Mid-Curricular HESI
The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. 1- Sitting up and leaning on a table 2-Standing and leaning against a wall 3-Lying supine with the feet elevated 4-Sitting up with the elbows resting on knees 5-Lying on the back in a low-Fowler's position
1- Sitting up and leaning on a table 2-Standing and leaning against a wall 4-Sitting up with the elbows resting on knees Rationale:The client would use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client would not lie on the back because this reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.
The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply. 1-Nocturia 2-Incontinence 3-Enlarged prostate 4-Nocturnal emissions 5-Decreased desire for sexual intercourse
1-Nocturia 2-Incontinence 3-Enlarged prostate Rationale: Nocturia, incontinence, and an enlarged prostate are characteristics of BPH and need to be assessed for in clients over 50 years of age. Nocturnal emissions are commonly associated with prepubescent individuals. Low testosterone levels (not BPH) may be associated with a decreased desire for sexual intercourse.
A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How would the nurse correctly interpret this rhythm? 1-Sinus tachycardia 2-Sinus bradycardia 3-Sinus dysrhythmia 4-Normal sinus rhythm
1-Sinus tachycardia Rationale:Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute.
Which nursing actions apply to the care of a child who is having a seizure? Select all that apply. 1-Time the seizure. 2-Restrain the child. 3-Stay with the child. 4-Insert an oral airway. 5-Loosen clothing around the child's neck. 6-Place the child in a lateral side-lying position.
1-Time the seizure. 3-Stay with the child. 5-Loosen clothing around the child's neck. 6-Place the child in a lateral side-lying position. Rationale:During a seizure, the nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure. The child is not restrained, because this could cause injury to the child. The child is placed on the side in a lateral position. Nothing is placed in the child's mouth during a seizure because this could injure the child's mouth, gums, or teeth. Positioning on the side prevents aspiration, because saliva drains out of the corner of the child's mouth. The nurse would loosen clothing around the child's neck and ensure a patent airway.
A breast-feeding/chest-feeding parent of an infant with lactose intolerance asks the nurse about dietary measures. What foods would the nurse tell the parent are acceptable to consume while breast-feeding/chest feeding? Select all that apply. 1-1% milk 2-Egg yolk 3-Dried beans 4-Hard cheeses 5-Green leafy vegetables
2-Egg yolk 3-Dried beans 5-Green leafy vegetables Rationale:Breast-feeding or chest-feeding parents with lactose-intolerant infants need to be encouraged to limit dairy products. Milk and cheese are dairy products. Alternative calcium sources that can be consumed by the parent include egg yolk, dried beans, green leafy vegetables, cauliflower, and molasses.
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1-Glipizide 2-Metformin 3-Repaglinide 4-Regular insulin
2-Metformin Rationale:Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of a contrast medium during the procedure. Metformin is excreted by the kidneys. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization. Repaglinide is metabolized by the liver and excreted in bile. Glipizide is eliminated primarily by hepatic biotransformation.
The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had a laryngectomy. Which instructions would be included in the list? Select all that apply. 1-Restrict fluid intake. 2-Obtain a MedicAlert bracelet. 3-Keep the humidity in the home low. 4-Prevent debris from entering the stoma. 5-Avoid exposure to people with infections. 6-Avoid swimming and use care when showering.
2-Obtain a MedicAlert bracelet. 4-Prevent debris from entering the stoma. 5-Avoid exposure to people with infections. 6-Avoid swimming and use care when showering. Rationale:The nurse would teach the client how to care for the stoma, depending on the type of laryngectomy performed. Most interventions focus on protection of the stoma and the prevention of infection. Interventions include obtaining a MedicAlert bracelet, preventing debris from entering the stoma, avoiding exposure to people with infections, and avoiding swimming and using care when showering. Additional interventions include wearing a stoma guard or high-collared clothing to protect the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin.
The nurse is creating a plan of care for a client in skin traction. The nurse would monitor for which priority finding in this client? 1-Urinary incontinence 2-Signs of skin breakdown 3-The presence of bowel sounds 4-Signs of infection around the pin sites
2-Signs of skin breakdown Rationale:Skin traction is achieved by Ace wraps, boots, or slings that apply a direct force on the client's skin. Traction is maintained with 5 to 8 lb (2.3 to 3.6 kg) of weight, and this type of traction can cause skin breakdown. Urinary incontinence is not related to the use of skin traction. Although constipation can occur as a result of immobility and monitoring bowel sounds may be a component of the assessment, this intervention is not the priority assessment. There are no pin sites with skin traction.
A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client? 1-Begin to teach relaxation techniques. 2-Encourage the client to discuss the assault. 3-Remain with the client until the anxiety decreases. 4-Place the client in a quiet room alone to decrease stimulation.
3-Remain with the client until the anxiety decreases. Rationale:This client is in a severe state of anxiety. When a client is in a severe or panic state of anxiety, it is crucial for the nurse to remain with the client. The client in a severe state of anxiety would be unable to learn relaxation techniques. Discussing the assault at this point would increase the client's level of anxiety further. Placing the client in a quiet room alone may also increase the anxiety level.
The nurse reviews the arterial blood gas results of a client with emphysema and notes that the laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27 mEq/L. The nurse interprets that the client has which acid-base disturbance? 1-Metabolic acidosis 2-Metabolic alkalosis 3-Respiratory acidosis 4-Respiratory alkalosis
3-Respiratory acidosis Rationale:The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis, the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values identified in the question.
