is not helpful in addressing changes needed to resolve constipation.

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement? A. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed. B. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet. C. Estimate the blood pressure by assessing the pulse volume of the clients radio pulses. D. Document why the blood pressure cannot be accurately measured at the present time.

Answer A. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed. Rationale The popliteal pulse can be used to measure blood pressure while the client is in the prone or supine position, and the nurse should demonstrate the technique with the client in the supine position and the knee flexed (A). Recording a previously obtained blood pressure as the current reading (B) is falsification of the medical record. The blood pressure cannot be accurately estimated by palpating the radial pulse volume (C). The blood pressure can be accurately measured at this time (D).

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse is attaching a 16 gauge needle. What action should the charge nurse take? A. Direct the nurse to remove the needle before the procedure. B. Override the medication scanning device's variance warning. C. Send an unlicensed assistive personnel to gather equipment. D. Instruct the nurse to use water with 5% dextrose (D5W).

Answer A. Direct the nurse to remove the needle before the procedure. Rationale And IV catheter should be irrigated without a needle by inserting the irrigating syringe's luer-lock tip into the IV catheter or IV tubing port. The charge nurse should direct the nurse to remove the 18 gauge needle before the procedure (A). (B, C, and D) are not indicated.

A morbidly obese woman is scheduled for gastric bypass surgery. She completes the required preoperative nutritional counseling and signs the operative permit. To promote effective discharge planning, which intervention is most important for the nurse to implement? A. Discuss small, low-fat, low sugar meal preparation techniques. B. Encourage the client to keep a daily dietary diary for two weeks. C. Suggest that the client's husband do the family grocery shopping. D. Advise the client to arrange for dietary counseling after discharge.

Answer A. Discuss small, low-fat, low sugar meal preparation techniques. Rationale Following gastric bypass surgery, a lifestyle changes required, one which includes eating small portions and avoiding high-fat foods. Discussing with the client and family how to prepare such meals (A) reinforces the necessary lifestyle change and helps them start the process. (B, C, and D) might be helpful interventions, but further information is needed about the family to determine the value of these interventions for the client and the family.

The nurse is preparing to send a client to the cardiac cath lab for elective cardioversion. Which intervention should the nurse implement before the client leaves the medical unit? A. Document that the client has remained NPO. B. Secure cardioversion pads on the client's chest. C. Notify the rapid response team of the transfer. D. Confirm monitor reading in synchronous mode.

Answer A. Document that the client has remained NPO. Rationale A client undergoing elective cardioversion should be NPO prior to the procedure, and the nurse should confirm the client's NPO status and document in the electronic record (A). (B and D) are completed in the cardiac cath lab just prior to the procedure, and (C) is not necessary.

An older adult female asks the clinic nurse about getting a Herpes vaccination because she gets cold sores on her mouth when she is sick or stressed. How should the nurse respond? A. Explain the use of the vaccination to reduce risk for Herpes zoster. B. Describe the use of the vaccination to treat Herpes Symplex Type 2. C. Confirm that a consent form is signed before administering the vaccination. D. Arrange for skin testing to evaluate if the client is a candidate for the vaccine.

Answer A. Explain the use of the vaccination to reduce risk for Herpes zoster. Rationale Herpes zoster (shingles) is a virus that resides in the root ganglia and causes outbreaks of multiple lesions in segmental distribution patterns on the skin dermatomes that are innervated by the infected nerves. Varicella zoster (Chicken Pox) is the virus that precedes Herpes zoster and can manifest lesions in a dermatome because it lies dormant in the root ganglia. The Herpes vaccine is given to prevent shingles outbreaks in adults over the age of 60 who had chickenpox as a child (A). (B) provides inaccurate information. Obtaining signed consent may be indicated if the client first makes an informed decision (C). (D) is not necessary.

A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant's plan of care? A. Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%. B. Administer diuretics via secondary infusion in the morning only. C. Evaluate heart rate for effectiveness of cardiotonic medications. D. Use high energy formula 30 calories/ounce at q3 hour feeding via soft nipples. E. Ensure uninterrupted and frequent rest periods between procedures.

Answer A. Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%. C. Evaluate heart rate for effectiveness of cardiotonic medications. D. Use high energy formula 30 calories/ounce at q3 hour feeding via soft nipples. E. Ensure uninterrupted and frequent rest periods between procedures. Rationale (A, C, D, and E) are correct. Pulse oximetry screening supports prescribed level of O2 (A), which can be difficult to assess when oral mucosa changes color. HR provides an evaluative criterion for cardiac medications (C), which reduce heart rate, increase strength of contraction (inotropic effects), and consequently affect systemic circulation and tissue oxygenation. Breast milk or basic formula provide 20 calories/ounce, so frequent feedings with high energy formula (D) helps minimize fatigue is necessary.

The client with which type of wound is most likely to need immediate intervention by the nurse? A. Laceration. B. Abrasion. C. Contusion. D. Ulceration.

Answer A. Laceration. Rationale A laceration (A) is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged and often contaminated with bacteria and debris from whatever object caused the cut, so this type of wound is likely to require the most immediate nursing intervention. (B) is an open wound, but is superficial and less likely to cause significant bleeding than a laceration. (C) is a closed wound that appears ecchymotic because of damaged blood vessels. (D) is typically more chronic in nature requiring less immediate intervention than an acute laceration.

The home health nurse is visiting an older client who was just charge from the hospital 3 days ago following hip pinning surgery. The client lives with her daughter, who prepares the family meals. In discussing nutrition for postoperative healing it, which meal choices should the nurse suggest for this clients diet? (Select all that apply.) A. Low-fat milk. B. Oat bran. C. White rice. D. Grilled salmon. E. Baked chicken.

Answer A. Low-fat milk. B. Oat bran. D. Grilled salmon. E. Baked chicken. Rationale (A, B, D, and E) are correct. Dairy products such as low-fat milk (A) provide calcium, Vitamin D, and protein. Salmon and tuna fish are high in omega 3 (D), which provides Vitamin D which promotes absorption of dietary calcium. Decreased mobility following hip surgery, combined with slower peristalsis, leads to constipation, so including oat bran foods (B) provides increased dietary fiber. Protein (E) is important for healing. White rice (C) does not provide nutritional value that promotes healing.

A male client who was just discharged 3 days ago after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen lower left leg. The nurse is preparing to initiate heparin therapy. What additional intervention should the nurse include in this clients plan of care? A. Maintain the client on bed rest. B. Encourage the client to dangle his legs frequently. C. Administer the clients routine daily aspirin. D. Encourage a diet high in iron and asorbic acid.

