practice hesi questions
The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug?
"Fill your lungs with air through your mouth and then compress the inhaler." The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration.
Disulfiram is prescribed for a client. Which questions does the nurse make a priority of asking the client before administering this medication? Select all that apply.
- when was your last drink of alcohol? - do you have a history of thyroid problems?
avoid administering medications with antacids and grapefruit juice as it contains an enzyme that inhibits absorption of many meds
...
lithium levels
0.6-1.2 toxicity requires immediate attention with lavage and possible peritoneal dialysis or HD
normal serum creatinine levels
0.6-1.3
normal therapeutic range for theophylline
10-20
A cleansing enema is prescribed for an adult client. The nurse understands that which is the maximal volume of fluid that can be administered?
1000 mL
normal platelet count
150,000-400,000
Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the health care provider's prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)?
3 L/min Because the client with emphysema has long-standing hypercapnia, the respiratory drive is triggered by a low oxygen level rather than by a high carbon dioxide level. Too much oxygen in this client could cause respiratory failure. The client with emphysema usually receives oxygen at a flow rate of 1 to 2 (and no more than 3) L/min.
A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which serum amylase value, noted by the nurse reviewing the results, would be expected in this client at this time?
395 units/L (6.715 μkat/L The normal serum amylase range is 30 to 122 U/L (0.51 to 2.07 μkat/L). In acute pancreatitis, the amylase level is greatly increased; the level starts rising 3 to 6 hours after the onset of pain, peaks at about 24 hours, and returns to normal in 2 to 3 days after the onset of pain.
A nurse is preparing to administer a soap suds enema to an adult client. After explaining the procedure and positioning the client, the nurse begins the procedure. The nurse inserts the rectal tube into the client's rectum a maximal distance of of how many inches?
4 inches (10 cm)
A spouse of a client appears to be in spiritual distress over the anticipated death of the client and is crying "Why is this happening to me?" What is the nurse's most therapeutic response? A. Remain with the spouse and listen empathetically. B. Explain to the spouse the steps of the grieving process. C. Gently ask the spouse why this is happening. D. Redirect the spouse's thoughts to think about of the good times.
ANS: A A client experiencing spiritual distress does not require answers but requires someone who will actively listen and respond with empathy.
A client reports intermittent episodes of erectile dysfunction? Which should the nurse identify as the most likely cause? A. Psychological stress. B. Pelvic fractures. C. Prostatectomy. D. Alcohol consumption.
ANS: A Intermittent episodes of erectile dysfunction are usually the result of functional (psychological) causes. Clients may experience erectile dysfunction following periods of high stress.
The nurse is creating a teaching care plan for a client taking tadalafil (Cialis) 2.5 mg PO once per day. Which information should the nurse include? A. Avoid use with isosorbide. B. Discontinue alcohol use. C. Refrain from sexual intercourse. D. Immediately report feelings of heartburn.
ANS: A Tadalafil (Cialis) is a phosphodiesterase type 5 (PDE5) inhibitor that is used for men with erectile dysfunction. This medication cannot be combined with nitrates, such as isosorbide. This combination may result in severe hypotension and poor organ perfusion.
A pregnant client is diagnosed with gestational diabetes. Which statement should the nurse include when educating the client about her condition? A. "You are at a higher risk for a cesarean delivery." B. "Your baby will be at risk for hyperglycemia shortly after birth." C. "You will continue to have high glucose levels six weeks postpartum." D. "You are not at risk of developing type 2 diabetes."
ANS: A When educating the pregnant client with gestational diabetes, the nurse may inform her that she is at a higher risk for cesarean delivery due to the fact fetuses of gestational diabetes tend to be large for gestational age, therefore may require a cesarean section if not able to delivered vaginally due to their large size.
In an adult client, which pulse should the nurse assess to determine if there is a pulse discrepancy or pulse deficit with the radial pulse? A. Apical. B. Brachial. C. Femoral. D. Popliteal.
ANS: A Pulse deficit should be completed by two nurses at the same time, one counting the radial pulse while the other is counting the apical.
The nurse is assessing a client's peripheral pulses. What data should the nurse include in the documentation? SATA A. Bilateral comparison of peripheral pulses. B. Comparison of the apical pulse to peripheral pulses. C. Rate and intensity of the pulses. D. Description of the rhythm. E. Amount of time it took for the "Allen" test to blanch the extremity.