The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction? 1-"I will handle the area gently." 2-"I will wear loose-fitting clothing." 3-"I will avoid the use of deodorants." 4-"I will limit sun exposure to 1 hour daily."
4-"I will limit sun exposure to 1 hour daily." Rationale:The client needs to be instructed to avoid exposure to the sun. Because of the risk of altered skin integrity, options 1, 2, and 3 are accurate measures in the care of a client receiving external radiation therapy.
The nurse is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage would the nurse instruct the client to select from the menu? 1-Tea 2-Cola 3-Coffee 4-Apple juice
4-Apple juice Rationale:A client with a diagnosis of MI should not consume caffeinated beverages. Caffeinated products can produce a vasoconstrictive effect, leading to further cardiac ischemia. Coffee, tea, and cola all contain caffeine and need to be avoided in the client with MI. Apple juice does not contain caffeine.
The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? 1-Age 2-Hypertension 3-Hyperlipidemia 4-Glucose intolerance
4-Glucose intolerance Rationale:Hypertension, cigarette smoking, and hyperlipidemia are modifiable risk factors that are predictors of CAD. Glucose intolerance, obesity, and response to stress are contributing modifiable risk factors for CAD. Age is a nonmodifiable risk factor. The nurse places priority on risk factors that can be modified. In this scenario, the abnormal value is the fasting blood glucose level, indicating glucose intolerance as the priority risk factor.
The nurse assesses a client with the admitting diagnosis of bipolar affective disorder, mania. Which client symptoms require the nurse's immediate action? 1-Incessant talking and sexual innuendos 2-Grandiose delusions and poor concentration 3-Outlandish behaviors and inappropriate dress 4-Nonstop physical activity and poor nutritional intake
4-Nonstop physical activity and poor nutritional intake Rationale:Mania is a mood characterized by excitement, euphoria, hyperactivity, excessive energy, decreased need for sleep, and impaired ability to concentrate or complete a single train of thought. The client's mood is predominantly elevated, expansive, or irritable. All of the options reflect a client's possible symptoms. However, the correct option clearly presents a problem that compromises physiological integrity and needs to be addressed immediately.
A client admitted to the hospital with coronary artery disease complains of dyspnea at rest. The nurse caring for the client uses which item as the best means to monitor respiratory status on an ongoing basis? 1-Apnea monitor 2-Oxygen flowmeter 3-Telemetry cardiac monitor 4-Oxygen saturation monitor
4-Oxygen saturation monitor Rationale:Dyspnea in the cardiac client often is accompanied by hypoxemia. Hypoxemia can be detected by an oxygen saturation monitor, especially if it is used continuously. An apnea monitor detects apnea episodes, such as when the client has stopped breathing briefly. An oxygen flowmeter is part of the setup for delivering oxygen therapy. Cardiac monitors detect dysrhythmias.
The nurse has just completed education on myocardial infarction (MI) to a group of new nurses. Which statement made by one of the nurses indicates that the teaching has been effective? 1-"Chest pain is caused by tissue hypoxia in the myocardium." 2-"Chest pain is caused by tissue hypoxia in the vessels of the heart." 3-"Chest pain is caused by tissue hypoxia in the parietal pericardium." 4-"Chest pain is caused by tissue hypoxia in the visceral pericardium."
1-"Chest pain is caused by tissue hypoxia in the myocardium." Rationale:The myocardial layer of the heart is damaged when a client experiences an MI. This is the middle layer that contains the striated muscle fibers responsible for the contractile force of the heart. In an MI, an obstruction causes an interruption in blood flow and ensuing hypoxia; this affects the myocardial layer. The endocardium is the thin inner layer of cardiac tissue. The parietal pericardium and visceral pericardium are outer layers that protect the heart from injury and infection.
The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? 1-"Pulse rate will increase." 2-"Blood pressure will decrease." 3-"Edema will be present in the legs." 4-"Crackles in the lungs will be present."
1-"Pulse rate will increase." Rationale:The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the blood pressure will decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in fluid volume.
The nurse is listening to a lecture about angina. Which statement by the nurse indicates that the teaching has been effective? 1-"Stable angina is chronic." 2-"Variant angina is caused by emotional stress." 3-"Unstable angina is not a life-threatening condition." 4-"Intractable angina rarely limits the client's lifestyle."
1-"Stable angina is chronic." Rationale:Stable angina is triggered by a predictable amount of effort or emotion and is a chronic condition. Variant angina is triggered by coronary artery spasm; the attacks are of longer duration than in classic angina and tend to occur early in the day and at rest. Unstable angina is triggered by an unpredictable amount of exertion or emotion and may occur at night; the attacks increase in number, duration, and severity over time. Intractable angina is chronic and incapacitating and is refractory to medical therapy.
The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? 1-"The enema will be given while I am sitting on the toilet." 2-"I would try and hold the fluid as long as possible after it is run in." 3-"I know that there will be some cramping after the enema solution is run in." 4-"I would tell the nurse if cramping occurs when the fluid is running in."
1-"The enema will be given while I am sitting on the toilet." Rationale:The enema is never administered while on a toilet due to safety. The enema is administered while the client is in a left side-lying position with the right knee flexed. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. It is important for the client to retain the fluid for as long as possible to promote peristalsis and defecation. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping.
The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? 1-"This is a normal finding." 2-"This is indicative of atrial flutter." 3-"This is indicative of atrial fibrillation." 4-"This is indicative of impending reinfarction."