Answer A. Maintain the client on bed rest. Rationale A warm, tender, reddened, and swollen lower leg is indicative of a potential deep vein thrombosis (DVT) related to blood pooling during the surgical procedure. Bed rest (A) with evaluation of the affected extremity (B) is maintained until anticoagulation is started. Aspirin (C) causes an additive effect if given concomitantly with anticoagulants, such as warfarin or heparin, used in the treatment of DVT to prevent clot propagation and emobilization. (D) is not indicated.

A client who had a right total knee replacement two days ago is progressed to a soft diet. Which food selections should the nurse recommend to this client? (Select all that apply.) A. Pasta with a cream sauce. B. Pancakes with syrup. C. Scrambled eggs and potatoes. D. Steamed rice and cooked squash. E. Ice cream with nuts. F. Fried chicken and green salad.

Answer A. Pasta with a cream sauce. B. Pancakes with syrup. C. Scrambled eggs and potatoes. D. Steamed rice and cooked squash. Rationale The correct selections are (A, B, C, and D). A soft diet includes foods with a soft consistency they can be chewed easily. Nutritionally dense foods such as whole grains, nuts (E), fried meats and fresh fruits and vegetables (F) should be avoided on a soft diet.

In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Place personal religious artifacts on the body. B. Confirm the clients wishes for tissue donation. C.Observe consent for autopsy signature by family. D. Attach identifying name tags to the body. E. Follow cultural beliefs in preparing the body.

Answer A. Place personal religious artifacts on the body. D. Attach identifying name tags to the body. E. Follow cultural beliefs in preparing the body. Rationale With adequate supervision and instruction, (A, D, and E) can be delegated to the UAP. (B and C) require the expertise of the nurse and should not be delegated to the UAP.

To evaluate the effectiveness of a male clients new prescription for ezetimibe, what action should the clinic nurse implement? A. Remind the client to keep his appointments to have his cholesterol level checked. B. Teach the client to weigh himself weekly and keep a log of the measurements. C. Assess the elasticity of the client's skin at the next scheduled clinic appointment. D. Encourage the client to keep a diary of his food intake until his next visit to the clinic.

Answer A. Remind the client to keep his appointments to have his cholesterol level checked. Rationale Ezetimibe lowers total cholesterol and LDL levels, so it is important for the nurse to remind the client to keep his appointments at the laboratory (A). Ezetimibe does not promote weight loss or gain (B) or alter fluid volume (C). Although the client's dietary choices (D) may influence his serum lipid levels, laboratory findings provide the best indicator of the drug's therapeutic response.

During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? A. Respiratory apnea of 30 seconds. B. Oxygen saturation rate of 88%. C. Eight premature ventricular beats every minute. D. Disconnected monitor signal for the last 6 minutes.

Answer A. Respiratory apnea of 30 seconds. Rationale The priority is the client whose alarm indicating respiratory apnea (A) that should be assessed first. (B) is experiencing poor oxygen perfusion, but the client who is having apnea is the priority. Excessive premature ventricular beats (C) indicate an increased risk for ventricular fibrillation, but immediate action is required for the client who is not breathing. (D) should be re-connected to the monitor so the client's EKG and hemodynamic status can be monitored.

The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decreased milk supply for the mother who is breastfeeding? A. Supplemental feedings with formula. B. Maternal diet high in protein. C. Maternal intake of increased oral fluids. D. Breastfeeding every 2 or 3 hours.

Answer A. Supplemental feedings with formula. Rationale Infant sucking at the breast increases prolactin release and proceeds a feedback mechanism for the production of milk. The nurse should explain that supplemental bottle formula feeding (A) minimizes the infant's time at the breast and decreases milk supply. (B) promotes milk production and healing after delivery. (C) supports milk production. (D) is a recommended routine for breast feeding that promote adequate milk supply.

A client is admitted to the mental health unit with relationship distress with spouse and depressed mood. Findings of which diagnostic tests provide the most information for developing this client's plan of care? A. Urine drug screen. B. Complete blood count. C. Basic metabolic panel. D. Electrocardiogram.

Answer A. Urine drug screen. Rationale Substance-related disorders often interfere with primary support support systems, causing marital discord and depressed mood. A urine drug screen (A) identifies substance abuse, which determines if the client is at immediate risk for toxicity or withdrawal. (B, C, and D) are common admission laboratory tests routinely obtained to screen for comorbidities.

A 26-year-old female client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences A. palpitations and shortness of breath. B. bradycardia and constipation. C. lethargy and lack of appetite. D. muscle cramping and dry, flushed skin.

Answer A. palpitations and shortness of breath. Rationale An overdose of thyroid preparation generally manifests symptoms of an agitated state such as tremors, palpitations, shortness of breath, tachycardia, increased appetite, agitation, sweating and diarrhea (A). (B, C, and D) are not related to overdosage of thyroid preparations.

When delegating a task to an unlicensed assistive personnel (UAP) newly assigned to a nursing unit, what question is most important for the nurse to ask the UAP? A. "How long have you been working as a UAP?" B. "What experience do you have performing this task?" C. "Did you receive training in performing this task?" D. "Where did you work before coming to this unit?"

Answer B. "What experience do you have performing this task?" Rationale It is most important for the nurse to determine the UAP's prior experience in performing any task (B) before assigning care. (C) May also provide useful information, but the UAP may have received training for the skill necessary, yet never had experience in performing the task. (A and D) provide less useful information than (B).

In determining the one minute Apgar score of a male infant, the nurse assesses a heart rate of 120 beats per minute and 44 respirations per minute. He has flaccid muscle tone with slight flexion and slight resistance to straightening. He has a loud cry with stimulation, and his color is acrocyanotic. What is the correct Apgar score for this infant? A. 7. B. 8. C. 9. D. 10.

Answer B. 8. Rationale The maximum Apgar score is 10 (2 points for 5 variables). Subtract one point for muscle tone (slight flexion with slight resistance to straightening), and subtract one point for color due to acrocyanosis (bluing of the extremities is normal at birth). A heart rate over 100 earns 2 points, respirations of 40 earns 2 points, and a loud cry in response to stimulation indicates reflex irritability and earns 2 points. The correct Apgar score for this child is, therefore, 8 (B). Three variables received a score of 2 (2x3=6) and two a score of 1 (2x1=2) for a total of 8 (6+2=8).

A 3-year-old boy is brought to the emergency department after the mother found the child in the back yard holding a piece of a toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement? A. Obtain a pulse oximetry reading and arterial blood gases. B. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver. C. Request a stat chest x-ray and prepare medications for an asthmatic episode. D. Determine if the child ingested a toxic substance and if vomiting occurred.

