Were Gonna Pass this HESI Exit
A male college student brings his roommate to the campus clinic because the roommate has been talking to someone who is not present. the client tells the nurse that the voices are saying , "Kill Kill", What question should the nurse ask the client next? A. "When did these voices begin?" b. "Have you taken any hallucinogens?" c. "Are you planning to obey the voices?" d. "Do you believe the voices are real?"
"Are you planning to obey the voices?
A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? a. Ask the client with her children present if she fully understands the decision she has made. b. Discuss success of clinical trials and ask the client to consider participating for one month. c. Explain to the family that they must accept their mother's decision .d. Explore the client's decision to refuse treatment and offer support
.d. Explore the client's decision to refuse treatment and offer support Rationale: as long as the client is alert, oriented and aware of the disease prognosis, the healthcare team must abide by her decisions. Exploring the decision with the client and offering support provides a therapeutic interaction and allows the client to express her fears and concerns about her quality of life. Other options are essentially arguing with the client's decisions regarding her end of life treatment or diminish the opportunity for the client to discuss her feelings
A client with a lower respiratory tract infection received a prescription for ciprofloxacin 500 milligrams POQ 12 hours when the client requests an afternoon snack which dietary choice should the nurse provide? A. Vanilla flavored yogurt B. low-fat chocolate milk C. calcium supplements D. cinnamon applesauce
A. Vanilla flavored yogurt
A client who experienced a cerebrovascular accident SCI is aphasic and has left-sided paralysis which nurse should be responsible for coordinating the progression of this client's care? A. nurse care manager B. neurology unit supervisor C. adult nurse practitioner D. Risk management nurse
B. neurology unit supervisor
An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? a. Tell the client that the vaccine for HPV is not indicated b. Inform the client that warts do not return following cryotherapy c. Recommended the use of latex condoms to prevent HPV transmission. d. Reinforce the importance of annual papanicolaou (Pap) smears.
Reinforce the importance of annual papanicolaou (Pap) smears.
Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?
Report any painful urination, blood in urine, or fever
The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? a. Instruct the mother to change the child's diaper more often. b. Encourage the mother to apply lotion with each diaper charge c. Tell the mother to cleanse with soap and water at each diaper change d. Ask the mother to decrease the infant's intake of fruits for 24 hours.
a. Instruct the mother to change the child's diaper more often.
During shift report the central electrocardiogram monitoring system alarms which client alarm should the nurse investigate first? a. Respiratory apnea of 30 seconds b. Oxygen saturation rate of 88% c. Eight premature ventricular beats every minute d. Disconnected monitor signal for the last 6 minutes.
a. Respiratory apnea of 30 seconds Rationale: The priority is the client whose alarm indicating respiratory apnea that should be assessed first.
The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which foods should the nurse encourage this client to eat? a. Yogurt and/or buttermilk. b. Avocados and cheese c. Green leafy vegetables d. Fresh fruits
a. Yogurt and/or buttermilk. .Rationale: A should be encouraging to help maintain intestinal flora and decrease diarrhea, which is a common side effect of antibiotic therapy, particularly cephradine. B and C are contraindicated because they can increase bowel elimination, thereby exacerbating diarrhea as a side effect.
The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands the prescribed diet? a. roasted turkey canned vegetables b. baked potatoes with skin raw carrots c. pancakes whole-grain cereal's d. roast pork fresh strawberries
a. roasted turkey canned vegetables
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. Brain damage with CP is not progressive but it does have variable course c. CP is one of the most common permanent physical disability in children d. Severe motor dysfunction determines the extent of successful habilitation
b. Brain damage with CP is not progressive but it does have variable course
An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? a. Report the results to the healthcare provider. b. Increase ventilator rate. c. Administer a dose of sodium carbonate. d. Decrease the flow rate of oxygen.
b. Increase ventilator rate. Rationale: This client is experience respiratory acidosis. Increasing the ventilator rate depletes CO2 a, which returns the PH toward normal. Report findings is important but only after increasing ventilator rate
What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? a. Assess the client's ability to use a numeric pain scale b. Initiate the dosage lockout mechanism on the PCA pump c. Instruct the client to use the medication before the pain become severe d. Assess the abdomen for bowel sounds
b. Initiate the dosage lockout mechanism on the PCA pump Morphine depress respiration, so ensuring that the client cannot overdose on the medications
An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. This client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse a copy of the client's living will. Which action should the nurse take? a. Facilitate a family meeting with the palliative care team. b. Notify the healthcare provider of the client's wishes. c. Place a certified copy of the living will in the client's record. d. Alert the nursing staff of the client's don't resuscitate status.
b. Notify the healthcare provider of the client's wishes.
