study hesi exam 2

An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer?

(ANS- 0.4

The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.) 1. Open the sterile catheter kit close to the client's perineum 2. Don sterile gloves and prepare to sterile field 3. Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

(ANS- 1. Open the sterile catheter kit close to the client's perineum2. Don sterile gloves and prepare to sterile field3. Cleanse the urinary meatus using the solution, swabs, and forceps provided 4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus

After administering a 12 ounce can of nutritional supplement, 3 teaspoons of medication, and 120 mL of water, the nurse should document the client's fluid intake as how many mL?

(ANS- 495

During the admissions assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI)

(ANS- 4th intercostal left side

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply) A. perform daily surgical dressing change for a client who had an abdominal hysterectomy b. Obtain postoperative vital signs for a client one day following following unilateral knee arthroplasty c. initiate patient- controlled analgesia (PCA) pumps for two clients immediately postoperatively d. administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)

(ANS- A. perform daily surgical dressing change for a client who had an abdominal hysterectomyb. Obtain postoperative vital signs for a client one day following following unilateral knee arthroplastyd. administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM)

The healthcare provider prescribed furosemide for a 4- year- old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? A. Urinary output decrease of 5 ml/hour B. Urine specific gravity change from 1.021 to 1.031 C. Daily weight decreases of 2 pounds (0.9 kg) D. Blood urea nitrogen (BUN) increase from 8 to 12 mg/dL (2.9 to 4.3 mmol/L)

(ANS- C. Daily weight decreases of 2 pounds (0.9 kg)

A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine sulfate 4 mg IV. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care? A. assess for back muscle aches B. obtain body weight daily C. Monitor urinary output hourly D. Record drainage from drain.

(ANS- C. Monitor urinary output hourly

When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention b the nurse. A. Headache B. Pruritis C. Stridor D. Nausea

(ANS- C. Stridor

When attempting to establish risk reduction strategies in a community, the nurse note that regional studies indicates a high number of persons with growth stunting and irreversible mental deficiencies caused by hypothyroidism (cretinism). The nurse should seek funding to implement which screening measure? A. TSH levels in women over 45 B. T3 levels in school- aged children C. T4 levels in newborn d. Iodine levels in all persons over 60

(ANS- C. T4 levels in newborn

The nurse assesses a client with new onset diarrhea. It is important for the nurse to question the client about recent use of which type of medication? a. Antibiotics b. anticoagulants c. antihypertensive d. anticholinergic

(ANS- a. Antibiotics

A female client with chronic kidney disease and renal failure has an indwelling peritoneal catheter in used for peritoneal dialysis. While bathing, her abdominal dressing becomes wet. What action should the nurse take? a. Change the dressing b. reinforce the dressing c. flush the peritoneal dialysis catheter d. scrub the catheter with povidone- iodine

(ANS- a. Change the dressing

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse? a. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete. b. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion c. Monitor the client carefully for the next three hours and report the onset of a reaction immediately d. Notify the nurse when the transfusion has finished, so further client assessment can be done

(ANS- a. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete.

During a postpartum assessment of a client who is 5 hours post vaginal delivery, the nurse determines the fundus is 3 finger breadths above the umbilicus and positioned to the client's side. Which action should the nurse implement first? a. Encourage the client to void b. massage the fundus until firm c. catheterize for residual urinary volume d. Provide additional oral replacement fluids

(ANS- a. Encourage the client to void

Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the near intensive care unit with a temperature of 102.8 F (39.3 C) axillary, pulse of 180 beats/ minute, and a blood pressure of 90/60. What is the priority intervention to include in the client's plan care? a. Maintain intravenous access b. keep the suture line clean and dry c. measure hourly urine output d. check near vital signs q4 hours

(ANS- a. Maintain intravenous access

The nurse identifies an electrolyte imbalance, an elevated pulse rate, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with chronic kidney disease. What intervention should the nurse include in the plan of care? a. Monitor serum electrolytes daily b. Provide only distilled water c. Document abdominal girth d. Perform range of motion exercises

(ANS- a. Monitor serum electrolytes daily

A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. Which dietary instruction is most important for the nurse to explain to the client? a. Plan volume- controlled evenly- space meal through the day b. Sip fluid slowly with each meal and between meals c. Eliminate or reduce intake fatty and gas forming food d. Chew food slowly and thoroughly before attempting to swallow

(ANS- a. Plan volume- controlled evenly- space meal through the day

The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? a. Position a firm wedge to support pelvis and thorax at 30 degree tilt b. apply oxygen by mask after opening the airway c. apply less compression force to reduce aspiration d. Give continuous compression with a ventilation ration at 20:3

(ANS- a. Position a firm wedge to support pelvis and thorax at 30 degree tilt

The nurse enters the room of a client who is awaiting surgery for appendicitis. The unlicensed assistive personnel (UAP) has a helped the client to a position ofcomfort with the right leg flexed and has applied a heating pad to the client's abdomen to relieve the client's pain. Which action should the nurse implement first? a. Remove the heating pad from the client's abdominal area b. Determine if the consent form has been signed by the client c. Evaluate the effectiveness of the heating pad in relieving pain d. Confirm that UAP has assisted the client to a position of comfort

(ANS- a. Remove the heating pad from the client's abdominal area

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

(ANS- a. Topical corticosteroid e. Oral antihistamine

A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin for a methicillin- resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? SATA a. collect multiple site screening culture for MRSA b. call hcp for a prescription for linezolid (Zyrovix) c. place the client on contact transmission precautions d. obtain sputum specimen for culture and sensitivitye. continue to monitor for client sign of infection

(ANS- a. collect multiple site screening culture for MRSAc. place the client on contact transmission precautionse. continue to monitor for client sign of infection