Answer B. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver. Rationale Sudden onset of strider, dusky color, and weak ineffective cough strongly suggest that the child aspirated a foreign body. After auscultation of lung fields to determine the quality of air exchange, a Heimlich maneuver (B) is indicated to release the obstruction. After effective breathing is restored, the child may be assessed for complications (A). A history of asthma with symptoms of wheezing (C) is not a part of this child's clinical findings. Although respiratory distress may occur with laryngeal chemical exposure, oral facial burns and systemic manifestations are more likely indications of toxic substance ingestion (D).

The nurse is assessing a client with diabetes mellitus who is at risk of developing acute renal failure. Which assessment finding is earliest indication of acute renal failure? A. Urine output of 30 mL/hour. B. Blood urea nitrogen 35 mg/dL (12.4 mmol/L SI units). C. Creatinine 1.3 mg/dL (114.5 mmol/L SI units). D. Concentrated urine.

Answer B. Blood urea nitrogen 35 mg/dL (12.4 mmol/L SI units). Rationale In acute renal failure, the blood urea nitrogen (BUN) and creatinine levels rise and urinary output decreases. The normal BUN is 5 to 20 mg/dL (B) (or 3.6-7.1 mmol/L SI units), so this client's increased BUN is possibly an early indication of acute renal failure. Urinary output of less than 30 mL (A) and creatinine over 1.3 mg/dL (C) (norm creatinine 0.6 to 1.2 mg/dL or 50 to 106 mmol/L SI units) indicate renal failure. Concentrated urine (D) is not a definitive symptom of acute renal failure.

An older client is admitted with pneumonia, and the healthcare provider prescribes penicillin G potassium IV. Which assessment finding increases the risk of adverse reactions in this client? A. Previous treatment with penicillin for pneumonia. B. Daily use of spironolactone for hypertension. C. Documented allergy to sulfa drugs. D. Sputum culture results of streptococcus pneumoniae.

Answer B. Daily use of spironolactone for hypertension. Rationale. Spironolactone (B) is a potassium-sparing diuretic, and the administration of penicillin G potassium can lead to hyperkalemia, so the client's potassium level should be carefully monitored during this treatment. Previous treatment with penicillin (A) increases the likelihood of an allergic reaction, but hyperkalemia is a greater risk for this client. Sulfa drug allergy (C) does not increase the risk of adverse reaction. Penicillin G potassium is the drug of choice for Streptococcus pneumoniae (D) infection.

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increase in glaucoma surgeries? A. Decreased morbidity in the elderly population. B. Decreased prevalence of glaucoma in the population. C. Increased mortality in the elderly population. D. Increased incident of glaucoma in the population.

Answer B. Decreased prevalence of glaucoma in the population. Rationale Prevalence (B) describes the number of existing cases of glaucoma. Since glaucoma occurs mostly in the elderly population and the elderly are obtaining the curative surgery, a decreased prevalence of glaucoma in the population at large can be expected. (A) refers to the number of people who become afflicted with glaucoma within the population, and would likely be unchanged. (C) refers to the number of deaths, which should not be affected by a low-risk outpatient surgical procedure. (D) is the occurrence of new diagnoses of glaucoma, which would likely be unchanged.

After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? A. Assess the client's dressing for bleeding. B. Determine client's pulse, blood pressure, and respirations. C. Administer a PRN dose of IV morphine. D. Check the client's orientation to time and place.

Answer B. Determine client's pulse, blood pressure, and respirations. Rationale Colon resection, a major abdominal surgical procedure, causes severe pain in the immediate postoperative period and requires administration of IV morphine regularly to maintain analgesic serum levels. Before administering a central nervous system (CNS) depressing analgesia, the client's vital signs should be assessed (B) to determine the client's current level of CNS depression. In the immediate postoperative period, during admission to PACU, (A, C, and D) should be evaluated.

A client who received partial thickness (second degree) burns over the anterior surfaces of both arms, legs, and chest in a burning vehicle collision receives a prescription for daily dressing changes and therapeutic baths. The nurse determines that a hoist is required to move the immobile client from a stretcher into the therapeutic bath. Which intervention should the nurse implement first? A. Obtain the hoist from the supply room. B. Explain the procedure to the client. C. Medicate the client with an analgesic. D. Remove all bandages prior to moving the client.

Answer B. Explain the procedure to the client. Rationale Before implementing any new procedure, an explanation of the procedure should be provided (B). Bringing large pieces of equipment into the client's room (A), such as a mechanical lift, may alarm the client if the procedure has not been explained. The client should be medicated (C), but first explaining what is involved in the procedure helps prepare the client for subsequent actions. Dressing bandages provide protection for the wounds and help eliminate exposure to air, which can cause pain, so removal should be done immediately prior to submersion in the bath (D).

Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipation. The client's fluid and fiber intake is deficient and he eats microwaved foods at home and frequents fast-food restaurants. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply) A. Decrease laxative use to every other day, and use oil retention enemas as needed. B. Include oatmeal with stewed pruned for breakfast as often as possible. C. Increase fluid intake by keeping water glass next to recliner. D. Recommend seeking help with regular shopping and meal preparation. E. Report constipation to healthcare provider related to cardiac medication side effects.

Answer B. Include oatmeal with stewed pruned for breakfast as often as possible. C. Increase fluid intake by keeping water glass next to recliner. D. Recommend seeking help with regular shopping and meal preparation. Rational (B, C, and D) are correct. Older adults are at higher risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduced motility. Oatmeal with prunes (B) increases dietary fiber and bowel stimulation, thereby decreasing need for laxatives. Increased fluid intake (C) also decreases constipation. Assistance with food preparation (D) might help the client eat more fresh fruits and vegetables and result in less reliance on microwaved and fast foods, which are usually high in sodium and fat with little fiber. Laxatives can be reduced gradually by improving the diet, without resorting to using enemas (A). Although the use of diuretics promotes fluid loss which contribute to constipation, it is not necessary to contact the healthcare provider (E).

A woman with an anxiety disorder calls her obstetrician's office and tells the nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? A. Describe the transmission of drugs to the infant through breast milk. B. Inform her that some antianxiety medications are safe to take while breastfeeding. C. Encourage her to use stress relieving alternatives, such as deep breathing exercises. D. Explain that anxiety is a normal response for the mother of a 3-week-old.

Answer B. Inform her that some antianxiety medications are safe to take while breastfeeding. Rationale There are several antianxiety medications that are not contraindicated for breastfeeding mothers (B). The woman is apparently already aware that drugs can be transmitted through breastmilk, so (A) is not helpful. Stress relieving alternatives (C) might be helpful but the client's history suggests that nonpharmacologic methods of anxiety management do not produce the best outcome. Although (D) is incorrect, the mother's history of places her at risk for severe anxiety.

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.