1-"This is a normal finding." Rationale:The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The normal range for the PR interval is 0.12 to 0.20 seconds. The remaining options are incorrect and indicate that further education is needed.
The nurse is performing an admission assessment on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain at home. During the assessment the client complains of chest pain. The nurse would immediately ask the client which question? 1-"Where is the pain located?" 2-"Are you having any nausea?" 3-"Are you allergic to any medications?" 4-"Do you have your nitroglycerin with you?"
1-"Where is the pain located?" Rationale:If a client complains of chest pain, the initial assessment question is to ask the client about the pain intensity, location, duration, and quality. Although the questions in the remaining options all may be components of the assessment, none of these questions is the initial assessment question for this client.
The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs? 1-Actual or life-threatening concerns 2-Completing care in a reasonable time frame 3-Time constraints related to the client's needs 4-Obtaining needed supplies to care for the client
1-Actual or life-threatening concerns Rationale:Setting priorities means deciding which client needs or problems require immediate action and which can be delayed until a later time because they are not urgent. Client problems that involve actual or life-threatening concerns are always considered first. Although completing care in a reasonable time frame, time constraints, and obtaining needed supplies are components of time management, these items are not the priority in planning care for the client, based on the options provided
The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse plans for which intervention as the priority for this client? 1-Administration of dopamine 2-Administration of whole blood 3-Administration of intravenous fluids 4-Administration of packed red blood cells
1-Administration of dopamine Rationale:The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed red blood cells are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided.
A client with heart failure has been experiencing difficulty with completion of daily activities, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? 1-Ambulates 10 feet (3 meters) farther each day 2-Verbalizes the benefits of increasing activity 3-Chooses a healthy diet that meets caloric needs 4-Sleeps without awakening throughout the night
1-Ambulates 10 feet (3 meters) farther each day Rationale:Each of the options indicates a positive outcome on the part of the client. Both option 2 and the correct one relate to the client problem of difficulty with completion of daily activities. However, the question asks about progress. The correct option is more action-oriented and therefore is the better choice. Option 3 would most likely indicate progress if the client had a problem of inadequate nutritional intake. Option 4 would be a satisfactory outcome for a client experiencing difficulty sleeping.
A client has refused to eat more than a few spoonfuls of breakfast. The primary health care provider has prescribed that tube feedings be initiated if the client fails to eat at least half of a meal because the client has lost a significant amount of weight during the previous 2 months. The nurse enters the room, looks at the tray, and states, "If you don't eat any more than that, I'm going to have to put a tube down your throat and get a feeding in that way." The client begins crying and tries to eat more. Based on the nurse's actions, the nurse may be accused of which violation? 1-Assault 2-Battery 3-Slander 4-Invasion of privacy
1-Assault Rationale:Assault occurs when a person puts another person in fear of harmful or offensive contact and the victim fears and believes that harm will result from the threat. In this situation, the nurse could be accused of the tort of assault. Battery is the intentional touching of another's body without the person's consent. Slander is verbal communication that is false and harms the reputation of another. Invasion of privacy is committed when the nurse intrudes into the client's personal affairs or violates confidentiality.
A client presents to the emergency department with upper gastrointestinal bleeding and is in moderate distress. In planning care, what is the priority nursing action for this client? 1-Assessment of vital signs 2-Completion of abdominal examination 3-Insertion of the prescribed nasogastric tube 4-Thorough investigation of precipitating events
1-Assessment of vital signs Rationale:The priority nursing action is to assess the vital signs. This would provide information about the amount of blood loss that has occurred and provide a baseline by which to monitor the progress of treatment. The client may be unable to provide subjective data until the immediate physical needs are met. Although an abdominal examination and an assessment of the precipitating events may be necessary, these actions are not the priority. Insertion of a nasogastric tube is not the priority and will require a primary health care provider's prescription; in addition, the vital signs would be checked before performing this procedure.
The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the primary health care provider (PHCP)? 1-Dark red drainage 2-Dark brown drainage 3-Green-tinged drainage 4-Light yellowish-brown drainage
1-Dark red drainage Rationale:For the first 12 hours after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green tinge. The PHCP needs to be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively.
The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse would next assess the client for which finding? 1-Hypotension 2-Flat neck veins 3-Complaints of nausea 4-Complaints of headache
1-Hypotension Rationale:The client with uncontrolled atrial fibrillation with a ventricular rate greater than 100 beats/minute is at risk for low cardiac output because of loss of atrial kick. The nurse assesses the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins.
The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence? 1-Inability to pass flatus 2-Loss of anal sphincter control 3-Severe, constant pain with rapid onset 4-Firm, nontender mass palpable at the lower right costal margin
1-Inability to pass flatus Rationale:An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction.
The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1-Listening to lung sounds 2-Palpating for organomegaly 3-Assessing for jugular vein distention 4-Assessing for peripheral and sacral edema
1-Listening to lung sounds Rationale:The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left-sided heart function.
The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse would include which intervention in the plan? 1-Maintain activity level as prescribed. 2-Maintain the affected leg in a dependent position. 3-Administer an opioid analgesic every 4 hours around the clock. 4-Apply cool packs to the affected leg for 20 minutes every 4 hours
1-Maintain activity level as prescribed. Rationale:Standard management for the client with DVT includes maintaining the activity level as prescribed by the PHCP; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Recent research is showing that ambulation, unlike as previously thought, does not cause pulmonary embolism and does not cause the existing DVT to worsen. Therefore, the nurse needs to maintain the prescribed activity level. Opioid analgesics are not required to relieve pain, and pain normally is relieved with acetaminophen.