A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first? a. determine serum potassium level b. calculate the client's daily fluid intake c. assess client for signs of vertigo d. review the client's pulse oximetry reading

(ANS- a. determine serum potassium level

A 16 years old male client who has been treated in the past for a seizure disorder is admitted to the hospital immediately after admission he begins to have a grand mal seizure. Which action should the nurse implement? a. observe the client carefully b. place a padded tongue blade between client's teeth c. obtain assistance in holding him to prevent injury d. call the rapid respond team

(ANS- a. observe the client carefully

A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond? a. offer to provide the influenza vaccination to the student while she is at the clinic b. encourage the student to obtain a vaccination prior to the next influenza season c. confirm that a history of asthma can increase risks associated with the vaccine d. advise the student that the nasal spray vaccine reduce side effects for people with asthma

(ANS- a. offer to provide the influenza vaccination to the student while she is at the clinic

The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize? a. protect joint function b. improve circulation c. control tremors d. increase weight bearing

(ANS- a. protect joint function

An older client with a history of pernicious anemia has developed ataxia and paresthesia. In planning care, which nursing intervention has the highest priority? a. provide assistance with ambulation b. keep the head of the bed elevated c. offer a PRN sleep aid at night d. instruct about healthy diet choices.

(ANS- a. provide assistance with ambulation

The charge nurse is marking assignments on a psychiatric unit for a practical nurse (PN) and a newly licensed registered nurse (RN). Which client should be assigned to the RN? a. An older male who tells the staff and other clients that he is superman and can fly b. A young male with schizophrenia who says voices are telling him to kill his psychiatrist. c. A middle- aged client who is in the depressive phase of bipolar disease and is receiving lithium d. An adult client who has been depressed for the past several months and denies suicidal ideation

(ANS- b. A young male with schizophrenia who says voices are telling him to kill his psychiatrist.

An older adult resident of a long- term care facility has a 5- year- history of hypertension. The client has a headache and rates the pain 5 on a pain scale of 0 to 10. The client's blood pressure is currently 142/89. Which intervention should the nurse implement? (Select all that apply) a. Notify the healthcare provider immediately b. Administer a daily dose of lisinopril as scheduled c. withhold the next scheduled daily dose of warfarin d. provide a PRN dose of acetaminophen for headachee. Assess the client for postural hypertension

(ANS- b. Administer a daily dose of lisinopril as scheduledd. provide a PRN dose of acetaminophen for headache

While assisting a client who recently had a hip replacement onto the bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to touch, and there is a strong odor from the urine. Which action should the nurse take? a. Remove the dressing and assess surgical b. Measure the client's temperature c. Insert an indwelling urinary catheter d. Obtain a urine sample from the bed pan.

(ANS- b. Measure the client's temperature

A mother brings her 4- month- old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanations should the nurse provide? a. An abdominal binder can be worn daily to reduce the protrusion b. This hernia is a normal variation that resolves without treatment c. The quarter should be secured with an elastic bandage wrap d. Restrictive clothing will be adequate to help the hernia go away

(ANS- b. This hernia is a normal variation that resolves without treatment

On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain? a. Which family member has the client's suicide note b. What drugs the client used for the suicide attempt c. when the client last took drugs for bipolar disorder d. Whether the client ever attempted suicide in the past

(ANS- b. What drugs the client used for the suicide attempt

The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. Which information about the most commonly prescribed medication, mebendazole, should be taken? a. insert the medication as rectal suppository b. a second dose of medication should be given in two weeks c. it is safe for children of all ages to take this medication. d. Only children with perianal itching should take this medication.

(ANS- b. a second dose of medication should be given in two weeksIf the child is given a single dose of mebendazole, rather than twice a day for 3 days, the child may need another single dose two weeks later, to prevent re- infection.

While receiving a male postoperative client's staples the nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed." After acknowledgement the client's anxiety, what action should the nurse implement? a. Reassure the client that this is a simple nursing procedure b. attempt to distract the client with general conversation c. encourage the client to continue verbalize his anxiety d. explain the procedure in detail while removing the staples

(ANS- b. attempt to distract the client with general conversation

The nurse is measuring the output of an infant admitted for vomiting and diarrhea. During a 12- hour shift, the infant drinks 4 ounces of Pedialyte, vomits 25 mL, and voids twice. The dry diaper weight is 50 grams, and one wet diaper weight 75 grams, and the other weights 105 grams. Which computer documentation should the nurse enter in the infant's record? a. Document in the flow sheet that the infant voided times 2 and vomited 25 ml b. calculate differences in wet and dry diapers and document 80 ml urine output c. compare the difference between the infant's body weight and admission weight d. subtract vomits from 120 ml Pedialyte than document 95 ml oral intake

(ANS- b. calculate differences in wet and dry diapers and document 80 ml urine output

In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? a. lactate b. glucose c. hemoglobin d. creatinine

(ANS- b. glucose

A client with diabetic peripheral tells the nurse that her healthy "chubby" baby is irritable and not very active. After obtaining a dietary history, the nurse determines that the infant refuses to eat any infant cereals. Which finding is most important to report to the healthcare provider? a. Breast feeds 10 minutes at night to go to sleep b. has porcelain- like skin and tripled birth weight c. does not take an infant vitamin supplement d. ingests 6 ten- ounce bottles of cow's milk daily

(ANS- b. has porcelain- like skin and tripled birth weight

A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include sodium 129 mEQ/l, glucose 54 mg/dl, and potassium 5.3 mmol. When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? a. regular insulin b. hydrocortisone c. broad spectrum antibiotic d. potassium chloride

(ANS- b. hydrocortisone

When implementing a disaster intervention plan, which intervention should the nurse implement first? a. initiate the discharge of stable clients from hospital units b. identify a command center where activities are coordinated c. assess community safety needs impacted by the disaster d. instruct all essential off- duty personnel to report to the facility