ANS: A, B, C, D It is important to assess bilateral peripheral pulses simultaneously to be able to make comparisons. The comparison of the apical pulse and peripheral pulses are important to check for the presence or absence of a pulse deficit. It is also important to note the rate and the intensity of the pulses such as weak or pounding, along with the rhythm of the pulses, such as regular or irregular.
Then nurse is working with a client from a dysfunctional family. Which behaviors indicate ineffective coping skills? SATA A. Denies or minimizes existing problems. B. Detaches self from the present problem. C. Is responsive and flexible in chaotic situations. D. Refuses to offer or accept any help or assistance. E. Shows unconditional acceptance of family members.
ANS: A, B, D Indicators of ineffective coping include family members who deny or minimize problems, detach themselves, or refuse to offer any help.
The effects of long-term, unrelieved stress on the human body has been associated with which physiological effects? SATA A. Fatigue. B. Central obesity. C. Bradycardia. D. Amenorrhea. E. Hypotension.
ANS: A, B, D Long term effects of unrelieved stress lead to release of stress hormones and eventually to an allostatic load which causes chronic HTN, depression, sleep deprivation, chronic fatigue syndrome, autoimmune disorders, amenorrhea and delayed ovulation in females. In addition, elevated levels of cortisol increase central fat retention and body weight.
The nurse is teaching a group of daycare workers about healthy food choices for children. The nurse stresses that adequate intake of fruit, vegetables and protein is important in preventing which conditions? SATA. A. Retarded growth. B. Behavioral problems. C. Autoimmune disorders. D. Developmental delays. E. Depression in individuals.
ANS: A, B, D Not providing children with adequate nutrient-rich food such as fruits and vegetables and the appropriate amount of protein can result in nutritional deficiencies causing subsequent growth and developmental delays, depression and behavioral problems
Which approaches should the nurse incorporate when conducting a sexual health teaching session with a client who is recovering from a myocardial infarction? SATA A. Give specific suggestions about resuming sexual relations. B. Obtain permission from the client prior to initiating the discussion. C. Provide recommendations to address presumed sexual issues or concerns. D. Use open ended and straight forward questions to limit embarassment. E. Allow the client to invite the life partner to the session.
ANS: A, B, D, E Keeping the session straight forward and including the partner are two important approaches. Seeking permission to discuss the topic is respectful. Providing direct information is also important. The nurse should not presume to know what the client's concerns are.
A terminally ill client is demonstrating anger by often blaming the spouse for the disease. The spouse asks the nurse how best to deal with this anger. Which are therapeutic responses from the nurse? SATA A. Advise the spouse not to argue with the client, but listen to the concerns. B. Reassure the spouse that displaced anger is common in the grieving process. C. Offer to talk to the client about how to behave when family members visit or call. D. Suggest that family members should not visit until the client has better control of the anger. E. Encourage the spouse to focus on the present time and not to dwell on previous negative behavior.
ANS: A, B, E The nurse should explain to the spouse that the client needs the opportunity to express feelings and anger about being terminally ill. The most effective way to deal with this behavior is not to argue, but listen to the concerns, deal with them in present time and not dwell on previous negative behavior.
Which signs and symptoms are the earliest indicators of shock? SATA. A. Tachycardia. B. Hypotension. C. Restlessness. D. Decreased urine output. E. Weakened peripheral pulses.
ANS: A, C When shock first occurs the heart rate will increase to try to compensate and the client may display neurological changes such as restlessness, agitation and confusion because the brain cells are very sensitive to oxygen deprivation due to the poor tissue perfusion
An adult client has vomiting, diarrhea, dry mucous membranes, skin tenting, and delayed capillary refill. The client's vital signs are: HR 110, sitting BP 104/72 that drops to 84/62 when the client stands up. The client's laboratory results include: BUN 24 mg/dl and urine specific gravity 1.032. Which conditions should the nurse consider in planning care for this client? SATA A. Extracellular fluid volume deficit.. B. Urinary retention. C. Postural hypotension. D. Cardiac output impairment. E. Impaired tissue perfusion.
ANS: A, C E The nursing assessment indicates a fluid deficit. Skin tenting, postural hypotension, hemoconcentration noted in labs, and impaired tissue perfusion all indicate fluid volume deficit.
Which medical conditions are most likely to affect sexual functioning in men or women? A. Depression. B. Peripheral neuropathy. C. Colon cancer. D. Uncontrolled hypertension. E. Macular degeneration.