A client refuses to ambulate, reporting abdominal discomfort and bloating caused by "too much gas buildup" the client's abdomen is distended. Which prescribed PRN medication should the nurse administer? a. Hydrocodone/Acetaminophen (Lortab) b. Simethicone (Mylicon) c. Promethazine (Phenergan) d. Nalbupine (Nubain)
b. Simethicone (Mylicon) Simethicone is an antiflatulent that is used to increase the client's ability to expel flatus (B), which relieves the clients discomfort (A and D) are analgesic used to manage pain but do not alleviate the causes of the pain (C) is an antiemetic used to treat nauseas and does not relive excess flatus.
Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? a) Ensure that the restraints are snug against the client's wrists. b) Move the ties so the restraints are secured to the side rails. c) Ensure that the knot can be quickly released. d) Tie the knot with a double turn or square knot.
c) Ensure that the knot can be quickly released.
The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN? a. An adult female who has been depressed for the past several months and denies suicidal ideations. b. A middle-age male who is in a depressive phase of bipolar disease and is receiving Lithium. c. A young male with schizophrenia who said voices are telling him to kill his psychiatrist. d. An elderly male who tells the staff and other clients that he is superman and he can fly.
c. A young male with schizophrenia who said voices are telling him to kill his psychiatrist. Rationale: The RN should deal with the client with command hallucinations and these can be very dangerous if the client's acts on the commands, especially if the command is a homicidal in nature. Other client present low safety risk
Which problem, noted in the client's history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)? a. Bulimia nervosa b. Obsessive compulsive disorder c. Aural migraine headaches. d. Erectile dysfunction.
c. Aural migraine headaches.
The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement?a. Give the child syringes or hospital mask to play it at home prior to hospitalization. b. Include the child in pay therapy with children who are hospitalized for similar surgery. c. Provide a family tour of the preoperative unit one week before the surgery is scheduled. d. Provide doll an equipment to re-enact feeling associated with painful procedures
c. Provide a family tour of the preoperative unit one week before the surgery is scheduled. Rationale: School age children gain satisfaction from exploring and manipulating their environment, thinking about objectives, situations and events, and making judgments based on what they reason. A tour of the unit allows the child to see the hospital environment and reinforce explanation and conceptual thinking.
A young adult client is admitted to the emergency room following a motor vehicle collision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? a. Infection b. Increase intracranial pressure c. Shock d. Head Injury.
c. Shock This client has symptoms of shock. Two signs of shock are decreased BP, and increased (often weak and thread) pulse, this client has both symptoms. A temperature of 98.6 F is average normal. An increase of temperature. D is correct but is vague and is not specifically related to the assessment date describe, so it is not the best answer.
The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse's proposal? a. Case management and screening for clients with HIV. b. Regional relocation center for earthquake victims c. Vitamin supplements for high-risk pregnant women. d. Lead screening for children in low-income housing.
c. Vitamin supplements for high-risk pregnant women. Primary prevention activities focus on health promotions and disease preventions, so vitamin for high-risk pregnant women provide adequate vitamin and mineral for fetal
The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take? a. Monitor daily sodium intake. b. Record usual eating patterns. c. Measure ankle circumference. d. Auscultate for irregular heart rate.
d. Auscultate for irregular heart rate. Rational: Chronic kidney failure (CKF) is a progressive, irreversible loss of kidney functions, decreasing glomerular filtration rate (GFR), and the kidney's inability to excrete metabolic waste products and water, resulting in fluid overload, elevated pulse, elevated BP and electrolytes imbalances. The most important action for the nurse to implement is to auscultate for irregular heart rate (D) due to the decreased excretion of potassium by the kidneys. (A, B, and C) are not as important as monitoring for fatal cardiac dysrhythmias related to hyperkalemia.
The nurse is assessing a pt who reported falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The pt states the left knee is swollen and extremely painful to the touch. Which instructions should the nurse include in the discharge teaching?
decrease consumption of red meat and most seafood. google rationale: Allopurinol doesn't cure gout, but it helps to prevent gout by lowering uric acid levels. Additional diet modifications can help to decrease uric acid levels to help prevent gout. This includes limiting or avoiding alcohol intake and limiting the amount of meat that you eat.