(ANS- b. identify a command center where activities are coordinated

An adult male is brought to the emergency department by ambulance following a motorcycle accident. He was not wearing a helmet and presents with periorbital bruising and bloody drainage from both ears. Which assessment finding warrants immediate intervention by the nurse? a. rebound abdominal tenderness b. nausea and projectile vomit c. rib pain with deep inspiration d. diminished bilateral breath sounds

(ANS- b. nausea and projectile vomit. Rationale: projectile vomit is indicative of increasing intracranial pressure which can lead to ischemic brain damage or death

The nurse observes an unlicensed assistive personnel (UAP) begin to provide oral care to an unresponsive client who is at risk for aspiration as seen in the picture. What instruction should the nurse provide the UAP? SATA A. flex the client neck forward b. turn the clients head to the side c. remove the gloved finger from the mouth d. elevate the head of the bed to semi fowlerse. apply lubricant to the toothed

(ANS- b. turn the clients head to the side c. remove the gloved finger from the mouthd. elevate the head of the bed to semi fowlers

What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? a. avoid using heat or ice to injured muscles while taking this medication .b. use cold and allergy medications only as directed by a healthcare provider c. take the medication on an empty stomach d. discontinue all non- steroidal anti- inflammatory medications.

(ANS- b. use cold and allergy medications only as directed by a healthcare provider

A client with a traumatic brain injury becomes progressively less responsive to stimuli. The client has a "Do Not Resuscitate" prescription, and the nurse observes that the unlicensed assistive personnel (UAP) has stopped turning the client from side to side as previously scheduled. What action should the nurse take? a. Encourage the UAP to provide comfort care measures only b. assume total care of the client to monitor neuralgic function c. Advise the UAP to resume positioning the client on schedule d. Assign a practical nurse to assist the UAP in turning the client

(ANS- c. Advise the UAP to resume positioning the client on schedule

A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take? a. Notify the family that treatments have been discontinued b. arrange a meeting with family, physician, and client c. Ask the chaplain to discuss death issues with the client d. request a consultation with the hospital social worker

(ANS- c. Ask the chaplain to discuss death issues with the client

The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who is frequent urinary incontinence while the client is positioned on a bedpan. What action should the nurse take? a. recommend a complete bath to cleanse the perineal area more fully b. instruct the PN that this technique promotes infection in elderly females c. Evaluate the effectiveness of this measure to stimulate client voiding d. suggest contacting the healthcare provider for a prescription for catheter insertion

(ANS- c. Evaluate the effectiveness of this measure to stimulate client voiding

A male client approaches the nurse with an angry expression on his face and raises his voices, saying, "My roommate is the most selfish, self- centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out" The nurse recognizes that the client is using which defense mechanism? a. Denial b. Splitting c. Projection d. Rationalization

(ANS- c. Projection

The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome shows a plan of care for this client? a. The client will express acceptance of his changing health status b. The client's family will state signs and symptoms about the disease c. The nurse will demonstrate the procedure for accurate eye care d. The client's daily blood pressure will be less than 140/80 mmHg this month

(ANS- c. The nurse will demonstrate the procedure for accurate eye care

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

(ANS- c. brain damage with CP is not progressive but does have a variable course

A client is admitted reporting an acute onset of right flank pain and urinary urgency. Which assessment is most important for the nurse to obtain? a. Numerical rated pain intensity b. amount of daily caffeine intake c. Current body temperature d. Fluid intake for the past 24 hours

(ANS- c. current body temperature

During the administration of albuterol per nebulizer, the client complains of shakiness. The client's vital signs are heart rate 120 bpm, respirations 20, blood pressure 140/88. What action should the nurse take? a. Administer an anxiolytic b. obtain 12 lead electrocardiogram c. educate client about the side effects of albuterol d. stop the albuterol administration and restart in 30 minutes

(ANS- c. educate client about the side effects of albuterol

A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately? a. stomal output of 40 mL in last hour b. liquid brown drainage c. red edematous stomal appearance d. Mucous strings floating in the drainage

(ANS- c. red edematous stomal appearance

The nurse auscultates a client's abdomen and hears a loud bruit near the umbilicus. What is the nurse's best action based on this assessment finding? a. document the assessment finding in the medical record b. palpate the abdomen lightly in all four quadrants c. report the finding to the health care provider d. place the client in a semi- fowler's position

(ANS- c. report the finding to the health care provider

A bruit heard over the aorta usually indicates the presence of an aneurysm. The nurse should not percuss or palpate the abdomen and should immediately notify the health care provider of the findings. The nurse is caring for a 3 year old child who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction? a. blood pressure trend is downward, and pulse is rapid and irregular b. the pressure dressing at right femoral area is moist and oozing blood c. right foot is cool to the touch and appears pale and blanched d. pulse distal to the femoral artery is weaker on left foot than right foot.