ANS: A, C, D An estimated 50% of men with diabetes mellitus are affected by sexual dysfunction due to damage to vessels that serve the sex organs and due to autonomic neuropathy. Sexual dysfunction may be experienced by those affected by cardiovascular disease due to circulatory deficiencies and potential side effects of the cardiac medications such as adrenergic inhibitors. Individual's treatment to treat their cancers, may cause sexual dysfunction. Hypothyroidism may affect sexual functioning due to activity intolerance, infertility issues in females, mood swings and depression which may suppress a client's libido.
The nurse is interviewing a middle-aged client. Which factors indicate that the client is in a state of well-being? SATA. A. Positive social relationships. B. Financial wealth. C. Good health with regular exercise. D. Has multiple roles and responsibilities. E. Sense of control over life issues.
ANS: A, C, E Factors that promote Well-being in Midlife are good health and exercise; sense of control and life investment; positive social relationships; a good marriage; and mastery of multiple roles.
The nurse is preparing a client education class at the adult senior center about strokes. Which mnemonic should be used to teach to assess for the warning signs of a stroke? A. RACE. B. FAST. C. STOP. D. ABCD.
ANS: B The mnemonic FAST is used to teach the warning signs of a stroke: Face: ask the person to smile (does one side of the face droop?); Arms: ask the person to raise both arms (does one arm drift downward?); Speech: ask the person to repeat a simple phrase (is their speech slurred or strange?); Time: If any of these signs are present, call 9-1-1 immediately.
The nurse is assessing an older client at a marathon for heat exhaustion whose main complaint is muscle cramps. Which assessment finding indicates that the client needs to be transported to the hospital immediately? A. The client continues to sweat while being cooled. B. The client becomes confused and disoriented. C. The client complains of weakness and nausea. D. The clients lips and mucous membranes are dry.
ANS: B Heat stroke is a medical emergency. Heat stroke commonly occurs during prolonged episodes of elevated temperatures. Heat stroke is usually a complication from another heat related injury such as heat exhaustion and heat cramps. An individual suffering from heat stroke core body temperature elevates greater than 104° F (40° C) which in turn can cause complications to the central nervous system. Older individuals are more prone to heat stroke than younger individuals.
While assessing an older client with a 12-year history of diabetes, the client complains of a decreased sensory perception in both of their feet. Which action should the nurse take first? A. Test sensory perception in the client's extremities. B. Examine the feet for injuries or wounds. C. Educate the client about peripheral neuropathy. D. Document the client's symptom and complaint.
ANS: B Older people with diabetes who have developed diabetic neuropathy and/or impaired peripheral circulation are more likely to develop foot ulcers which can develop into infections resulting for a higher risk of amputations. The first nursing action is to examine the feet for injuries or wounds and pressure points from the client's footwear.
A four day old infant with no family members present is crying while lying in a bassinet in the nursery. What should the nurse do prior to implementing therapeutic touch? A. Assess the cultural beliefs of the infant's parents. B. Verify if the infant is receptive to being touched. C. Don't touch and allow the infant to self-soothe first. D. Dim the light, pick up the infant and rock teh infant slowly.
ANS: B The nurse should be aware or verify that the child is receptive to being touched. This is true regardless of the age of the client. In this example, if this was a drug-exposed infant and going through withdrawals, touching them may overstimulate them and make the withdrawal symptoms worse. A caring touch can be used to soothe and let the client know they are not alone and another human being cares.
The nurse is assessing the effectiveness of cardiac compressions during cardiopulmonary resuscitation (CPR) for an adult client. Which are the accepted sites for assessing pulse? SATA A. Radial. B. Carotid. C. Femoral. D. Posterior tibial. E. Dorsalis pedis.
ANS: B, C During CPR, the carotid or femoral pulse should be assessed to determine the pulse rate and adequacy of cardiac compressions.
Which elements have been shown to be beneficial when incorporated into a stress management plan? SATA A. Retreating from friends. B. Exercise. C. Mindfulness practices. D. Social media. E. Balanced diet.
ANS: B, C, E Sleep is essential to engage in activities of daily living. Exercise has been found to decrease stress levels and cortisol levels and increase sense of well-being. Relaxation reduces psychological or physiological distress. Multitasking facilitated by technology has been identified as a significant source of stress. Well-balanced diet can facilitate stress reduction and improve physical well-being.
The nurse is assessing a client who expresses feeling overwhelmed with the care of an elderly parent. Which question best uncovers the client's perception of this event as a stressor? SATA A. Have you started drinking or smoking as a result of this stressor? B. What impact does this stressor have on your life? C. Are you having trouble getting to sleep or staying asleep? D. What do you believe is causing you stress right now? E. Who else is helping with the caregiving and household chores?