A client presents to the emergency dept with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a swab for COVID -19 testing. Which action is most important for the nurse to take?
place the nasal swab specimen for COVID 19 directly in a biohazard bag.
An older adult client with systematic inflammatory response syndrome SIRS has a temperature of 101.8 Fahrenheit heart rate of 110 beats/ minutes and respiratory rate of 24 breaths/ minutes which additional finding is most important to report to the healthcare provider?
serum creatinine of 2.0 mg
The nurse assesses a child in 90 to 90 skeletal tractions where should the nurse assess for signs of compartment syndrome? A. tip of the toes of the foot that is on traction B. tip of the toes of the non-affected leg C. the thigh of the affected leg D. Anterior Neck
tip of the toes of the foot that is on traction
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to deliver how many mL/hour?
18
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)?
36 (1 total leg front/back = 18, 1 total arm front/back = 9, torso = 18, back = 18, head = 9, pubic = 1 = 100%)
A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? A. Send stool sample to the lab for a guaiac test B. Observe stool for a day-colored appearance. C. Obtain specimen for culture and sensitivity analysis D. Asses for fatty yellow streaks in the client's stool.
A. Send stool sample to the lab for a guaiac test
A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
83
A client diagnosed with CALCIUM KIDNEY STONES has a HX of GOUT. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? A. Allopurinol (Zyloprim) B. Aspirin C. low doseFurosemide (lasix) D. Enalapril (vasote)
A. Allopurinol (Zyloprim)RATIONALE: TAKINGS AMPHOGEL WILL DECREASE EFFECT OF ALLOPURINOL
A client with leukemia who is receiving a myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 103/L). Which intervention is most important for the nurse to include in this client's plan of care? A. Assess urine and stool for occult blood B. Monitor for signs of activity intolerance C. Require visitors to wear respiratory masks D. Obtain clients temperature q4 hours
A. Assess urine and stool for occult blood
he nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available? A. Bacterial meningitis B. Viral encephalitis C. Septic shock D. Brain abscess
A. Bacterial meningitis
The nurse is teaching a primigravida about preeclampsia. Which findings are indicators of preeclampsia and should be reported to the healthcare provider? A. Blurred vision B. Headache C. Lack of appetite D. Urinary frequency E. Chills and fever F. Swollen hands
A. Blurred vision B. Headache F. Swollen hands
While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A. Culture for sensitive organisms B. Serum blood glucose (BG) level C. Creatinine level D. Serum albumin
A. Culture for sensitive organisms
When conducting diet teaching for a client who was diagnosed with hypertension, which foods should the nurse encourage the client to eat? A. Fruits without sauce B. Canned soup C. Fresh or frozen vegetables without sauce D. Cottage cheese E. Pickled olives
A. Fruits without sauce C. Fresh or frozen vegetables without sauce D. Cottage cheese
After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? A. Gently close the eyes B. Remove resuscitation equipment from the room C. Take out dentures and place in a labeled cup D. Apply a body shroud E. Place a small pillow under the head
A. Gently close the eyes B. Remove resuscitation equipment from the room E. Place a small pillow under the head
An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the clients compliance with self-care? A. Have the client vocalize the instructions provided B. Ensure that someone will stay with a client for 24 hours C. Speak clearly and face the client for lip reading D. Provide written instructions for eye drop administration
A. Have the client vocalize the instructions provided Rationale: A client with both hearing and visual sensory deficit should be repeat the instruction provided so the nurse needs to be sure the clients understand the self-care instructions.
Which woman should the nurse consider at the highest risk for cervical cancer? A. History of unprotected sex with multiple partners B. Postmenopausal for 5 years with intermittent vaginal spotting C. Taking birth control pills after 40 years of age D. Multiparous delivery of infants more than 9 pounds
A. History of unprotected sex with multiple partners
client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective? A. Reduced level of pain B. Full volume of pedal pulses C. Granulating tissue in foot ulcer D. Improved visual acuity
A. Reduced level of pain Rationale: Pregabalin is prescribed to decrease the pain associated with diabetic peripheral neuropathy. A, C and D are not expected outcomes of this medication's effectiveness.