(ANS- c. right foot is cool to the touch and appears pale and blanched

A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the client is admitted to the telemetry unit, which interventions is most important for the nurse to implement? a. offer additional blankets and a warm drink b. assess for presence of non-pitting edema c. note the client's most recent hemoglobin level d. Administer prescribed dose of levothyroxine

(ANS- d. Administer prescribed dose of levothyroxine

When administering brompheniramine maleate, an extended release antihistamine tablet, the nurse is told by the male client that he cannot swallow tablets. Which intervention should the nurse implement? a. Document the client's refusal to take medication b. Crush tablet and mix with small amount of pudding c. document that the client cannot take the prescription d. Ask the pharmacist to send it in liquid form

(ANS- d. Ask the pharmacist to send it in liquid form

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

(ANS- d. Consumes 3 meals and 1500 mL of fluid per day

An older female client living in a low income apartment complex tells the home health nurse that she is concerned about her 81- year-old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive, but is occasionally seen walking outside wearing only a robe and slippers. What response should the nurse offer? A. provide the number for Adult Protective Services so the client can report any suspicion of elder abuse b. encourage the client to avoid becoming involved in the neighbor's problems, for one's own protection c. tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities. d. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors

(ANS- d. Explain that it is not unusual for older adults to suffer from dementia, which often causes such behaviors

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client? a. Lists 5 calcium- rich foods to be added to her daily diet b. identifies 2 treatments for constipation due to immobility c. State 4 risk factors for the development of osteoporosis d. Names 3 home safety hazards to be resolve immediately

(ANS- d. Names 3 home safety hazards to be resolve immediately

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

(ANS- d. a client taking corticosteroids who has become disoriented in the last two hoursRationale: meeting the client's need for safety is a priority intervention. Mania and psychosis can occur during corticosteroids therapy, places the client at risk for injury, so the patient taking corticosteroids should be seen first

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? a. Give the wife a straw to help facilitate the client's drinking b. assist the wife and carefully give the client small sips of water c. obtain a thickening powder before providing any more fluids d. ask the wife to stop and assess the client's swallow reflex

(ANS- d. ask the wife to stop and assess the client's swallow reflex

A client with chronic kidney disease has an arteriovenous fistula (AV) in the left forearm. Which observation by the nurse indicates that the fistula is patent? a. distended, tortuous veins in the left hand b. The left radial pulse is +2 bounding c. Auscultation of a thrill on the left forearm d. assessment of a bruit on the left forearm

(ANS- d. assessment of a bruit on the left forearm

A 15 year old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? a. recommend he avoid fast food restaurants until he is familiar with his prescribed diet b. advise him to take his own food with him when going to fast food restaurants with his friends. c. encourage him to find activities to do with his friends that do not involve eating d. assist him in identifying popular fast foods that are within his meal plan for diabetes

(ANS- d. assist him in identifying popular fast foods that are within his meal plan for diabetes

The nurse is preparing a discharge plan for a client who had a liver transplant. Which instruction is most important to include in this plan? a. limit intake fatty foods for one month after surgery b. notify hcp if edema occurs c. increase activity and exercise gradually, as tolerated d. avoid crowds for first two months after surgery

(ANS- d. avoid crowds for first two months after surgery

A 6 year old child who had surgery yesterday absolutely refuses to use the incentive spirometer. Which intervention should the nurse implement? a. ask the mother to assist when it is time to use the spirometer b. allow the child to choose when to perform incentive spirometry c. contract with the child to use spirometer only after meals d. blow out lights, blow bubbles, and encourage child's laughing.

(ANS- d. blow out lights, blow bubbles, and encourage child's laughing.

The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first? a. Continue to monitor intake and output with next exchange. b. check the client's blood pressure and serum bicarbonate c. irrigate the dialysis catheter d. change the client's position

(ANS- d. change the client's position

A female client is admitted for diabetic crisis resulting from inadequate dietary practice. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet? a. knows that insulin must be given 30 min before eating b. frequently eats fruits and vegetables at meals and between meals. c. has someone available who can prepare and oversee the dietd. demonstrates willingness to adhere to the diet consistently

(ANS- d. demonstrates willingness to adhere to the diet consistently

A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? a. Remove electrodes and observe for skin redness .b. decrease the strength of the electrical signals c. check the amount of gel coating on the electrodes d. determine if the sensation feels uncomfortable

(ANS- d. determine if the sensation feels uncomfortable

A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement? a. allow client to choose foods from a menu b. assign a staff member to feed the client c. have meals brought to the client's room d. encourage the client to eat finger foods

(ANS- d. encourage the client to eat finger foods

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values? a. serum potassium and sodium levels b. C- reactive protein level c. platelet count d. neutrophil count

(ANS- d. neutrophil count

The nurse is planning discharge teaching for a client who has an evacuation of gestational trophoblastic disease (GTD) two days age. Which information is most important for the nurse to include in this client's teaching plan? a. Location and times for a local support group b. Rho (D) immune globulin to prevent isoimmunization c. Schedule follow up visit with the healthcare provider d. Oral contraceptive use for at least one year.

(ANS- d. oral contraceptive use for at least one year

During a Women's health fair, which assignment is best for the practical nurse (PN) who is working with a registered nurse (RN)? a. Encourage a woman at risk for cancer to obtain colonoscopy b. present a class on bread self- examination c. explain the follow up needed for a client with prehypertension d. prepare a woman for a bone density screening

(ANS- d. prepare a woman for a bone density screening

An older adult male is admitted with complication related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? a. Limit the intake of high calorie foods b. maintain a low protein diet c. eat meals at the same time daily d. restricts daily fluid intake

(ANS- d. restricts daily fluid intake

A client who is admitted to the intensive care unit with a right chest tube attached to a THORA- SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determines the client is tachypneic with absent breath sounds in the client's right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? a. continuous bubbling in the water seal chamber b. decrease bright red blood drainage c. tachypnea and difficulty breathing d. tracheal deviation toward the left lung

(ANS- d. tracheal deviation toward the left lung

A male client with an antisocial personality disorder is admitted to an inpatient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client's history is most likely to include which finding? A. Multiple convictions of misdemeanors and Class B felonies B. Delusions of grandiosity and persecution C. Suicidal ideations and multiple attempts D. Photos and panic attacks when confronted by authority figures

- A. Multiple convictions of misdemeanors and Class B felonies

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

- a. a tuna fish sandwich with chips and ice cream

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? a. begin to show signs of improvement in affect b. lacks interest in the activity of the family and friends c. express feelings of sadness and loneliness d. neglects personal hygiene and has no appetite.