Answer B. Initiate seizure precautions. Rationale Withdrawal of CNS depressants, such as Xanax, results in rebound over-excitation of the CNS. Since the client exhibiting tremors, the nurse should anticipate seizure activity and protect the client (B). (A) is used to treat opioid overdose. (C and D) can be implemented after the client has been protected from him/herself.

The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicates that the client understood the teaching? A. Turns to the left side to instill the irrigating solution into the stoma. B. Keeps the irrigating container less than 18 inches above the stoma. C. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation. D. Inserts irrigating catheter deeper into stoma when cramping occurs.

Answer B. Keeps the irrigating container less than 18 inches above the stoma. Rationale Keeping the irrigating container less than 18 inches above the stoma (B) permits the solution to flow slowly with little force so that excessive peristalsis does not cause immediate release of stool. A side-lying position (A) does not facilitate the irrigate's flow into stoma. The amount of irrigate (C) needed to stimulate peristalsis varies from client to client. Inserting the catheter (D) too deeply may cause damage to the stoma.

When providing diet teaching for a client with cholecystitis, which types of food choices should the nurse recommend to the client? A. High protein. B. Low fat. C. Low sodium. D. High carbohydrate.

Answer B. Low fat. Rationale A client with cholecystitis is at risk for gall stones that can move into the biliary tract and cause pain or obstruction. Reducing dietary fat (B) decreases stimulation of the gall bladder, so bile can be expelled, along with possible stones, into the biliary tract and small intestine. Protein (A) and carbohydrate (D) intake do not need to be altered. Sodium restriction (C) is not indicated.

An adult woman who was seen earlier today in the clinic is admitted to the hospital because she is very nervous, has a racing heart beat, and reports a weight loss of 15 pounds in the last month. The healthcare provider suspects that she has hyperthyroidism and prescribes further testing. What intervention should the nurse include in this client's plan of care? A. Provide extra blankets to prevent heat loss. B. Monitor the client for shortness of breath. C. Assess for hyperactive bowel sounds. D. Prepare the client for a thyroidectomy.

Answer B. Monitor the client for shortness of breath. Rationale The client is at risk for heart failure related to thyrotoxicosis if treatment is not initiated. Monitoring the client for shortness of breath, and early sign of poor cardiac output and a failing heart, should be included in the plan of care. Hyperthyroidism may cause heat intolerance due to a hypermetabolic state, so (A) is not indicated. Bowel sounds (C) are more closely monitored after therapy is initiated when constipation is a potential side effect of drug therapy. Further testing must be completed to evaluate the need for surgical intervention, so (D) is not needed at this time.

An older male adult resident of a long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during the night. What actions should the nurse take? (Select all that apply.) A. Recommend a 24-hour caregiver on discharge to the long-term facility. B. Notify the healthcare provider of the client's change in mental status. C. Include q2 hour reorientation in the client's plan of care. D. Request immediate evaluation by Rapid Response Team. E. Apply soft wrist restraints so that the operative site is protected.

Answer B. Notify the healthcare provider of the client's change in mental status. C. Include q2 hour reorientation in the client's plan of care. Rationale (B and C) Are correct. The client's condition reflects mental changes that could be related to post procedure stress, sundowner's syndrome, or cerebral complications. The nurse should inform the healthcare provider of the client's change in mental status (B). For the client's safety, q2 hour reorientations and evaluations should be included in the plan of care (C). A 24-hour caregiver (A) is not indicated at this time, but the client should be reassessed for cognitive dysfunction when he is psychologically stable enough for discharge. The Rapid Response Team provides treatment for life-threatening emergencies, so (D) is not indicated at this time. Restraints may protect the client from self injury (E), but may also increase his confusion.

A female client's estranged husband arrives at the hospital and demands that his wife have no other visitors. The client becomes angry and insists that the estranged husband be barred from visiting her. Which intervention should the nurse implement? A. Obtain a prescription to allow client to dictate who can visit. B. Request a multidisciplinary care conference to discuss husband's demands. C. Have the hospital's medical-legal department meet with the client. D. Encourage the client to speak with husband regarding his disruptive behavior.

Answer B. Request a multidisciplinary care conference to discuss husband's demands. Rationale A multi-disciplinary care conference involves the healthcare team to evaluate difficult situations that conflict with client safety and autonomy. During this conference, the client's wishes regarding her health care decisions can be clarified to all team members. All other options are not indicated.

While caring for a client who is mechanically ventilated, the nurse response to a high-pressure alarm. Which assessment finding warrants immediate intervention by the nurse? A. Bilateral crackles with increased secretions. B. Restless client who is biting the endotracheal tube. C. Decreased lung compliance when ventilation. D. Endotracheal cough pressure greater than 25 cm H2O.

Answer B. Restless client who is biting the endotracheal tube. Rationale Clients who are restless and biting the endotracheal tube (B) are in immediate danger of cutting off the oxygen and ventilation that the ventilator is trying to provide, so this finding requires the most immediate intervention. Crackles with secretions (A) indicate a need to suction the client. Decreased lung compliance (C) indicates that the lungs are stiff and the client may need sedation to assist with maximum ventilation. Cuff pressures over 5 cm H2O may cause a esophageal erosion and should be decreased and reassessed regularly.

To reduce staff nurse role ambiguity, which strategy should the nurse-manager implement? A. Confirm that all the staff nurses are being assigned to equal number of clients. B. Review the staff nurse job description to ensure that it is clear, accurate, and current. C. Assign each staff nurse a turn as the unit charge nurse on a regular, rotating basis. D. Analyze the amount of overtime needed by the nursing staff to complete assignments.

Answer B. Review the staff nurse job description to ensure that it is clear, accurate, and recurrent. Rationale Role ambiguity occurs when there is inadequate explanation of job descriptions (B) and assigned tasks, as well as the rapid technological changes that produce uncertainty and frustration. (A and D) may be implemented if the nurse-manager is concerned about role overload, which is the inability to accomplish the tasks related to one's role. (C) is not related to role ambiguity.

The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply.) A. Change a saturated surgical dressing for a client who had an abdominal hysterectomy. B. Take postoperative vital signs for a client who has an epidual following knee arthroplasty. C. Start a blood transfusion for a client who had a below-the-knee amputation. D. Collect a sputum specimen for a client with a fever of unknown origin E. Ambulate a client who had a femoral-popliteal bypass graft yesterday.

Answer B. Take postoperative vital signs for a client who has an epidual following knee arthroplasty. D. Collect a sputum specimen for a client with a fever of unknown origin E. Ambulate a client who had a femoral-popliteal bypass graft yesterday. Rationale (B, D, and E) are correct. Measuring vital signs (B), collecting specimens (D), and ambulating a mobile client (E) are within the scope of practice for a UAP. Surgical dressing changes (A) and initiating blood transfusions (C) should be performed by a licensed nurse.