The nurse recognizes that which interventions are likely to facilitate effective communication between a dying client and family? Select all that apply. 1-The nurse encourages the client and family to identify and discuss feelings openly. 2-The nurse assists the client and family in carrying out spiritually meaningful practices. 3-The nurse removes autonomy from the client to alleviate any unnecessary stress for the client. 4-The nurse makes decisions for the client and family to relieve them of unnecessary demands. 5-The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger.
1-The nurse encourages the client and family to identify and discuss feelings openly. 2-The nurse assists the client and family in carrying out spiritually meaningful practices.5-The nurse maintains a calm attitude and one of acceptance when the family or client expresses anger. Rationale: Maintaining effective and open communication among family members affected by death and grief is of the greatest importance. Option 1 describes encouraging discussion of feelings and is likely to enhance communication. Option 2 is also an effective intervention because spiritual practices give meaning to life and have an impact on how people react to crisis. Option 5 is also an effective technique because the client and family need to know that someone will be there who is supportive and nonjudgmental. The remaining options describe the nurse removing autonomy and decision making from the client and family, who are already experiencing feelings of loss of control in that they cannot change the process of dying. These are ineffective interventions that could impair communication further.
The nurse is assigned to care for a client in traction. The nurse creates a plan of care for the client and would include which action in the plan? 1-Ensure that the knots are at the pulleys. 2-Check the weights to ensure that they are off the floor. 3-Ensure that the head of the bed is kept at a 45- to 90-degree angle. 4-Monitor the weights to ensure that they are resting on a firm surface.
2-Check the weights to ensure that they are off the floor. Rationale:To achieve proper traction, weights need to be free-hanging, with knots kept away from the pulleys. Weights would not be kept resting on a firm surface. The head of the bed is usually kept low to provide countertraction.
A client who is positive for human immunodeficiency virus (HIV) delivers a newborn infant. The nurse provides instructions to help the client with care of the infant. Which client statement indicates the need for further instruction? 1-"I will be sure to wash my hands before and after bathroom use." 2-"I need to chest-feed with my milk, especially for the first 6 weeks postpartum." 3-"Support groups are available to assist me with understanding my diagnosis of HIV." 4-"My newborn infant needs to be on antiviral medications for the first 6 weeks after delivery."
2-"I need to chest-feed with my milk, especially for the first 6 weeks postpartum." Rationale:The mode of perinatal transmission of HIV to the fetus or neonate of an HIV-positive parent can occur during the prenatal, intrapartal, or postpartum period. HIV transmission can occur during chest-feeding. In the United States and most developed countries, HIV-positive clients are encouraged to bottle-feed their infants (the primary health care provider's prescription is always followed). Frequent handwashing is encouraged. Support groups and community agencies can be identified to assist the parents with the newborn infant's home care, the impact of the diagnosis of HIV infection, and available financial resources. It is recommended that infants of HIV-positive clients receive antiviral medications for the first 6 weeks of life.
The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1-"I'll need to become a strict vegetarian." 2-"I should use polyunsaturated oils in my diet." 3-"I need to substitute eggs and whole milk for meat." 4-"I should eliminate all cholesterol and fat from my diet."
2-"I should use polyunsaturated oils in my diet." Rationale:The client with coronary artery disease needs to avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian.
The home care nurse has taught a client with heart failure and a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? 1-"I will try to exercise vigorously to strengthen my heart muscle." 2-"I will eat enough daily fiber to prevent straining during bowel movement." 3-"I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4-"Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."
2-"I will eat enough daily fiber to prevent straining during bowel movement." Rationale:Standard home care instructions for a client with this problem include, among others, lifestyle changes such as avoiding alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload.
The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching? 1-"I will avoid using table salt with meals." 2-"It is best to exercise once a week for 1 hour." 3-"I will take nitroglycerin whenever chest discomfort begins." 4-"I will use muscle relaxation to cope with stressful situations."
2-"It is best to exercise once a week for 1 hour." Rationale:Exercise is most effective when done at least 3 times a week for 20 to 30 minutes to reach a target heart rate. Other healthful habits include limiting salt and fat in the diet and using stress management techniques. The client also should be taught to take nitroglycerin before any activity that previously caused the pain and to take the medication at the first sign of chest discomfort.
The nurse educator is lecturing new registered nurses (RNs) about serum calcium levels. Which statement by one of the new RNs indicates that teaching has been effective? 1-"Calcium has no effect on the risk for stroke." 2-"Low calcium levels can lead to cardiac arrest." 3-"Low calcium levels cause high blood pressure." 4-"Calcium has no effect on urinary stone formation."
2-"Low calcium levels can lead to cardiac arrest." Rationale:The normal calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A low calcium level could lead to severe ventricular dysrhythmias, prolonged QT interval, and ultimately cardiac arrest. Calcium is needed by the heart for contraction. Calcium ions move across cell membranes into cardiac cells during depolarization and move back during repolarization. Depolarization is responsible for cardiac contraction. Option 1 is unrelated to calcium levels. A low calcium level is unrelated to hypertension. Elevated calcium levels can lead to urinary stone formation. The nurse would take action and contact the health care provider when a calcium level is abnormal.
A client with severe coronary artery disease who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1-Hypovolemia 2-Acute kidney injury 3-Glomerulonephritis 4-Urinary tract infection
2-Acute kidney injury Rationale:The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10 to 20 mg/dL (3.6 to 7.1 mmol/L), and creatinine, male 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection.