- a. begin to show signs of improvement in affect

When should the nurse conduct an Allen's test? a. When pulmonary artery pressures are obtained b. just before arterial blood gasses are drawn peripherally c. Prior to attempting a cardiac output calculation d. To assess for presence of a deep vein thrombus in the leg

- b. just before arterial blood gasses are drawn peripherally

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

- c. Observe for signs of deep vein thrombosis

A client with multiple sclerosis (MS) is receiving interferon beta- 1b 0.1875 mg subcutaneously QOD. The nurse reconstitutes the vial by slowly injecting 1.2 ml of diluent into the interferon vial for a reconstituted solution of 0.25 mg/1 ml. How many ml should the nurse administer?

0.75

A client with multiple sclerosis is receiving baclofen 15 mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24-hour period?

4.5

The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be influenced over 4 hours. The IV administration set delivers 10 gtt/mL. How many gtt/minute should the nurse regulate the infusion?(round the nearest whole number)

42

A nurse who usually works on a step- down unit is moved to work a 12- hour shift in the critical care unit. Which client is the best for the charge nurse to assign to this nurse? a. A ventilator dependent client with chronic obstructive pulmonary disease COPD b. A client who has a new onset DKA and is on an insulin drip c. A client admitted for a narcotic overdose who is ventilated with respiratory alkalosis d. A ventilated client admitted today with respiratory failure and respiratory acidosis

A. A ventilator dependent client with chronic obstructive pulmonary disease COPD

A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which action should the nurse implement? Select all that apply A. Monitor stools for presence of blood B. Auscultate bowel sounds in all quadrants C. Assess characteristics of pain D. Review last partial thromboplastin time results

A. Monitor stools for presence of blood C. Assess characteristics of pain D Review last partial thromboplastin time results

After 2 days treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing, and the child's urine output is 50 mL/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which action should the nurse implement? A. Perform a fingerstick glucose test. B. Obtain arterial blood gases. C. Increase the IV fluid flow rate. D. Review 24 hour intake and output.

A. Perform a fingerstick glucose test.

After receiving IV fluids in the emergency department, an elderly client is admitted to the acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9% normal saline at 125 mL/hour via saline lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the healthcare provider, the nurse anticipates a prescription what intervention? A. Remove the saline lock from the client's arm B. Increase the rate of the normal saline infusion C. Decrease the rate of the normal saline infusion D. Change the IV solution to 0.45% saline solution

A. Remove the saline lock from the client's arm

The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? A. Ask the client about soft food preferences B. Determine which side of the body is weak C. Obtain and record the client's vital signs D. Auscultate the client's breath sounds.

ANS- B. Determine which side of the body is weak

The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommend? A. Apply a gait belt around the client's waist once a standing position has been assumed B. Pull the client into position by reaching from the opposite side of the bed C. Hold the client at arm's length while transferring to better distribute the body weight. D. Place the client's locked wheelchair on the client's strong side next to the bed

ANS- D. Place the client's locked wheelchair on the client's strong side next to the bed

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. What action should the nurse take? A. Apply bilateral eye shields to reduce photosensitivity B. Administer an antiemetic to prevent vomiting C. Begin postoperative prophylactic antibiotics D. Report the complaint of eye pain to the surgeon

ANS- D. Report the complaint of eye pain to the surgeon

A client taking Clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first? a. Observe the appearance of the stool b. review the client's laboratory values c. auscultate the client's bowel sounds d. assess the elasticity of the client's skin

ANS- a. Observe the appearance of the stool

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

ANS- a. Urine drug screen

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? a. Referral for social services for the child and family b. Instruction about how much fluid the child should drink daily c. Signs of addiction to opioid pain medications d. Information about non-pharmaceutical pain relief measures

ANS- b. Instruction about how much fluid the child should drink daily

The nurse administers the osmotic diuretic mannitol to a client who has a closed head injury. Which assessment finding indicates immediate response to administration of the mannitol? a. a decrease in skin turgor b. a decrease in intracranial pressure c. an increase in serum sodium d. an increase in serum osmolality values (

ANS- b. a decrease in intracranial pressure

A nurse who is working the emergency department triage area is presented with four client the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse? a. Unable to bear weight on the left foot, with swelling and bruising b. chest discomfort one hour after consuming a large, spicy meal c. one- inch bleeding laceration on the chin of a crying 5- year old d. low- grade fever, headache, and malaise for the past 72.

ANS- b. chest discomfort one hour after consuming a large, spicy meal

A small round area appears under the client's skin as the administer an intradermal medication. What action should the nurse take? a. Elevate the area and apply light pressure over the site b. notify the healthcare provider of the allergic response c. document the site where the medication was given d. apply a cold pack to the area for twenty minutes

ANS- b. notify the healthcare provider of the allergic response

The nurse is assessing a client who recently has an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing. Based on these finding, this client is at greatest risk for which pathophysiology condition? a. epstein bar virus b. cytomegalovirus c. guillen barre syndrome d. mycoplasma pneumonia

ANS- c. guillen barre syndrome

A client with bleeding esophageal varices receives vasopressin IV. What should the nurse monitor for during the IV infusion of this medication? A. Vasodilatation of the extremities B. Chest pain and dysrhythmia C. Hypotension and tachycardia D. decreasing GI cramping and nausea

B. Chest pain and dysrhythmia

A client who is admitted to the care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? A. Patch one eye B. Evaluate swallow C. Reorient often D. Range of motion

B. Evaluate swallow

A 17- year- old adolescent is brought to the Emergency Department by both parents because the adolescent has been coughing and running a fever with flu- like symptoms for the past 24 hours. Which intervention should the nurse implement first? A. assess the client's temperature B. Place a mask on the client's face C. Determine the client's blood pressure D. Obtain a chest x-ray per protocol

B. Place a mask on the client's face

At 40-week gestation, a laboring client who is lying in a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? A. Place a pillow under the client's head and knees B. Place a wedge under the client's right hip C. Encourage the client to turn on her left side D. Explain to the client that her position is not safe

B. Place a wedge under the client's right hip

The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication? A. Dilute the dextrose in one liter of 0.9% Normal Saline solution B. Push undiluted slowly through the currently infusing IV C. Mix the dextrose in a 50 mL piggyback for a total volume of 100 mL D. Ask the pharmacist to add the Dextrose to a TPN solution.