ANS: B, D A change in someone's financial status, other stressors present, and an unanticipated stress are factors that have an affect on individuals regardless of their social cultural background or age or gender.
The health care provider prescribes levodopa/carbidopa (Sinemet) for an older client with Parkinson disease. Which instruction should the nurse teach the client in regards to taking this medication? A. With the largest meal of the day. B. With a high-protein meal. C. 30 to 60 minutes before eating. D. Only when symptoms occur.
ANS: C It is best to take Sinemet (levodopa/carbidopa) 30 to 60 minutes before eating a meal. This allows the medication to be quickly absorbed in the intestines before food can interfere with the absorption process.
A client tells the nurse that the family members living at home include a mother, a father, two children from this union and the elderly paternal grandmother. The nurse should document this family unit using which term? A. Nuclear family. B. blended family. C. Extended family. D. Single-parent family.
ANS: C The extended family includes relatives (aunts, uncles, grandparents, and/or cousins) in addition to the nuclear family.
The nurse is caring for older clients with delirium, dementia, and depression. Which characteristic helps the nurse differentiate clients with delirium from clients with the other conditions? A. Aggressiveness. B. Lethargy. C. Symptom fluctuation. D. Hallucinations.
ANS: C The fluctuating, evolving nature of delirium is the main differentiating feature of delirium from depression and dementia. Delirium is a syndrome of a disturbance in consciousness with reduced ability to focus, sustain, or shift attention that occurs over a short period of time and tends to fluctuate over the course of the day.
A client's laboratory report shows that Treponema pallidum was detected via darkfield microscopy. Which clinical diagnosis does this finding support? A. Gonorrhea. B. Chlamydia. C. Syphilis. D. Genital warts.
ANS: C Treponema pallidum is a bacterium that is detected by darkfield microscopy. This finding confirms a diagnosis of syphilis.
Which steps and attitudes should a nurse incorporate when completing a sexual history? SATA A. Avoid asking matter-of-fact or direct questions. B. Convey a sense of empathy and approval of client's responses. C. Clarify the vocabulary used by the client to describe sexual health. D. Allow time for discussion and exploration of the client's concerns. E. Ensure the client that confidentiality and privacy will be maintained.
ANS: C, D, E When conducting an interview for sexual history of a client, the nurse needs to ask matter-of-fact questions; allow sufficient time for discussion and the exploration of the client's concerns; seek out clarification of the vocabulary used by the client and the nurse; and always maintain confidentiality and privacy.
A nurse has administered a dose of furosemide to a client with diminished urine output. The nurse expects the urine output to increase once the medication has had time to exert an effect on which structure in the kidney?
ANS: Loop of Henle Furosemide works by inducing excretion of sodium, potassium, and chloride in the ascending limb of the loop of Henle. Furosemide does not exert an effect on the areas identified in the other options.
hemoglobin A1c in diabetic patient should be
An acceptable measure of diabetic control is present if the client's glycosylated HbA1C is 7.0% or less
A nurse has a prescription to get the client out of bed and into a chair on the first postoperative day after total knee replacement. Which action should the nurse take to protect the knee?
Applying a knee immobilizer before getting the client up, then elevating the affected leg while the client is sitting
what is arthroscopy
Arthroscopy is used to diagnose acute and chronic conditions of the joint
A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?
Asking the client to swallow as the tube is being advanced
A nurse is assessing a client who has a closed chest tube drainage system. The nurse notes constant bubbling in the water seal chamber. What actions should the nurse take? (Select all that apply). Clamp the chest tube Chang the drainage system Incorrect Assess the system for an external air leak Reduce the degree of suction being applied Document assessment findings, actions taken, and client response
Assess for external air leak Document assessment findings, actions taken, and clients response Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an external air leak if constant bubbling were noted in this chamber. If an external air leak is not present and the air leak is a new occurrence, the health care provider is notified immediately, because an air leak may be present in the pleural space. Leakage and trapping of air in the pleural space can result in a tension pneumothorax. Clamping the chest tube is incorrect. Additionally, a chest tube is not clamped unless this has been specifically prescribed in the agency's policies and procedures. Changing the drainage system will not alleviate the problem. Reducing the degree of suction being applied will not affect the bubbling in the water seal chamber and could be harmful. The nurse would document the assessment findings and interventions taken in the client's medical record.