A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage would the nurse expect? 1-Serous 2-Bloody 3-Serosanguineous 4-Bloody, with frequent small clots
2-Bloody Rationale:In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client would not experience frequent clotting. Proper chest tube function would allow for drainage of blood before it has the chance to clot in the chest or the tubing.
The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge? 1-"I need to start exercising more to improve my health." 2-"I will be sure to keep my appointment with the cardiologist." 3-"I don't have anyone to help me with doing heavy housework at home." 4-"I think I have a good understanding of what all my medications are for."
3-"I don't have anyone to help me with doing heavy housework at home." Rationale:To ensure the best outcome, the client needs to be able to comply with instructions related to activity, diet, medications, and follow-up health care on discharge from the hospital after an MI. All of the options except the correct one indicate that the client will be successful in these areas.
A client with a diagnosis of angina pectoris is hospitalized for an angioplasty. The client returns to the nursing unit after the procedure, and the nurse provides instructions to the client regarding home care measures. Which statement, if made by the client, indicates an understanding of the instructions? 1-"I need to cut down on cigarette smoking." 2-"I am so relieved that my heart is repaired." 3-"I need to adhere to my dietary restrictions." 4-"I am so relieved that I can eat anything I want to now."
3-"I need to adhere to my dietary restrictions." Rationale:After angioplasty, the client needs to be instructed on the specific dietary restrictions that must be followed. Making the recommended dietary and lifestyle changes will assist in preventing further atherosclerosis. Abrupt closure of the artery can occur if the dietary and lifestyle recommendations are not followed. Cigarette smoking needs to be stopped. An angioplasty does not repair the heart.
A client with terminal cancer arrives at the emergency department dead on arrival (DOA). After an autopsy is prescribed, the client's family requests that no autopsy be performed. Which response to the family is most appropriate? 1-"The decision is made by the medical examiner." 2-"An autopsy is mandatory for any client who is DOA." 3-"I will contact the medical examiner regarding your request." 4-"It is required by federal law. Tell me why you don't want the autopsy done."
3-"I will contact the medical examiner regarding your request." Rationale:An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. A client may have provided oral or written instructions regarding an autopsy after death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin.
A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The parent of the child asks the nurse why radiation therapy was not prescribed as a part of the treatment. The nurse would plan to make which best response? 1-"It's very costly, and chemotherapy works just as well." 2-"I'm not sure. I'll discuss it with the primary health care provider." 3-"Sometimes age has to do with the decision for radiation therapy." 4-"The primary health care provider would prefer that you discuss treatment options with the oncologist."
3-"Sometimes age has to do with the decision for radiation therapy." Rationale:Radiation therapy is usually delayed, whenever possible, until a child is 8 years old to prevent retardation of bone growth and soft tissue development. Options 1, 2, and 4 are inappropriate responses to the parent and place the parent's question on hold.
The nurse provides instructions to a malnourished pregnant client regarding iron supplementation. Which client statement indicates an understanding of the instructions? 1-"Iron supplements will give me diarrhea." 2-"Meat does not provide iron and should be avoided." 3-"The iron is best absorbed if taken on an empty stomach." 4-"On the days that I eat green leafy vegetables or calf liver I can omit taking the iron supplement."
3-"The iron is best absorbed if taken on an empty stomach." Rationale:Iron is needed to allow for transfer of adequate iron to the fetus and to permit expansion of the maternal red blood cell mass. During pregnancy, the relative excess of plasma causes a decrease in the hemoglobin concentration and hematocrit, known as physiological anemia of pregnancy. This is a normal adaptation during pregnancy. Iron is best absorbed if taken on an empty stomach. Taking it with a fluid high in ascorbic acid such as tomato juice enhances absorption. Iron supplements usually cause constipation. Meats are an excellent source of iron. The client needs to take the iron supplements regardless of food intake.
The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? 1-"Oxygen has a calming effect." 2-"Oxygen will prevent the development of any thrombus." 3-"The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." 4-"Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle."
3-"The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." Rationale:The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client.
A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? Refer to chart. Gravida, Term Births, Preterm Births, Abortions, Living Children (GTPAL) 1,0,0,0,0 Venereal Disease Research Laboratory (VDRL) =nonreactive Medications: Prenatal vitamins Weight 135 lb (61 kg) Rubella immune Positive Goodell and ChadwickRh positive, type O 1-"You need to avoid all school-age children during pregnancy." 2-"There is no need to be concerned if you don't have a fever or rash within the next 2 days." 3-"You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." 4-"Be sure to tell the primary health care provider in 2 weeks, as additional screening will be prescribed during your second trimester."
3-"You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." Rationale:Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the first trimester include hearing loss and congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella titer determination is a standard prenatal test for pregnant women during their initial screening and entry into the health care delivery system. As noted in this client's chart, she is immune to rubella. The correct option is the only option that helps clarify maternal concerns with accurate information.
A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse would document that these findings identify which type of ulcer? 1-A stage 1 ulcer 2-A vascular ulcer 3-An arterial ulcer 4-A venous stasis ulcer
3-An arterial ulcer Rationale:Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion.