An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse's response should be based on which information about assistive devices? A. They can contribute to increased dependency. B. They decrease the risk for joint trauma. C. They promote muscle tone and strength. D. They diminish range of motion ability.

Answer B. They decrease the risk for joint trauma. Rationale Assistive devices of this kind are very beneficial in reducing joint trauma (B) caused by excessive twisting. These devices promote independence (A), rather than increasing dependency. (C and D) are not impacted by the use of these devices.

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? A. To promote retraction of the intercostal accessory muscle of respiration. B. To reduce abdominal pressure on the diaphragm. C. To promote bronchodilation and effective airway clearance. D. To decrease pressure on the medullary center which stimulates breathing.

Answer B. To reduce abdominal pressure on the diaphragm. Rationale A semi-sitting position is the best position for matching ventilation and perfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing (B). (A) is an indication of worsening of respiratory effort, rather than a measure to promote respirations. (C) is incorrect. Bronchodilation is not affected by a change in position, and is not the cause of respiratory distress in ARDS. The respiratory center is not particularly affected by body position (D).

The nurse is assigned to care for clients on a medical unit. Based on the notes taken during the shift report, which client situation warrants the nurse's immediate attention? A. A young adult with Crohn's disease who reports having diarrheal stools. B. An older adult with type 2 diabetes whose breakfast tray arrives 20 minutes late. C. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. D. A teenager who reports continued pain 30 minutes after receiving an oral analgesic.

Answer C. A 10-year-old who is receiving chemotherapy and the infusion pump is beeping. Rationale The nurse should immediately assess the child whose infusion pump is alarming during chemotherapy administration (C) because infiltration of a caustic agent can cause tissue damage and children are at greater risk for fluid volume imbalances. Diarrheal stools are a common occurrence for those with Crohn's disease (A). Late consumption of food for a diabetic is of concern, but 20 minutes late is usually not life-threatening (B). Treatment of pain is important, but it has only been 30 minutes since the client was medicated and this issue can be assessed in 10 minutes or delegated to another nurse (D).

A primigravida client at 36-weeks gestation is admitted to labor and delivery unit because her membranes ruptured 30 minutes ago. Initial assessment indicates 2 cm cervical dilation, 50% effaced, -2 station, vertex presentation, greenish colored amniotic fluid, and contractions occurring 3 to 5 minutes with a decrease in fetal heart rate after the last contraction peaks. Which action should the nurse implement first? A. Apply an internal fetal heart monitor. B. Notify the healthcare provider. C. Administer Oxygen via face mask. D. Use a vibroacoustic stimulator.

Answer C. Administer Oxygen via face mask. Rationale The nurse should administer oxygen (C) to increase the amount of oxygen available to the fetus, because this contraction pattern is characteristic of late deceleration, caused by uteroplacental insufficiency. Applying the internal fetal heart monitor (A) to provide a continuous tracing of the fetal heart rate can be implemented after administering the oxygen, and then, notifying the healthcare provider (B) should be done. (D) is used to awaken the fetus, and it is often used if the fetus is in a sleep cycle during a stress test, which is not the case here.

A woman at 24 weeks gestation who has fever, bodyaches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescription has the highest priority? A. Obtain specimens for cultures. B. Vital signs q4 hours. C. Assign private room. D. Ringers lactate IV 125 mL/8 hours.

Answer C. Assign private room. Rationale Novel H1N1 ("swine flu virus"), a new subtype of influenza A virus, is exhibited by fever, cough, sore throat, runny nose, body aches, headache, chills, fatigue, diarrhea, and vomiting. According to the Center for Disease Control, it is best to place a client requiring Contact or Droplet Precautions in a single client room, so to protect others, the client who is exhibiting signs of Novel H1N1 influenza should be assigned to a private room (C). (A, B, and D) do not have the right the priority of (C).

A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most import for successful adherence to the diabetic diet? A. Frequently eats fruits and vegetables at meals and between meals. B. Knows that insulin must be given 30 minutes before eating. C. Demonstrates willingness to adhere to the diet consistently. D. Has someone available who can prepare and oversee the diet.

Answer C. Demonstrates willingness to adhere to the diet consistently. Rationale And individual's willingness to learn, (defined as change in behavior) is the most important factor for success of any teaching (C). (A) is not essential to a successful diabetic diet regimen. Insulin should be given 30 minutes before eating (B), but many diabetics do not take insulin, and administration does not affect success with a diabetic diet. (D) is neither practical nor necessary. Autonomy and responsibility for self-care are important aspects of successful diabetic management.

In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? A. Prepare the client to independently treat their disease process. B. Reduce healthcare costs related to diabetic complications. C. Enable clients to become active participating in controlling the disease process. D. Increase client's knowledge of the diabetic disease process and treatment options.

Answer C. Enable clients to become active participating in controlling the disease process. Rationale The primary goal of diabetic self-management education is to enable the client to become an active participant in the care and control of disease process (C), matching levels of self-management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professionals rather than (A). (B) may occur, but this is not a primary goal of self-management. (D) is an interim goal that facilitates the overall goal of self-management.

A newly hired male unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? A. Assign the newly hired UAP to clients who receive the least complex level of care. B. Ask the most experienced UAP on the team to partner with the newly hired UAP. C. Evaluate the newly hired UAP's level of competency by observing him deliver care. D. Review the UAP's skills checklist and experience with the person who hired him.

Answer C. Evaluate the newly hired UAP's level of competency by observing him deliver care. Rationale Before delegating tasks to a UAP, his skills should be evaluated (C). Prior to assigning the newly hired UAP to care for clients (A and B), his skills should be evaluated. A skills checklist (D) needs to be validated.

A client has been taking an oral corticosteroid for two weeks. Nursing assessment reveals that the client has developed a rounded face. What action should the nurse take in response to this finding? A. Withhold the next dose of medication. B. Review the client's current allergies. C. Explain this side effect to the client. D. Assess the client's intake and output.

Answer C. Explain this side effect to the client. Rationale Corticosteroids may cause many side effects, including a "moon face" appearance, caused by abnormal fat deposits. The nurse should explain this side effect to the client (C), including information that this effect is reversible when the medication is discontinued. (A, B, and D) are not necessary.

The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn's survival? A. Hypoglycemia. B. Fluid balance. C. Heat loss. D. Bleeding tendencies.

Answer C. Heat loss. Rationale Adequate thermoregulation is the nurse's next priority (C). The newborn is at risk for significant heat loss due to a large surface area exposed to the environment, a thin layer of subcutaneous fat, and distribution of brown fat. Heat loss increases the neonate's metabolic pathway's utilization of oxygen and glucose. Due to low hepatic stores of glycogen at birth and the immature kidneys' ability to concentrate urine, (A and B) are consequential to the neonate's rate of metabolism. Bleeding tendencies are addressed in the 1st hours of life by administering vitamin K by injection for hepatic synthesis of prothrombin (D).