A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions. Which action should the nurse take first?
Check the degree of suction being applied The return of bloody secretions is an unexpected outcome of suctioning. If it occurs, the nurse should first assess the client and then determine the degree of suction being applied. The degree of suction pressure may need to be decreased. The nurse must also remember to apply intermittent suction and perform catheter rotation during suctioning. Continuing the suctioning or performing vigorous suctioning through the mouth will result in increased trauma and therefore increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. It is therefore unlikely that the client will be able to cough out the bloody secretions.
why cranberry juice for UTI
Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder.
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which effect?
Decrease the client's oxygen-based respiratory drive Normally the respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD, this natural drive becomes ineffective after exposure to a high carbon dioxide level over a prolonged period. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD cannot increase the oxygen level independently because this could halt the respiratory drive, leading to respiratory failure.
STUDY MODE: Fundamentals Question 42 of 75 ID: 3_51 Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
Dorsiflex and plantarflex the feet 10 times each hour. To reduce the risk of venous thrombosis, the nurse should instruct the client in measures that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful to prevent other complications of immobility but are less effective in preventing venous thrombus formation than option C.
client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. For which signs and symptoms does the nurse assess this client?
Dysrhythmias and decreased respiratory rate and depth Rationale: The client with metabolic alkalosis is likely to exhibit dysrhythmias and a decreased respiratory rate and depth as a compensatory mechanism. The client with metabolic acidosis would exhibit the symptoms such as drowsiness, headache, and tachypnea. The client with respiratory acidosis or alkalosis would exhibit the disorientation and dyspnea or tachypnea, dizziness, and paresthesias, respectively.
A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the nurse why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The nurse responds that the primary purpose of the water is to promote which goal?
Humidify the oxygen that is bypassing the client's nose
A client with a thoracic spinal cord injury is receiving dantrolene sodium. Which statement by the client indicates to the nurse that the client is experiencing an adverse effect of the medication?
I'm feeling really drowsy
A nurse provides instructions to a client about preventing injury while using crutches. The nurse tells the client to avoid resting the underside of the arm on the crutch pad, mainly because it could result in which problem?
Injury to the nerves
A nurse is getting a client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first?
Lower the head of the bed slowly until the dizziness is relieved Dizziness or a feeling of faintness is not uncommon when a client is positioned upright for the first time after surgery. If this occurs, the nurse lowers the head of the bed slowly until the dizziness is relieved. The nurse then checks the client's pulse and blood pressure. Because the problem is circulatory, not respiratory, checking the oxygen saturation level and having the client take some deep breaths are not the first actions to be taken.
A nurse is evaluating the client's use of a cane for left-sided weakness. The nurse determines that the client needs further teaching if the client is observed doing what?
Moves the cane when the right leg is moved
A client recovering from surgery has a large abdominal wound. Which food, high in vitamin C, should the nurse encourage the client to eat as a means of promoting wound healing?
Oranges Citrus fruits and juices are especially high in vitamin C. Other sources are potatoes, tomatoes, and other fruits and vegetables. Meats and dairy products are not especially high in vitamin C. Meats are high in protein. Dairy products are high in calcium.
A nurse is repositioning a client who has returned to the nursing unit after internal fixation of a fractured right hip. The nurse should use which for repositioning?
Pillow to keep the right leg abducted while turning the client
Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.)
Place the client in a side-lying position. Pull the auricle upward and outward. the correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).
A nurse is instructing a client about the foods that will acidify the urine and inhibit the growth of microorganisms. Which foods does the nurse tell the client are most likely to acidify the urine? Select all that apply. Plums Prunes Apples Broccoli Cabbage Cranberries
Plums, Prunes, Cranberries
A nurse checks the residual volume from a client's nasogastric tube feeding before administering an intermittent tube feeding and finds 35 mL of gastric contents. What should the nurse do before administering the prescribed 100 mL of formula to the client?
Pour the residual volume into the nasogastric tube through a syringe with the plunger removed After checking the residual feeding contents, the nurse reinstills the gastric contents into the stomach by removing the syringe bulb or plunger and pouring the gastric contents, with the use of the syringe, into the nasogastric tube. Removal of the contents could disturb the client's electrolyte balance. The other options are incorrect.
A nurse administers an oil retention enema to a client. Afterward, the nurse should provide which instruction to the client?
Retain the enema for several hours
Which client is most likely to be at risk for spiritual distress?
Roman Catholic woman considering an abortion In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement.