The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? 1-Anxiety related to the need to make lifestyle changes 2-Boredom resulting from having already learned the material 3-An attempt to ignore or deny the need to make lifestyle changes 4-Lack of understanding of the material provided at the teaching session and embarrassment about asking questions
3-An attempt to ignore or deny the need to make lifestyle changes Rationale:Denial is a defense mechanism that allows the client to minimize a threat that may be manifested by refusal to discuss what has happened. Denial is a common early reaction associated with chest discomfort, angina, or myocardial infarction (MI). Anxiety usually is manifested by symptoms of sympathetic nervous system arousal. No data are provided in the question that would lead the nurse to interpret the client's behavior as boredom or as either understanding or not understanding the material provided at the teaching session.
The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1-Bananas 2-Broccoli 3-Antacids 4-Cantaloupe
3-Antacids Rationale:The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium.
The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? 1-Flat neck veins 2-A pulse rate of 60 beats/minute 3-Muffled or distant heart sounds 4-Wheezing on auscultation of the lungs
3-Muffled or distant heart sounds Rationale:Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). The other options are not signs of cardiac tamponade.
A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level would the nurse encourage for the client immediately after transfer? 1-Ad lib activities as tolerated 2-Strict bed rest for 24 hours after transfer 3-Bathroom privileges and self-care activities 4-Unsupervised hallway ambulation for distances up to 200 feet (60 meters)
3-Bathroom privileges and self-care activities Rationale:On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client would ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet (15, 30, and 60 meters).
A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? 1-Rhonchi 2-Wheezes 3-Crackles in the bases 4-Crackles throughout the lung fields
3-Crackles in the bases Rationale:Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. As the client's condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds indicate full resolution of the episode.) Rhonchi and wheezes are not associated with pulmonary edema. Auscultation of the lungs reveals crackles throughout the lung fields.
The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1-Restricting fluids 2-Placing a pillow under the knees 3-Encouraging active range-of-motion exercises 4-Applying a heating pad to the lower extremities
3-Encouraging active range-of-motion exercises Rationale:Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat would not be applied without a primary health care provider's prescription.
A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse would assess the client for which signs and symptoms characteristic of this disorder? 1-Bradycardia and hyperactivity 2-Decreased respiratory rate and depth 3-Headache, restlessness, and confusion 4-Bradypnea, dizziness, and paresthesias
3-Headache, restlessness, and confusion Rationale:When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.
The nurse would include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1-Provide a cool environment for the client. 2-Instruct the client to consume a high-fat diet. 3-Instruct the client about thyroid replacement therapy. 4-Encourage the client to consume fluids and high-fiber foods in the diet. 5-Inform the client that iodine preparations will be prescribed to treat the disorder. 6-Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.
3-Instruct the client about thyroid replacement therapy. 4-Encourage the client to consume fluids and high-fiber foods in the diet. 6-Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur. Rationale:The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing measures to support the signs and symptoms related to decreased metabolism. The client often has cold intolerance and requires a warm environment. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. Iodine preparations may be used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone; they are not used to treat hypothyroidism. The client is instructed to notify the PHCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone.
The nurse is creating a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concern regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client? 1-Anxiety 2-Unrealistic outlook 3-Lack of ability to cope effectively 4-Disturbances in thoughts and ideas
3-Lack of ability to cope effectively Rationale:Lack of ability to cope effectively may be evidenced by a client's inability to meet basic needs, inability to meet role expectations, alteration in social participation, use of inappropriate defense mechanisms, or impairment of usual patterns of communication. Anxiety is a broad description and can occur as a result of many triggers; although the client was experiencing anxiety, the client's concern now is the ability to meet role expectations and financial obligations. There is no information in the question that indicates an unrealistic outlook or disturbances in thoughts and ideas.
A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1-Left atrium 2-Right atrium 3-Left ventricle 4-Right ventricle
3-Left ventricle Rationale: Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. The remaining options are not the chambers that are primarily responsible for this disease process, although these chambers may be affected as the disease becomes more chronic.
The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? 1-Heart failure 2-Atrial fibrillation 3-Myocardial infarction 4-Ventricular tachycardia
3-Myocardial infarction Rationale:Cardiac troponin T or cardiac troponin I have been found to be protein markers in the detection of myocardial infarction, and assay for these proteins is used in some institutions to aid in the diagnosis of a myocardial infarction. The test is not used to diagnose heart failure, atrial fibrillation, or ventricular tachycardia.
The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse notes that the ears are low-set. Which nursing action is most appropriate? 1-Document the findings. 2-Arrange for hearing testing. 3-Notify the pediatrician. 4-Cover the ears with gauze pads.
3-Notify the pediatrician. Rationale:Low or oddly placed ears are associated with various congenital defects and need to be reported immediately. Although the findings need to be documented, the most appropriate action would be to notify the pediatrician. Options 2 and 4 are inaccurate and inappropriate nursing actions.
The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is the best nursing action based on this information? 1-Apply restraints to the client. 2-Ask the family to stay with the client. 3-Place a clock and calendar in the client's room. 4-Ask the laboratory to perform electrolyte studies.
3-Place a clock and calendar in the client's room. Rationale:An inactive older adult may become disoriented because of lack of sensory stimulation. The most appropriate nursing intervention would be to reorient the client frequently and to place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and would not be applied unless specifically prescribed; agency policies and procedures need to be followed before the application of restraints. The family can assist with orientation of the client, but it is inappropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.