A client with type one diabetes mellitus and a large draining ulcer of the right foot is admitted with a suspected Staphylococcus Aureus infection which intervention should the nurse implement? select all that apply A. monitor the clients white blood cell count B. explain the purpose of the low bacteria diet C. send wound drainage for culture and sensitivity D. Institute contact precautions for staff and visitors E. use standard precautions and wear a mask
A. monitor the clients white blood cell count C. send wound drainage for culture and sensitivity D. Institute contact precautions for staff and visitors
The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take?
Administer a prescribed analgesia for pain.
TThe charge nurse of critical care unit informed at beginning of shift that less than optimal number registered nurses be working that shift. In planning assignments, which client should receive most care hours by a registered nurse a. A 34 yo admitted today after emergency appendendectomy who has peripheral intravenous catheter, Foley catheter. b. A 48 yo marathon runner w/a central venous catheter experiencing nausea, vomiting due to electrolyte disturbance following a race. c. A 63 yo chain smoker w/ chronic bronchitis receiving O2 nasal cannula and a saline-locked peripheral intravenous catheter. d. An 82 yo client with Alzheimer's disease newly-fractures femur w/Foley catheter and soft wrist restrains applied
An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied
The nurse is assessing a patient who is 36 hours post delivery. Which finding should the nurse report to the healthcare provider? A. White blood cell count 19,000 B. Oral temperature of 100.6 C. Fundus deviated to the right D. Breast are firm when palpated
B. Oral temperature of 100.6 Rationale: A temperature greater than 100.4 F (38 C) (B), which is indicative of endometriosis (infection of the lining of the uterus), should be reported to the health care provider. (A and D) are findings that are within normal limits in the postpartum period. Fundal deviation to one side (C) is an expected finding related to a full bladder, so the nurse should encourage the client to void.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care the nurse finds the radiation implant in the bed. What action should the nurse take? A. Apply double gloves to retrieve the implant for disposal B. Place the implant in a lead container using long-handled forceps C. Reinsert the implant into the vagina D. Call the radiology department
B. Place the implant in a lead container using long-handled forceps
The nurse identifies an electrolyte imbalance, an elevated central venous pressure (CVP) and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with full thickness burns. Which intervention should the nurse implement? A) auscultate for irregular heart rate B) review arterial blood glass blood gases results C) measure ankle circumference D) document abdominal girth
C) measure ankle circumference we don't ****in know
A male client suffering from depression has been taking an antidepressant medication for two days. He tells the nurse that he is smiling more and feeling better. Which response is best for the nurse to provide?
Antidepressants usually begin to improve your mood after 2 to 4 weeks.
5) An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter stated that her mother's behavior changed suddenly a few days ago and is now getting worse. Which actions should the nurse take? A. Encourage increased intake of high protein foods B. Instruct the daughter to check her mother's temperature C. Review the client's current food and medication allergies D. Ask if the mother is experiencing any pain with urination E. Determine if the mother has recently experienced a fall.
B. Instruct the daughter to check her mother's temperature D. Ask if the mother is experiencing any pain with urination E. Determine if the mother has recently experienced a fall.
During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? A. Canned fruit in heavy syrup B. Natural whole almonds C. Plain, air-popped popcorn D. Lightly salted potato chips E. Cheddar cheese cubes
B. Natural whole almonds C. Plain, air-popped popcorn
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate action? A. A 16-year-old client diagnosed with major depression who refuses to participate in group B. A 14-year-old with anorexia nervosa who is refusing to eat the evening snack C. An 18-year-old client with antisocial behavior who is being yelled at by other clients D. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby
C. An 18-year-old client with antisocial behavior who is being yelled at by other clients
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first? A. Elevate the foot of the bed B. Restrict the client's fluids C. Begin supplemental oxygen D. Prepare client for hemodialysis
C. Begin supplemental oxygen
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication? A. Excessive lochia. B. Saturation of more than one pad per hour. C. Hypertension. D. Difficulty locating the uterine fundus.
C. Hypertension. Rationale Methylergonovine, an ergot alkaloid, has vasoconstrictive effects that can exaggerate primary hypertension. The nurse should withhold the medication if the client's blood pressure is elevated (C) and notify the healthcare provider. (A, B, and D) are signs of uterine atony and are indications for the use of the medication.
While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Platelet count B. Serum sodium level C. Neutrophil count D. Hematocrit
C. Neutrophil count
An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? A. Ask the UAP to take the blood pressure in the other arm B. Tell the UAP to use a different sphygmomanometer. C. Review the client's serum calcium level D. Administer PRN antianxiety medication.