A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis does the nurse assess this client?
Tachypnea, dizziness, and paresthesias The client who is anxious is at risk for respiratory alkalosis as a result of hyperventilation. The client is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities. The client with respiratory acidosis would exhibit disorientation and dyspnea. The client with metabolic acidosis or alkalosis would exhibit symptoms such as drowsiness, headache, and tachypnea and dysrhythmias and decreased respiratory rate and depth, respectively.
terbutaline
Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.
A woman has been scheduled for a routine mammogram. The nurse should provide the client with which information about the test?
That deodorants, powders, or creams used in the axillary or breast area must be washed off before the test
A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply.
That informed consent is required That food and fluids will be withheld before the procedure That multiple position changes may be necessary to pass the tube
A nurse is reading the chest x-ray report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The nurse interprets that the tube is positioned above which anatomical area?
The bifurcation of the right and left main stem bronchi The carina is a cartilaginous ridge that separates the openings of the two main stem (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main stem bronchus as a result of the natural curvature of the airway. This is hazardous because only the right lung will be ventilated. It is easily detected, however, because only the right lung will have breath sounds and rise and fall with ventilation. The other options are incorrect.
A nurse is assessing the chest tube drainage system of a postoperative client who has undergone a right upper lobectomy. The closed drainage system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after the initial assessment, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first?
The chest tube connections The client's dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires health care provider intervention. Although the interventions identified in the other options should also be taken in this situation, they should be performed only after the nurse has tried to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client's symptoms should resolve.
A nurse has taught a client how to ambulate with the use of a cane. The nurse determines that the client needs additional instruction if which is observed?
The client moves the cane and the unaffected side together
normal CD4 count
The normal CD4+ count is between 500 to 1,500 cells per cubic millimeter of blood.Antiretroviral therapy is recommended when the CD4+ count is less than 500 cells per cubic millimeter of bloodor below 25%, or when the client shows symptoms of HIV.
uric acid normal range
The normal range for uric acid is 4.4 to 7.6 mg/dL (262 to 452 μmol/L)for males and 2.3 to 6.6 mg/dL (137 to 393 μmol/L)for females
antidote for acetaminophen
acetylcysteine (mucomyst)
A client with schizophrenia has been taking an antipsychotic medication for 2 months. For which adverse effect should the nurse monitor the client closely?
akathisia
The nurse is performing a respiratory assessment and is auscultating the client's breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds?
ans: pleural friction rub A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating. The sounds are localized over an area of inflammation on the pleura and may be heard in both the inspiratory and the expiratory phases of the respiratory cycle. Wheezes are musical noises heard on inspiration, expiration, or both and are the result of narrowed airway passages. Rhonchi are usually heard on expiration when there is an excessive production of mucus that accumulates in the air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together and indicate fluid in the alveoli.
sucralfate
anti ulcer antiulcer medication that promotes ulcer healing by creating a protective barrier against acid and pepsin. It should be taken on an empty stomach
scopolamine
anticholinergic causes dry mouth, urine retention, decreased sweating, pupil dilation
risperidone
antipsychotic get up slowly when changing positions
Olanzapine
antipsychotic used with schizophrenia
cholinergic crisis medication
atropine sulfate
A client who has undergone renal biopsy complains of pain, radiating to the front of the abdomen, at the biopsy site. For which finding should the nurse assess the client?
bleeding bleeding should be suspected if pain originates at the biopsy site and begins to radiate to the flank area and around to the front of the abdomen. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria are also indicators of bleeding. Signs of infection would not appear immediately after a biopsy. There is no information in the question to indicate the presence of renal colic.
Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet
broiled fish, green beans, apple
aspirin toxicity
causes tinnitus
a client with HF is given furosemide and digoxin. client calls the nurse complaining of anorexia and nausea. which action should the nurse take first?
check potassium from labs that were taken 3 hours ago
A client is receiving total parenteral nutrition (TPN) with fat emulsion (lipids) piggybacked to the TPN solution. For which signs of an adverse reaction to the fat emulsion should the nurse monitor the client? Select all that apply.
chills, headache, chest and back pain, n/v
A nurse is administering an enema to a client. While the enema solution is being instilled, the client complains of abdominal cramping. Which action should the nurse take?
clamp the enema bag tubing
A client arrives at the emergency department after sustaining an ankle injury, and the health care provider (HCP) prescribes the application of a cold compress to the ankle. The nurse, preparing to apply the compress, assesses the ankle and notes that it is extremely edematous. The nurse should take which action?
consult with HCP before applying cold compress Cold is usually contraindicated if the site of injury is extremely edematous because it further retards circulation to the area and prevents absorption of the interstitial fluid. For this reason, applying the cold compress to the ankle and elevating the ankle and placing a cold compress under and on top of the ankle are both incorrect. The nurse would not place heat on an injury without a prescription to do so. The nurse would consult with the HCP about the prescription for cold application.