B. Push undiluted slowly through the currently infusing IV

Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which interventions should the nurse implement first? A. assess the client's blood pressure every 15 minutes B. Relieve any kinks or obstruction in the client's Foley tubing C. Teach the client to response symptoms of dyreflexia D. administer a prescribed PRN dose of hydrazine (Apresoline)

B. Relieve any kinks or obstruction in the client's Foley tubing

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for them to explore further prior to the start of the procedure? a. Drank a glass of water in the past 2 hours b. Reports left chest wall pain prior to admission c. verbalize a fear of being in a confined space d. experience facial swelling after eating crab

B. Reports left chest wall pain prior to admissionThe report of left wall pain should be examined closer. There can be many causes for it if its is an abnormal report from the patient has he has never experienced it before. The HCP may push back the angiography until investigator of the chest pain is complete to rule out MI, angina or other heart issues

The nurse is supervising an unlicensed assistive personnel (UAP) who will be providing personal care for a client with watery diarrhea caused by Clostridium difficile. Which action by the nurse takes priority? A. Remind the UAP to keep the client's water pitcher filled B. Review use of personal protective equipment with the UAP C. Provide barrier cream for application to the perineal area. D. Instruct the UAP to record the number of bowel movements

B. Review use of personal protective equipment with the UAP

An older client is admitted for repair of a broken hip. To reduce the risk for infection postoperative period, which nursing care intervention should the nurse include the client's plan of care? Select all that apply A. administer low molecular weight heparin as prescribed B. Teach client to use incentive spirometer every 2 hours while awake C. Remove urinary catheter as soon as possible and encourage voiding D. Maintain sequential compression devices while in bed E. Assess pain level and medicate PRN as prescribed

B. Teach client to use incentive spirometer every 2 hours while awake C. Remove urinary catheter as soon as possible and encourage voiding

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

C. Last menstrual period 7 weeks ago.

In early septic shock states, what is the primary cause of hypotension? A. a vagal response B. Cardiac failure C. Peripheral vasodilation D. Peripheral vasoconstriction

C. Peripheral vasodilation

A male client reports to the on-call clinic nurse that he took Tadalafil 10 mg PO two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. What action should the nurse take? A. Tell the client to have someone bring him to an emergency department immediately. B. Advise the client to place one nitroglycerin tablet under his tongue as a precaution C. Reassure the client that skin flushing is a common side effect of the medication D. Instruct the client to increase his intake of oral until the skin flushing is relieved

C. Reassure the client that skin flushing is a common side effect of the medication

Following a gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement? A. administer normal saline solution until Type AB negative is available B. obtain additional consent for administration of Type A negative blood. C. Transfuse Type A negative blood until AB negative is available D. Recheck the client's hemoglobin, blood type, and Rh factor

C. Transfuse Type A negative blood until AB negative is available

A client who has a percutaneous coronary intervention (PCI) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction of 30%. Today the client has links which are clear, +1 pedal edema, and a 5- pound weight gain. Which intervention should the nurse implement? A. insert a saline lock for IV diuretic therapy B. arrange transport for admission to the hospital C. assess compliance with routine prescriptions D. instruct the client to monitor daily caloric intake

C. assess compliance with routine prescriptions

When caring for a client with a traumatic brain injury (TBI) who has a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. What goes this GCS finding indicate about this client? A. rehabilitative prognosis is an expected full recovery B. insertion of an ICP monitoring device is necessary C. neurologically stable without indications of an increased ICP D. Risk for irreversible cerebral damage related to increased ICP

C. neurologically stable without indications of an increased ICP

While caring for a client's postoperative dressing the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without daring. Which is the most important action for the nurse to take? A. determines if the drainage has an unpleasant smell B. Cleanse the wound with a sterile saline solution C. request a culture and sensitivity of the wound D. Monitor the client's white blood cell count (WBC)

C. request a culture and sensitivity of the wound

The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a Medela Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instruction should the nurse provide the mother about feedings? A. alternate milk with water during the feedings B. Squeeze the nipple base to introduce milk into the mouth. C. Position the baby in the left lateral position after feeding. D. Hold the newborn in an upright position.

D. Hold the newborn in an upright position.

A client peptic ulcer disease receives a prescription for intermittent suction via a SalemSump nasogastric tube (NGT). After inserting the NGT and obtaining coffee-ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit, the client complains of nausea. What action should the nurse implement first? A. administering a prescribed antiemetic agent B. provide oral suction using a Yankauer tip C. Connect the NGT to low intermittent suction D. Irrigate the NGT with sterile normal saline

D. Irrigate the NGT with sterile normal saline

The nurse is preparing to administer an IV does of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. WBC count of 12,000 mm^3 (12 x 10^9/L) B. Serum sodium of 145 men/L C. Urine culture positive for MRSAD. Serum creatinine of 4.5 mg/dl

D. Serum creatinine of 4.5 mg/dl

The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider? A. The client complains of abdominal fullness and cramping during installation B. The client complains of a slight shortness of breath during installation C. The amount of the returning dialysis fluid is greater than the amount instilled D. The appearance of the returning dialysate fluid is cloudy.