A client with cirrhosis is receiving a low protein diet. The nurse should explain to the family that the diet restriction is implemented to reduce the risk of which complication of cirrhosis? A. Delirium tremens. B. Abdominal ascites. C. Hepatic encephalopathy. D. Esophageal varices.

Answer C. Hepatic encephalopathy. Rationale Protein end-products (amino acids) are converted (deaminated) by the liver to a fuel source by the removal of ammonia (NH3), which accumulates in the blood in those with cirrhosis and contributes to the potentially fatal complication of hepatic encephalopathy (C). Decreased protein intake does not prevent (A, B, or D).

The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What findings should indicate to the nurse to withhold the next dose of the medication? A. Excessive lochia. B. Saturation of more than one pad per hour. C. Hypertension. D. Difficulty locating the uterine fundus.

Answer C. Hypertension. Rationale Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can exaggerate primary hypertension. The nurse should withhold the medication if the client's blood pressure is elevated (C) and notify the healthcare provider. (A, B, and D) are signs of uterine atony and are indications for the use of the medication.

The nurse learns during shift report that a client is experiencing frequent ectopic beats on the cardiac telemetry monitor. Which assessment findings should the nurse expect this client to exhibit? A. Loose electrode pads. B. S3 or S4 heart sounds. C. Irregular heart rhythm. D. Bounding pulse volume.

Answer C. Irregular heart rhythm. Rationale Ectopic beats originate outside the normal conduction pathway of the heart to usurp the pacemaker's impulse, which causes an irregular cardiac rhythm (C). Ectopic beats are not the result of loose or incorrect electrode pad placement (A), do not result in the production of S3 or S4 heart sounds (B), and may or may not be palpable distally. Ectopic beats are more likely to result in a diminished pulse volume, rather than a bounding pulse volume (D).

A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? A. Women, Infant, and Children program. B. Medicaid. C. Medicare. D. Consolidated Omnibus Budget Reconciliation Act provisions.

Answer C. Medicare. Rationale Title XVIII of the Social Security act of 1965 created the Medicare Program (C) to provide medical insurance for persons 65 years or older, disabled, or with permanent kidney failure. Women, Infant, and Children (WIC) program (A) provides supplemental nutrition to meet the needs of pregnant or breastfeeding women, infants, and children up to age 6. Title XIX of the Social Security Act of 1965 is Medicaid (B), which provides financial assistance to pay for medical services for poor older adults, blind, disabled, and families with dependent children. Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions (D) is a limited insurance plan for those who have been laid off or become unemployed.

The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies.) A. S1 S2. B. S1 S2 S3. C. Murmur. D. Pericardial friction rub.

Answer C. Murmur. Rationale A murmur (C) is auscultated as a swishing sound that is associated with the blood turbulence created by a heart or valvular defect. (A) are normal heart sounds described as the first heart sound (lub) and the second heart sound (dub). (B) includes a third heart sound that is auscultated after S1 S2 (lub dub) and is associated with heart failure (HF). (D) produces a rubbing sound that overlies the intracardiac sounds.

A female client with possible acute renal failure (ARF) is admitted to the hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? A. Collect a clean catch urine specimen. B. Instruct the client to empty the bladder. C. Obtain vital signs and breath sounds. D. No specific nursing action is required.

Answer C. Obtain vital signs and breath sounds. Rationale The client's baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds (C) associated with pulmonary edema, the administration of the fluid challenge should be terminated. Providing a urine specimen (A) and emptying the bladder (B) are difficult for a client with oliguria or anuria associated with ARF. Nursing action is required to evaluate the client's response to the challenge (D).

The nurse identifies the presence of a clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately? A. Change the dressing using a compression bandage. B. Document the findings in the electronic medical record. C. Test the fluid on the dressing for glucose using a chemstrip. D. Mark the drainage area with a pen and continue to monitor.

Answer C. Test the fluid on the dressing for glucose using a chemstrip. Rationale Following lumbar spinal surgery, the nurse should observe the surgical dressing for the presence of clear fluid, which could be cerebrospinal fluid. If the fluid on the dressing is positive for glucose (C), this verifies that it is cerebrospinal fluid and the surgeon should be notified immediately. The nurse should not implement (A) based on this finding. Although the nurse should document the finding (B), this is not a priority action. (D) delays necessary intervention.

A client who receives multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medications? A. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure. B. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness. C. The additive effect of multiple medications has caused the blood pressure to drop too low. D. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension.

Answer C. The additive effect of multiple medications has caused the blood pressure to drop too low. Rationale When medications with a similar action are administered, the additive effect occurs that is the sum of the effects of each of the medications. In this case, several medications that all lower blood pressure, when administered together, resulted in hypotension (C). A change in urinary drug clearance is unlikely to produce significant diuresis (A). The similar drugs have an additive effect, rather than an antagonistic effect (B). The client's hypotension is the result of an additive effect rather than drug toxicity (D).

The nurse discontinues a continuous IV heparin infusion for a male client on strict bed rest, and is now preparing to administer the client's first dose of in enoxaparin (Lovenox). Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse? A. Current lab report indicates an aPTT at 1.5 times the client's control. B. Several bruised areas are noted on the client's upper extremities bilaterally. C. The client states that his right calf is aching, and wants pain medication. D. The spouse is assisting the client who is shaving with an electric razor.

Answer C. The client states that his right calf is aching, and wants pain medication. Rationale A calf ache severe enough for the client to request pain medication (C) should be reported to the healthcare provider immediately so that an adjustment in the anticoagulation therapy can be made. Calf pain may be a sign of deep vein thrombosis indicative of ineffective anticoagulant heparin therapy. (A and B) are expected findings. Shaving with an electric razor is recommended to reduce the possibility of bleeding (D) and does not require intervention.

A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? A. "Is there a history of female baldness in your family?" B. "Are you under any unusual stress at home or work?" C. "Do you work with hazardous chemicals?" D. "Have you noticed any changes in your fingernails?"

Answer D. "Have you noticed any changes in your fingernails?" Rationale The pattern of reported manifestations is suggestive of hypothyroidism. A question about the finger nails (D) adds data to the clinical picture. The reported pattern of manifestations are not indicators of female baldness patterns (A), and are unlikely to be due to (B or C).

The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? A. An adolescent who works part time in a paint factory. B. A 10-year-old who is an insulin-dependent diabetic (Type 1). C. An 8-year-old who lives in a housing project. D. A 2-year-old who plays on aging outdoor playground equipment.