A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client's activated partial thromboplastin time (aPTT) level is 88 seconds (88 seconds). The client's baseline before the initiation of therapy was 30 seconds (30 seconds). Which action does the nurse anticipate is needed?
decreasing the rate of the heparin infusion The normal aPTT varies between 25 and 35 seconds (25 and 35 seconds), depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is designed to keep the aPTT between 1.5 and 2.5 times normal. Therefore the client's aPTT is somewhat increased but does not indicate a critical value. The infusion rate should be slowed and the aPTT rechecked as prescribed. A persistently increased aPTT indicates a risk for bleeding.
A nurse is assessing a client who is being hospitalized with a diagnosis of pneumonia. The client's husband tells the nurse that the client is taking donepezil hydrochloride. The nurse should ask the husband about the client's history of which disorder?
dementia
A client with a history of lung disease is at risk for respiratory acidosis. For which signs and symptoms does the nurse assess this client?
disorientation and dyspnea The client with respiratory acidosis would exhibit the symptoms identified in the correct option. The client will experience dyspnea and may be disoriented as a result of hypoxia and retention of carbon dioxide. Metabolic acidosis and alkalosis are marked by drowsiness, headache, and tachypnea and dysrhythmias and decreased respiratory rate and depth, respectively. The client with respiratory alkalosis is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities.
autologus donation
donation of clients own blood before procedure reduces risk of disease or transmission from transfusion
universal blood types
donor: O neg recipient: AB positive
Apelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving preprocedure instructions tell the client that it important to do before the procedure?
drink 6 to 8 glasses of water without voiding Pelvic ultrasound requires the ingestion of a large volume of water just before the procedure. A full bladder helps ensure that the bladder is easily visualized and not mistaken for a pelvic growth. A client undergoing abdominal (not pelvic) ultrasound may have to refrain from eating or drinking for several hours before the procedure.
A nurse develops a plan of care for a postoperative client who is receiving intravenous morphine sulfate every 4 hours as needed for pain. Which priority intervention does the nurse include in the plan?
encouraging coughing and deep breathing
meds that cannot be crushed
enteric-coated tablets and sustained release capsules CANNOT be crushed
Carbamazepine is prescribed for a client with trigeminal neuralgia. Which side/adverse effects does the nurse instruct the client to report to the health care provider? Select all that apply.
fever, sore throat, mouth sores
A client has just undergone lumbar puncture. Into which position does the nurse assist the client after the procedure?
flat
Polyethylene glycol-electrolyte solution
golytely
A nurse answers a call bell and finds that the total parenteral nutrition (TPN) solution bag of an assigned client is empty. The new prescription was written for a new bag at the beginning of the shift, but it has not yet arrived from the pharmacy. Which action should the nurse take first?
hang a solution of 10% dextrose in water
isotonic solutions
have same osmolarity as that of normal body fluids (NS is an example)
labs to test for effectiveness of folic acid supplements
hemoglobin and hematocrit
A nurse is preparing a plan of care for a client who will be receiving meperidine hydrochloride. Which side/adverse effects does the nurse make a note of needing to be alert to in the plan of care? Select all that apply.
hypotension, constipation, urine retention, respiratory depression
A client has been given a diagnosis of multiple myeloma. Which result does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis?
increased calcium level Multiple myeloma is characterized by hypercalcemia, anemia, increased BUN, and an increased number of plasma cells in the bone marrow. Hypercalcemia is a result of the release of calcium from deteriorating bone tissue. An increased WBC count may or may not be present and is not specifically related to this disease.