D. The appearance of the returning dialysate fluid is cloudy.

The healthcare provider prescribes potassium chloride 25 mEq in 500 mL D5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "How many mL of potassium chloride should the nurse add to the IV fluid? (Round to the nearest tenth.)

D/H* Q: 25 mEq/10 mEq *5ml (ANS- 12.5 mL

The nurse supplies a blood pressure cuff around a client's left thigh. To measure client's pressure, where should the diaphragm of the stethoscope be placed?

Left picture left lower calf

The nurse enters the room of a client who is awaiting surgery for appendicitis. The unlicensed assistive personnel (UAP) has helped the client to a position of comfort with the right leg flexed and has applied a heating pad to the client's abdomen to relieve the client's pain. Which action should the nurse implement first? A. Determine if the consent form has been signed by the client. B. Remove the heating pad from the client's abdominal area. C. Confirm that the UAP has assisted the client to a position of comfort D. Evaluate the effectiveness of the heating pad in relieving pain.

Remove the heating pad from the client's abdominal area.

A male client with cirrhosis has jaundice and pruritis. He tells the nurse that he was been soaking in hot baths at night with no relief of his discomfort. What action should the nurse take? A. Explain that the symptoms are caused by liver damage and cannot be relieved. B. Encourage the client to use cooler water and apply calamine lotion after soaking C. Obtain a PRN prescription for an analgesic that the client can use for symptom relief. D. Suggest that the client take brief showers and apply oil- based lotion after showering

Suggest that the client take brief showers and apply oil- based lotion after showering

A client is admitted to a medical unit with diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome? A. Atenolol B. Famotidine C. Thiamine D. Lorazepam

Thiamine

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? a. 36% b. 9% c. 45% d. 15%

a. 36%

An adult female tells the nurse that her grandmother was diagnosed with colorectal cancer at age 75 and the client is implementing measures to reduce her own risk. Which of the client's plan indicates the need for additional information? a. Annual sigmoidoscopy screening b. increased intake of fresh fruits, vegetables, and whole grains c. reduced dietary intake of animal fat and protein d. Yearly fecal occult blood testing

a. Annual sigmoidoscopy screening

A middle aged female client tells the clinic nurse that she has lost an inch of height in the last year. What is the priority nursing intervention? a. Assist the client to schedule a bone density exam b. Observe for the presence of a dowager's Hump c. Advise the client to begin stretching exercises d. Encourage the client to eat calcium rich foods.

a. Assist the client to schedule a bone density exam

An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62% What action should the nurse take first? a. Begin manual ventilation immediately b. silence the alarm and call the technician c. monitor manual ventilation immediately d. call respiratory therapy.

a. Begin manual ventilation immediatelyThe first action that must be taken is to begin manual ventilation. Remember the ABC's — airway, breathing and circulation! The nurse's highest priority is to ensure that the client is receiving oxygen. Also, remember Maslow — safety is a primary human need and breathing is fundamental to safety. (A, C, and D) do not have the priority of initiating manual ventilation.

A client with osteoporosis related to long- term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse? a. Creatinine 4 mg/dL b. Total calcium 9 mg/dl c. Phosphate 4 mg/dl d. Fasting glucose 95 mg/dl

a. Creatinine 4 mg/dL

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

a. Decerebrate posturing during position changes.

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

a. Measure urinary output every hour

A client who was splashed with a chemical has both eyes covered with bandages. When assisting the client with eating, which intervention should the nurse instruct the unlicensed assistive personnel (UAP) to implement?a. Orient the client to the location of the food on the plate b. Ask to visit during meal time to assist with feeding C. provide with only finger foods d. Feed the client the entire meal

a. Orient the client to the location of the food on the plate

An older woman who lives alone in a two- story home is admitted after falling while shopping. X- rays reveal a fractured left hip. With no immediate family in the area, the client is concerned about her pets. Which interventions should the nurse implement? (SELECT ALL THAT APPLY) a. Palpate and mark pedal pulses b. Alert social work of client's concerns c. Assess ability to bear weight when standing d. Evaluate pain using standard pain scalee. Support left leg with two pillows

a. Palpate and mark pedal pulses b. Alert social work of client's concerns d. Evaluate pain using standard pain scale

A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement? A. provide typed instructions for healthy diet selections B. reinforce need for adequate hydration C. explain exercises daily regimen D. demonstrate specific strengthening exercises.

a. Provide typed instructions for healthy diet selections

As adult client's apical pulse is 110 beats per minute, what intervention should the nurse implement first? a. assess the client's radial pulse and apical pulse at the same time b. Assess the client to determine the reason why the pulse is elevated c. notify the charge nurse that the client's pulse is elevated d. attempt to calm the client and take the pulse again in one hour.

a. assess the client's radial pulse and apical pulse at the same time

The nurse assesses a client who has bilateral total knee replacement (TKR) four hours ago. The nurse that the dressing on the client's right knee is saturated with serosanguineous drainage. What actions should the nurse implement? a. determine if the wound drainage device is suctioning correctly b. withhold next scheduled dose of low molecular weight heparin c. monitor the client's current white blood cell count (WBC) d. confirm that the continuous passive motion device is intact

a. determine if the wound drainage device is suctioning correctly

Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? a. A 3- week multigravida with a prescription for serial blood pressures b. A 39- week primigravida with biophysical profile score 5 out of 8 c. A 38- week primigravida who reports contractions occurring every 10 minutes d. A 41- week multigravida who is scheduled induction of labor today.