Answer D. A 2-year-old who plays on aging outdoor playground equipment. Rationale Children who ingest dust and soil and paint from playground equipment usually practice pica—the habitual, purposeful, and compulsive ingestion of non-food products, characteristic of toddlers (D). Lead enters the system by ingestion or inhalation, usually from paint, gasoline, dust and soil, food, and water. Though (A) may present a hazard, governmental regulations decrease the risk of contracting lead poisoning by requiring use of respirators in lead paint areas. (B) is not related to lead poisoning. (C) does not practice pica the way a toddler does.

Following surgery, a male client with antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? A. Ask the client to explain why he constantly requests the nurse. B. Encourage the client to verbalize his feelings about the nurse. C. Reassure the client that his request will be met whenever possible. D. Advise the client that assignments are not based on clients requests.

Answer D. Advise the client that assignments are not based on clients requests. Rationale Those with antisocial personality disorder are manipulative in order to meet their own needs. The charge nurse must set limits (D) on these behaviors. The client's superficial charm and emotional immaturity provide effective therapeutic communication and (A and B) will be used to the client's advantage. Promoting a special relationship (C) between the client and a staff member encourages further manipulative behavior.

While the nurse is providing morning care for a client with chronic obstructive pulmonary disease (COPD), the client becomes very dyspneic and starts to panic. What action should the nurse implement first? A. Instruct the client to perform diaphragmatic breathing. B. Use a calm voice to tell the client to breathe slowly. C. Administer two puffs of a metered-dose inhaler. D. Assist the client to an upright position.

Answer D. Assist the client to an upright position. Rationale The nurse should first assist the client to an upright position (D), which allows the lungs to expand fully. After this, the nurse can implement (A, B, and C) as needed.

A male client with angina pectoris is being discharged from the hospital. What instruction should the nurse plan to include in this discharge teaching? A. Engage in physical exercise immediately after eating to help decrease cholesterol levels. B. Walk briskly in cold weather to increase cardiac output. C. Keep nitroglycerin in a light-colored plastic bottle and readily available. D. Avoid all isometric exercises, but walk regularly.

Answer D. Avoid all isometric exercises, but walk regularly. Rationale Isometric exercises (static contraction) can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking (D) provides aerobic conditioning that improves lung, blood vessel, and muscle function. Clients with angina should refrain from physical exercise for 2 hours after meals (A), but exercising does not decrease cholesterol levels. Cold water causes vasoconstriction that may cause chest pain (B). Nitroglycerin should be readily available and stored in a dark-colored glass bottle, not (C), to ensure freshness of the medication.

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis? A. Egg whites, toast, and coffee. B. Brand muffin, mixed fruit, and orange juice. C. Granola bar and grapefruit juice. D. Bagel with jelly and skim milk.

Answer D. Bagel with jelly and skim milk. Rationale (D) includes dairy products which contain calcium and does not include any foods that inhibit calcium absorption. The primary dietary implication of osteoporosis is the need for increased calcium, and a reduction in foods that decrease calcium absorption, such as caffeine and excessive fiber. (A, B and C) do not include any source of calcium, and (A and B) contain foods that may reduce calcium absorption.

A nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual nutritional status? A. A 24-hour diet history. B. History of a recent weight loss. C. Status of current appetite. D. Condition of hair, nails, and skin.

Answer D. Condition of hair, nails, and skin. Rationale The assessment of hair, nails, and skin (D) is most indicative of long-term nutritional status, which is important in the healing process. (A, B, and C) evaluate only recent in short-term nutritional status.

The nurse assesses a client who has just returned from a diagnostic study, as seen in the picture. The client has a prescription for a nasogastric tube to low intermittent suction and now reports feelings of nausea. What action should the nurse implement first? A. Auscultate bowel sounds. B. Administer an IV antiemetic. C. Remove tape from the cheek. D. Connect the tube to suction.

Answer D. Connect the tube to suction. Rationale To relieve the client's nausea, the nurse should first connect the nasogastric tube to the prescribed suction (D). If this does not relieve the nausea, an antiemetic agent (B) should be administered. (A and C) can be completed after initial actions are taken to relieve the client's nausea.

Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? A. Ask a more experienced nurse to perform this crowd since it is the first one of the day. B. Validate that the nurse is implementing the OR policy for a surgical hand scrub. C. Inform the nurse that hand scrubs should be 3 minutes between cases. D. Direct the nurse to continue the surgical hand scrub for a 5 minute duration.

Answer D. Direct the nurse to continue the surgical hand scrub for a 5 minute duration. Rationale The surgical hand scrub should last for 5 to 10 minutes, so the nurse should be directed to continue the vigorous scrub using a reliable agent for the total duration of five minutes (D). It is not necessary to reassign staff (A). The length of the hand scrub and subsequent scrubs during the day require the same process for the same amount of time (B and C).

A female client with otosclerosis is scheduled for a stapedectomy. What information is most important to provide the client about the postoperative care? A. Medications to manage pain are available. B. Avoid turning head until dressings are removed. C. Can go to bathroom independently. D. Hearing may seem muffled initially.

Answer D. Hearing may seem muffled initially. Rationale Otosclerosis causes bone conduction deafness due to a calcification of the stapes in the bony labyrinth. Surgical correction requires stapedectomy and a stapes prosthetic implant to restore hearing. In the immediate postoperative period, the client should be prepared for muffled hearing (D) due to interauricular packing, swelling, and external dressings that reduce air conduction. Although information about pain medications (A) should be provided, the client's concern about hearing restoration is usually most significant. (B) is not necessary. Postoperative vertigo is common, so the client should request assistance when resuming ambulation or going to the bathroom (C).

A nurse assesses a client whose hand begins to spasm when the blood pressure cuff is inflated. The client complains of parenthesia in the fingers and toes. Which serum laboratory findings should the nurse expect to find? A. Elevated serum potassium. B. Low serum magnesium. C. Elevated serum calcium. D. Low serum calcium.

Answer D. Low serum calcium. Rationale Trousseau's sign is carpal spasms induced by inflating a blood pressure cuff above the systolic pressure for a few minutes and is an early sign of tetany associated with hypocalcemia (D). Although (A, B, and C) are related to muscular contractility, a Trousseau's sign supports a low serum calcium level.

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? A. Call the radiology department. B. Reinsert the implant into the vagina. C. Applied double gloves to retrieve the implant for disposal. D. Place the implant in a lead container using long-handled forceps.