The nurse is reinforcing instructions to a hospitalized client with heart block about the fundamental concepts regarding the cardiac rhythm. The nurse plans to explain to the client that the normal site in the heart responsible for initiating electrical impulses is which site? 1-Bundle of His 2-Purkinje fibers 3-Sinoatrial (SA) node 4-Atrioventricular (AV) node
3-Sinoatrial (SA) node Rationale:The SA node is responsible for initiating electrical impulses that are conducted through the heart. The impulse leaves the SA node and travels down through internodal and interatrial pathways to the AV node. From there, impulses travel through the bundle of His to the right and left bundle branches and then to the Purkinje fibers. This group of specialized cardiac cells is referred to as the cardiac conduction system. The ability of this specialized tissue to generate its own impulses is called automaticity.
The cardiologist has written a prescription for a client to have an echocardiogram. Which action would the nurse take to prepare the client for the procedure? 1-Questions the client about allergies to iodine or shellfish 2-Has the client sign an informed consent form for an invasive procedure 3-Tells the client that the procedure is painless and takes 30 to 60 minutes 4-Keeps the client on nothing by mouth (NPO) status for 2 hours before the procedure
3-Tells the client that the procedure is painless and takes 30 to 60 minutes Rationale:Echocardiography is a noninvasive, risk-free, pain-free test that involves no special preparation. It commonly is done at the bedside or on an outpatient basis. The client must lie quietly for 30 to 60 minutes while the procedure is being performed. It is important to provide adequate information to eliminate unnecessary worry on the part of the client.
The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care? 1-The informed consent does not need to be obtained. 2-The informed consent would be obtained from the family. 3-The informed consent needs to be obtained from the client. 4-The primary health care provider will provide the informed consent.
3-The informed consent needs to be obtained from the client. Rationale: Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.
The nurse working in a long-term care facility is assessing a client who is experiencing chest pain. The nurse would interpret that the pain is most likely caused by myocardial infarction (MI) on the basis of what assessment finding? 1-The client is not experiencing dyspnea. 2-The client is not experiencing nausea or vomiting. 3-The pain has not been relieved by rest and nitroglycerin tablets. 4-The client says the pain began while trying to open a stuck dresser drawer.
3-The pain has not been relieved by rest and nitroglycerin tablets. Rationale:The pain of MI is not relieved by rest and nitroglycerin and requires opioid analgesics, such as morphine sulfate, for relief. The pain of angina may radiate to the left shoulder, arm, neck, or jaw. It often is precipitated by exertion or stress, is accompanied by few associated symptoms, and is relieved by rest and nitroglycerin. The pain of MI also may radiate to the left arm, shoulder, jaw, and neck. It typically begins spontaneously, lasts longer than 30 minutes, and frequently is accompanied by associated symptoms (i.e., nausea, vomiting, dyspnea, diaphoresis, or anxiety).
On the second postpartum day, a client complains of burning on urination, urgency, and frequency of urination. A urinalysis indicates the presence of a urinary tract infection. The nurse instructs the client regarding measures to take for the treatment of the infection. Which client statement indicates to the nurse the need for further instruction? 1-"I need to urinate frequently throughout the day." 2-"The prescribed medication must be taken until it is finished." 3-"My fluid intake needs to be increased to at least 3000 mL daily." 4-"Foods and fluids that will increase urine alkalinity need to be consumed."
4-"Foods and fluids that will increase urine alkalinity need to be consumed." Rationale:A client with a urinary tract infection must be encouraged to take the prescribed medication for the entire time it is prescribed. The client would also be instructed to drink at least 3000 mL of fluid each day to flush the infection from the bladder and to urinate frequently throughout the day. Foods and fluids that acidify the urine need to be encouraged.
The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1-"I need to be sure not to go barefoot around the house." 2-"If I cut my toenails, I need to be sure that I cut them straight across." 3-"It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4-"I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."
4-"I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." Rationale:Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, needs to avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in the remaining options are correct statements and indicate that the teaching has been effective.
A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? 1-"I'm not supposed to eat cold cuts." 2-"I can have most fresh fruits and vegetables." 3-"I'm going to weigh myself daily to be sure I don't gain too much fluid." 4-"I'm going to have a ham and cheese sandwich and potato chips for lunch."
4-"I'm going to have a ham and cheese sandwich and potato chips for lunch." Rationale:When a client has HF, the goal is to reduce fluid accumulation. One way that this is accomplished is through sodium reduction. Ham (and most cold cuts), cheese, and potato chips are high in sodium. Daily weighing is an appropriate intervention to help the client monitor fluid overload. Most fresh fruits and vegetables are low in sodium.
The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement would the nurse make to try to motivate the client to quit smoking? 1- "None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 2-"Because most of the damage has already been done, it will be all right to cut down a little at a time." 3-"If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4-"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."
4-"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." Rationale:The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked. In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental smoke) substantially reduce blood flow in the coronary arteries. The statements in the remaining options are incorrect.
The nurse is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement would the nurse make to try to motivate the client to quit smoking? 1-"None of the cardiovascular effects are reversible, but quitting might prevent lung cancer." 2-"Because most of the damage has already been done, it will be all right to cut down a little at a time." 3-"If you totally quit smoking right now, you can cut your cardiovascular risk to zero within a year." 4-"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years."
4-"If you quit now, your risk of cardiovascular disease will decrease to that of a nonsmoker in 3 to 4 years." Rationale:The risks to the cardiovascular system from smoking are noncumulative and are not permanent. Three to 4 years after cessation, a client's cardiovascular risk is similar to that of a person who never smoked. In addition, tobacco use and passive smoking from "secondhand smoke" (also called environmental smoke) substantially reduce blood flow in the coronary arteries. The statements in the remaining options are incorrect.