b. A 39- week primigravida with biophysical profile score 5 out of 8

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

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

The nurse is planning care for a young adult client with acromegaly. It is most important for the nurse to monitor which of the client's serum laboratory test results? a. White blood cell count b. Glucose. c. Hemoglobin. d. Partial thromboplastin time

b. Glucose

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

b. To reduce abdominal pressure on the diaphragm

A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? a. obtain equipment of gastric lavage b. determine type of chemical exposure c. assess child for altered sensorium d. Call poison control emergency number

b. determine type of chemical exposure

An infant is unresponsive and gasping for breath. Prior to start CPR, which site should the nurse palpate for a pulse? (IMAGE)

brachial site

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? a. Prepare the client for an echocardiogram b. Limit the client's fluids c. Document in the client's record d. Notify the healthcare provider

c. Document in the client's record

Following a cardiac catheterization, an adult client is sent to the cardiovascular unit. The nurse instructs the client to keep the affected leg immobile. Which intervention should the nurse plan to include in the client's plan of care? a. Apply a sequential compression device b. Ambulate once vital signs stable c. Monitor telemetry of dysrhythmias d. Maintain NPO until bowel sounds return.

c. Monitor telemetry of dysrhythmias

A client presents to the clinic with concerns regarding her left breast. Which assessment findings most important for the nurse to report to the healthcare provider? a. Multiple firm, round, freely moveable masses b. A slight asymmetry of the breasts. c. a fixed nodular mass with dimpling of skin d. bloody discharge from the nipple

c. a fixed nodular mass with dimpling of skin

While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take? a. Remind the client that a rescue inhaler might save his life b. Gently touch the client then continue with the teaching c. ask the client what he is thinking about at this time d. leave the client alone so that he can grieve his illness

c. ask the client what he is thinking about at this time

Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form? a. The client is illiterate but verbalizes understanding and consent for the procedure b. A 15- year- old primigravida who has been self- supporting for the past 6 months c. the obstetrician explained a procedure that a neurologist will perform d. The client was mediated for pain with a narcotic IM 6 hours ago

c. the obstetrician explained a procedure that a neurologist will perform

The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendations for hypertension? a. Grilled steak, baked potato with sour cream, green beans, coffee b. Beef stir fry, fried rice, egg drop soup, diet coke, and pumpkin pie c. Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon menage pie d. Baked pork chop, applesauce, corn on the cob, 1% milk, and key lime pie

d. Baked pork chop, applesauce, corn on the cob, 1% milk, and key lime pie

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

d. Infuse an intravenous fluid bolus

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? a. administer antiemetic as needed b. initiate IV fluid replacement c. Evaluate intake and output ratio d. Withhold food and fluid intake

d. Withhold food and fluid intake

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? a. Balance and posture b. pressure sore risk c. risk for disuse syndrome d. upper body muscle strength

d. upper body muscle strength

The nurse is preparing a client who had a below the knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? SATA A. Wash the stump with soap and water B. Avoid range of motion exercise C. Apply alcohol to the stump after bathing D. Inspect skin for redness E. Use a residual limb shrinker

A. Wash the stump with soap and water D. Inspect skin for redness E. Use a residual limb shrinker

The nurse completed a dressing change for a client with partial thickness burns to both legs. After completing the dressing change, what intervention should the nurse implement? A. administer a PRN dose of pain medication B. Raise the head of bed to a 90 angle C. Perform passive range of motion D. Position ankles in a dorsiflexed position

A. administer a PRN dose of pain medication

A family member reports that the client who is bedridden has not been turned or repositioned all night and is sleeping on a special air mattress with no sheets. What information should the nurse provide to the family member? A. clarify that an aerated support surface does not use sheets that often cause skin breakdown. B. described the night staff's plan of care to ensure the client's sleep is not disturbed C. explained that turning is only necessary to reposition the client during waking hours D. Suggest that a family member turn the client during the night when someone is there

A. clarify that an aerated support surface does not use sheets that often cause skin breakdown.

A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client? A. dry roasted almonds B. Cheddar cheese and crackers C. Carrot and celery sticks D. Beef bologna sausage slices

A. dry roasted almonds

A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available tosend for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? A. stabilize the victim's neck and roll over to evaluate his status B. return to the car to call emergency response 911 for help C. Open the airway and initiate resuscitative measures D. examine the victim's body surfaces for arterial bleeding.

A. stabilize the victim's neck and roll over to evaluate his status

The nurse is complaining an admission assessment for a male client with paranoid schizophrenia. The client tells the nurse that the staff dislikes him. What action should the nurse take? A. assess the client's speech pattern for a flight of class B. Observe the client for obsessive activities such as repeated hand washing C. Determine if the client has formulated any plans regarding the staff D. Ask the client if he has a plan to harm himself

C. Determine if the client has formulated any plans regarding the staff

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? A. Ketonuria B. Peripheral edema C. Hypokalemia D. Elevated blood pressure

C. Hypokalemia

A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? A. increased time of ambulation between periods of rest B. Decrease in intracranial pressure and cerebral edema C. Absence of seizure activity for the duration of treatment D. Normal electroencephalogram after drug administration

C. Absence of seizure activity for the duration of treatment

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? A. Serum calcium B. Erythrocyte sedimentation rate C. Osmolality D. Hemoglobin

D. Hemoglobin

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A. provide information about survival rates women who have this genetic mutation B. gather additional information about the client's family history for all types of cancer C. Offer assurance that there are a variety of effective treatments for breast cancer. D. Explain that counseling will be provided to give her information about her cancer risk

D. Explain that counseling will be provided to give her information about her cancer risk

A male client is admitted to the hospital due to multiple fractures following a motor vehicle collision that occurred when he ran his car into his ex- spouse's home. When the client becomes angry and starts throwing objects at the staff, which PRN prescription should the nurse implement? A. apply soft wrist restraints if needed for client safety B. consult with the chaplain emotional support C. Hydromorphone (Dilaudid) 2 mg IV D. Haloperidol (Haldol) 1 mg IM

D. Haloperidol (Haldol) 1 mg IM