Answer D. Place the implant in a lead container using long-handled forceps. Rationale Solid or sealed radiation sources, such as Cesium which is removed after treatment, are inserted into an applicator or cervical implant to emit continuous, low energy radiation to adjacent tumor tissues. If the radiation source or the applicator becomes dislodged, long-handled forceps should be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then placed in the lead container (D). Although radiology should be notified (A), the sealed source should first be removed from the bed to prevent further contact with the radioactive element. (B) is not a nursing action. (C) places the nurse and others at risk for radiation exposure.

While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value? A. Hemoglobin. B. Protein. C. Calcium. D. Potassium.

Answer D. Potassium. Rationale As insulin lowers the blood glucose of a client with diabetic ketoacidosis, the serum potassium level also decreases as potassium returns to the cell. This can cause potentially fatal hypokalemia, so it is essential for the nurse to monitor the clients serum potassium (D). It is less critical to monitor (A, B and C) while an intravenous insulin infusion is being administered.

What action should the nurse take first when discontinuing and indwelling urinary catheter? A. Slide the catheter out of the urethra. B. Place the drainage bag in a biohazard container. C. Instruct the client to breathe deeply and exhale. D. Remove the normal saline from the balloon.

Answer D. Remove the normal saline from the balloon. Rationale The nurse should first remove the saline from the balloon (D), which deflates the balloon so the catheter can easily be removed. The nurse should then instruct the client to breathe deeply and exhale (C), sliding the catheter out of the meatus (A) while the client is exhaling. The drainage system can then be discarded (B).

A 6-month-old is admitted to the hospital with diarrhea. The mother is feeding the infant a bottle of tap water and tells the nurse that the baby has taken three 8-ounce bottles of water in the last four hours. Which laboratory finding is most important for the nurse to monitor? A. Creatinine clearance. B. White blood cell count. C. Serum potassium levels. D. Serum sodium levels.

Answer D. Serum sodium levels. Rationale Serum sodium levels (D) should be monitored because the recent water intake places this infants at risk for water intoxication and hyponatremia. (A) evaluates renal function efficiency in removing serum creatinine, and end-product of protein metabolism. (B and C) do not evaluate possible water intoxication.

When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? A. Crying. B. Straining on stool. C. Vomiting. D. Sitting upright.

Answer D. Sitting upright. Rationale The anterior fontanel closes at 9 months of age and may bulge when venous return is reduced from the head, but a bulging anterior fontanel is most significant if the infant is sitting up (D) and may indicate an increase in cerebrospinal fluid. Activities that reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or a dependent position of the head, cause a normal transient increase in intracranial pressure, so your bulging anterior fontanelle is an expected finding during (A, B, and C).

An older male client with a history of Type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? A. Obtain a serum potassium level. B. Administer the client's usual dose of insulin. C. Assess pupillary response to light. D. Start an intravenous (IV) infusion of normal saline.

Answer D. Start an intravenous (IV) infusion of normal saline. Rationale The nurse should first start an intravenous infusion of normal saline (D) to replace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which also contributes to diuresis and fluid electrolyte imbalance. (A and B) are correct interventions for ketoacidosis, but first the nurse should obtain venous access to administer fluids and obtain serum glucose levels. Based upon the client's current symptoms, (C) is not indicated.

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulses, and hypotension. Which assessment finding warrants immediate intervention by the nurse? A. Decreased urinary output. B. Low glucose levels. C. Profound weight gain. D. Ventricular arrhythmias.

Answer D. Ventricular arrhythmias. Rationale Adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralcorticoids and sodium excretion that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias (D) are life-threatening and require immediate intervention to correct critical potassium level. (A, B, and C) require intervention but do not have the priority of (D).

During a postpartum assessment of a client who is five hours post vaginal delivery, the nurse determines the fundus is three finger breadths above the umbilicus and positioned to the client's left side. What action should the nurse implement first? A. Encourage the client to void. B. Catheterize for residual urinary volume. C. Provide additional oral replacement fluids. D. Massage the fundus until firm.

Answer A. Encourage the client to void. Rationale During the immediate postpartum period, bladder distention prevents uterine contraction which predisposes the client to excessive uterine bleeding, so the client should void (A), which allows the uterus to contract and reposition midline between the umbilicus and the symphysis pubis. If the client is unable to void or completely empty the bladder, then (B) may be indicated. (C) does not address the malpositioned uterus. Fundal massage (D) may be indicated if the uterus does not become firm after voiding.

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is the best for the nurse to implement? A. Give the child syringes or hospital mask to play it at home prior to hospitalization. B. Include the child in pay therapy with children who are hospitalized for similar surgery. C. Provide a family tour of the preoperative unit one week before the surgery is scheduled. D. Provide dolls and equipment to re-enact feeling associated with painful procedures.

Answer C. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Rationale School age children gain satisfaction from exploring and manipulating their environment, thinking about objects, situations, and events, and making judgments based on what they reason. A tour of the unit (C) allows the child to see the hospital environment and reinforces explanations and conceptual thinking. Giving a child the opportunity to manipulate hospital equipment should allow for questions and discussion with the nurse (A). Although play therapy allows identification with a peer group, a group of

A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? A. Blindness secondary to cataracts. B. Acute kidney injury due to glomerular damage. C. Stroke secondary to hemorrhage. D. Heart block due to myocardial damage.

Answer C. Stroke secondary to hemorrhage. Rationale Stroke related to cerebral hemorrhage (C) is a major risk for uncontrolled hypertension. Poorly managed hypertension increases the risk for blindness due to retinal hemorrhage, not cataracts (A). Kidney damage from hypertension is a chronic process, not an acute injury (B). (D) is unrelated to hypertension.

When entering a client's room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next? A. Prepare to administer atropine 0.4 mg IVP. B. Gather emergency tracheostomy equipment. C. Prepare to administer lidocaine at 100 mg IVP. D. Place cardiac monitor leads on the client's chest.

Answer D. Place cardiac monitor leads on the client's chest. Rationale Before further interventions can be done, the client's heart rhythm must be determined. This can be done by connecting the client to the cardiac monitor (D). (A and C) are not a first-line drug given for any of the life-threatening, pulses dysrhythmias. (B) is not performed unless the airway is unable to be maintained by other means (CPR mask, oral or nasal intubation with an endotracheal tube).

The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client's Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine? A. When the client's stroke symptoms started. B. If the client is oriented to time. C. The client's previous GCS score. D. The client's blood pressure and respiration rate.

Rationale The normal GCS is 15, and it is most important for the nurse to determine if this abnormal score is a sign of improvement or a deterioration in the client's condition (C). (A) is a relevant. (B) is part of the GCS. The classic vital signs in late or sudden increasing intracranial pressure or Cushing's triad (widening pulse pressure, bradycardia with full, bounding pulses, and irregular respirations). Additional vital signs and trending of values are needed to evaluate the current findings (D), and (C) is a more sensitive, consistent evaluation.