An adolescent client is diagnosed with conjunctivitis, and the nurse provides information to the client about the use of contact lenses. Which client statement indicates the need for further information? 1-"I need to obtain new contact lenses." 2-"I need to not wear my contact lenses." 3-"My old contact lenses need to be discarded." 4-"My contact lenses can be worn if they are cleaned as directed."
4-"My contact lenses can be worn if they are cleaned as directed." Rationale:If the adolescent wears contact lenses, the adolescent needs to be instructed to discontinue wearing them until the infection has cleared completely. Obtaining new contact lenses would eliminate the chance of reinfection from contaminated contact lenses and would lessen the risk of a corneal ulceration.
Following a lecture on coronary artery disease, a nursing instructor asks a nursing student to describe the structure and function of the coronary arteries. Which response by the student indicates a need for further teaching on the anatomy and physiology of the heart? 1-"The coronary arteries branch from the aorta." 2-"The coronary arteries supply the heart muscle with blood." 3-"The left coronary artery provides blood for the left atrium and the left ventricle." 4-"The left coronary artery supplies the right atrium and right ventricle with blood."
4-"The left coronary artery supplies the right atrium and right ventricle with blood." Rationale:The left coronary artery divides into the anterior descending artery and the circumflex artery, providing blood for the left atrium and left ventricle. The right coronary artery supplies the right atrium and right ventricle. Options 1, 2, and 3 are correct.
When creating an assignment for a team consisting of a registered nurse (RN), a licensed practical nurse (LPN), and two assistive personnel (APs), which is the best client for the LPN? 1-A client requiring frequent temperature checks 2-A client requiring assistance with ambulation every 4 hours 3-A client on a mechanical ventilator requiring frequent assessment and suctioning 4-A client with a spinal cord injury requiring urinary catheterization every 6 hours
4-A client with a spinal cord injury requiring urinary catheterization every 6 hours Rationale:When creating nursing assignments, the nurse needs to consider the skills and educational level of the nursing staff. Frequent temperature checks and ambulation can most appropriately be provided by the APs, considering the clients identified in each option. The client on the mechanical ventilator requiring frequent assessment and suctioning would most appropriately be cared for by the RN. The LPN is skilled in urinary catheterization, so the client in option 4 would be assigned to this staff member
A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is an expected outcome of the medication? 1-Alleviates depression 2-Increases energy levels 3-Increases blood glucose levels 4-Achieves normal thyroid hormone levels
4-Achieves normal thyroid hormone levels Rationale:Laboratory determinations of the serum thyroid-stimulating hormone (TSH) level are an important means of evaluation. Successful therapy causes elevated TSH levels to decline. These levels begin their decline within hours of the onset of therapy and continue to decrease as plasma levels of thyroid hormone build up. If an adequate dosage is administered, TSH levels remain suppressed for the duration of therapy. Although energy levels may increase and the client's mood may improve following effective treatment, these are not noted until normal thyroid hormone levels are achieved with medication therapy. An increase in the blood glucose level is not associated with this condition.
The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse would assess which item based on priority? 1-Anxiety level of the client and family 2-Presence of a MedicAlert card for the client to carry 3-Knowledge of restrictions on postdischarge physical activity 4-Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver
4-Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver Rationale:The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority.
The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1-Checking for normal serum electrolyte levels 2-Checking for normal pH of the gastric aspirate 3-Checking for proper nasogastric tube placement 4-Checking for the presence of bowel sounds in all four quadrants
4-Checking for the presence of bowel sounds in all four quadrants Rationale:Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube.
Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse would include in the client's teaching plan? 1-Weight gain 2-Hypoglycemia 3-Flushing and palpitations 4-Gastrointestinal disturbances
4-Gastrointestinal disturbances Rationale:The most common side effect of metformin is gastrointestinal disturbances, including decreased appetite, nausea, and diarrhea. These generally subside over time. This medication does not cause weight gain; clients lose an average of 7 to 8 lb (3.2 to 3.6 kg) because the medication causes nausea and decreased appetite. Although hypoglycemia can occur, it is not the most common side effect. Flushing and palpitations are not specifically associated with this medication.
The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action? 1-Reassess the vital signs. 2-Palpate bilateral peripheral pulses. 3-Perform a neurological assessment. 4-Position the client in a Fowler's position.
4-Position the client in a Fowler's position. Rationale:Clients with fractures are at risk for fat embolism. With suspected fat embolism, the nurse would position the client in a sitting (Fowler's) position to relieve dyspnea. Supplemental oxygen is indicated to reduce the signs of hypoxia. The primary health care provider needs to be notified. Vital signs will need to be taken, but this action may delay initial and required interventions. Peripheral pulse assessment is not a priority action. A neurological assessment needs to be performed, but this would not be the initial nursing action.
A client is about to undergo a lumbar puncture. The nurse describes to the client that which position will be used during the procedure? 1-Side-lying with a pillow under the hip 2-Prone with a pillow under the abdomen 3-Prone in slight Trendelenburg's position 4-Side-lying with the legs pulled up and the head bent down onto the chest
4-Side-lying with the legs pulled up and the head bent down onto the chest Rationale:A client undergoing lumbar puncture is positioned lying on the side, with the legs pulled up to the abdomen and the head bent down onto the chest. This position helps open the spaces between the vertebrae and allows for easier needle insertion by the primary health care provider. The nurse remains with the client during the procedure to help the client maintain this position. The other options identify incorrect positions for this procedure.