A nurse is caring for a client who has been taking acetazolamide for glaucoma. Which, if documented in the assessment data, indicates to the nurse that the client may be experiencing an adverse effect of the medication?
jaundice
A nurse developing a plan of care for a client with a spinal cord injury includes measures to prevent autonomic dysreflexia (hyperreflexia). Which of the following interventions does the nurse incorporate into the plan to prevent this complication?
keep linens wrinkle free under patient
A nurse suspects that a client receiving total parenteral nutrition (TPN) through a central line has an air embolism. The nurse immediately places the client in which position?
left side with head lower than feet
digoxin levels and s/s of toxicity
levels: 0.5-2.0 but better to keep on the low side s/s of toxicity: anorexia, visual disturbances, diarrhea, low serum potassium
A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client?
metabolic acidosis Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. In conditions such as diarrhea, these fluids may be lost from the body before they can be reabsorbed. The decreased bicarbonate level produces the actual base deficit of metabolic acidosis.
taking a lot of antacids can lead to
metabolic alkalosis
A nurse is caring for a client with histoplasmosis who is receiving intravenous amphotericin B . What should the nurse do while the medication is being administered?
monitor clients urine output
A nurse is reading the medical record of a client receiving haloperidol. The nurse notes that the health care provider has documented that the client is experiencing signs of akathisia. On the basis of the health care provider's note, which clinical manifestation would the nurse expect to find during assessment of the client?
motor restlessness
baclofen for muscle spasms, s/e include
nasal congestion
when giving meds to a baby
never put medications in the baby's bottle
A nurse is reading the radiology report of a client with a chest tube attached to a closed drainage system who has undergone a chest x-ray. The report states that the client's affected lung is fully reexpanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding?
no fluctuation in the water seal chamber When the client's lung is fully reexpanded, the drainage system will no longer drain and fluctuation in the water seal chamber will be absent. This is because the lung has reexpanded and the pleural space is again a potential space. Continuous bubbling in the water seal chamber indicates an air leak in the system. Continuous gentle suction in the suction control chamber means that suction is being applied to the system.
normal BUN levels
normal BUN ranges from 6 to 20 mg/dL
normal cholesterol level
normal cholesterol value ranges between 140 and 199 mg/dL <200
UA normal ranges
normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from 1.016 to 1.022
serum amylase levels
normal serum amylase range is 30 to 122 U/L
erythromycin should be taken
on an empty stomach
for rectal suppository meds
place patient in Sims position, afterwards instruct patient to lay supine for 5-10 minutes
Propylthiouracil
prescribed for the treatment of hyperthyroidism. Excessive dosing with this agent may convert a hyperthyroid state to a hypothyroid state
when giving eardrops
pull back the pinna: In an adult client or older child, pull the pinna up and back; in an infant or child younger than 3 years, pull the pinna down and back
when giving regular insulin and NPH
remember RN: draw up REGULAR insulin first then NPH insulin
A client is scheduled for a barium swallow (esophagography) in 2 days. The nurse, providing preprocedure instructions, should tell the client to implement which measure?
remove all metal and jewelry before the test
remember your 6 rights for administering medications
right medication, right dose, right route, right time, right patient, right documentation
adverse effect of dantrolene sodium
severe drowsiness
A nurse is preparing a client for the insertion of a central intravenous line into the subclavian vein by the health care provider. The nurse gathers the equipment, places it at the bedside, and prepares to assist the health care provider with the procedure. As further preparation for the procedure, the nurse places the client in which position?
slight trendelenburg
s/s of magnesium toxicity
sudden decrease in fetal HR
A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?
taping the connection between the chest tube and drainage system The nurse tapes all system connections to prevent accidental disconnection. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. Assessment for crepitus is performed once every 8 hours or more often if needed. Sterile water is only added to the suction control chamber as needed to replace evaporative loss.
adverse effect of prednisone
tarry stools
A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test?
the test will need to be confirmed with a western blot test
A client has a chest drainage system in place. The fluid in the water seal chamber rises and falls during inspiration and expiration. The nurse interprets this finding as an indication of which?
the tube is patent
phenytoin (dilantin)
therapeutic serum phenytoin range is 10 to 20 mcg/mL anticonvulsant
explain to client the need to wear medic alert bracelet if
they're on anticoagulants, oral hypoglycemics or insulin, certain cardiac meds, corticosteroids, glucocorticoids, antimyasthenic meds, anticonvulsants, monoamine oxidase inhibitors
A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the health care provider? Select all that apply.
unequal chest expansion diminished breath sounds in right lung
A health care provider is about to perform paracentesis on a client with abdominal ascites. Into which position would the nurse assist the client?
upright
reason for immediate discontinuation of oxytocin?
uterine hyperstimulation
Intravenous tobramycin sulfate is prescribed for a client with a respiratory tract infection. For which of the following symptoms, indicative of an adverse effect, does the nurse monitor the client?
vertigo
ondansetron
zofran for n/v