C. Review the client's serum calcium level
When conducing diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? a. Lentils b. Chunky Potato soup c. Tea d. Cheese
C. Tea
An adult female client is admitted to the psychiatric unit because of a complex handwashing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? A.)Addiction B.)Phobia C.)Compulsion D.)Obsession
C.)Compulsion
While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement?
Contact the medical records department supervisor.
A multiparous client who delivered her infant three hours ago ask the nurse about sitz bath, because it helped reduce perineal pain after her last delivery. What answer should the nurse give to the client?
D) Review the use of sitz bath equipment with the client.
A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor which finding should the nurse report to the health care provider before initiating the infusion of oxytocin? A. Regular contractions occurring every 10 minutes B. Biophysical profile results showing oligohydramnios. C. Sterile vaginal exam revealing 3 cm dilation D. Fetal heart tones located in the upper right quadrant
D. Fetal heart tones located in the upper right quadrant google rationale: If the baby is breech, the transducer is placed on the upper quadrants of the patient's belly, depending on which way the fetus is facing. normal fetal tones should be heard in the lower quadrants.
the nurse is caring for a client with a sexually transmitted disease infection syphilis. the client reports having sex with someone who had many partners. Which response should the nurse provide? A. inform that follow-up may end after treatment is finished- B. Emphasize that using safe sex practices removes the risk of STDs C. Clarify that all STIs are transmitted through sexually intercourse- i eliminated this answer D. Remain non-judgmental and assure the client of confidentiality
D. Remain non-judgmental and assure the client of confidentiality
Nurses working on a surgical unit are concerned about the physicians treatment ofclients during invasive procedures, such as dressing changes and insertion of IV lines.Clients are often crying during the procedures, and the physician is usually unconcernedor annoyed by the client's response. To resolve this problem, what actions should the nurses take? (arrange from the first action on the top of the list on the bottom) A. contact the hospital's chief of medical services B. submit a written report to the director of nursing C. file a formal complaint with the state medical board D. talk to the physician as a group in a non-confrontational manner. E. document concerns and report them to the charge nurse
D. talk to the physician as a group in a non-confrontational manner. E. document concerns and report them to the charge nurse B. submit a written report to the director of nursing A. contact the hospital's chief of medical services C. file a formal complaint with the state medical board
Which instruction should the nurse provide a pregnant client who is complaining of heartburn? a. Limit fluids between meals to avoid over distension of the stomach b. Take an antacid at bedtime and whenever symptoms worsen c. Maintain a sitting position for two hours after eating. d. Eat small meal throughout the day to avoid a full stomach.
Eat small meal throughout the day to avoid a full stomach. Rationale: Eating small frequent meals throughout the day decreases stomach fullness and helps decrease heartburn.
After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement? a. Administer PRN medication b. Titrate the oxygen to keep saturation above 92% c. Hold oral intake until swallow evaluation is done. d. Elevate the head of his bed at least 45 degrees.
Hold oral intake until swallow evaluation is done. After oral intubation, the client is at high risk for swallowing difficulties. A swallowing evaluation should be done to determine what consistency of liquids the client can tolerate without aspirating. A, B and D helps but does not have the priority.
The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? A. Muscle spasms of the back and neck. B. tongue protrusion C. Restlessness D. Lip smacking
Muscle spasms of the back and neck. An extra pyramidal symptom (EPS) characterized by abnormal muscle spasms of the neck (A) requires immediate intervention because it can cause difficulty swallowing and jeopardize the airway. Though (A, B and C) are also EPS caused by antipsychotic medication medications used to manage schizophrenia (D) has the highest priority to insure client safety is (A).
When caring for a client with a traumatic brain injury who had a craniotomy for increased and cranial pressure the nurse assesses the client's using the glaucoma scale every two hours for the past eight hours the client's Glasgow coma scale score has been 14 what does the glaucoma scale finding indicates about the client?
Neurologically stable without in dictation of an increased cranial pressure
Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important for the nurse to implement?
Remove cigarettes for the client's room
Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?
Serum potassium, calcium, and phosphorus
To auscultate for a carotid bruit the nurse places the stethoscope at what location
The carotid artery
A client has both primary IV infusion and a secondary infusion of medication. An infusion pump is not available. The nurse needs to determine the current rate of infusion of the primary IV. Where should the nurse observe to determine the rate of infusion?
The drip chamber on the primary bag
an adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. chest tubes were inserted in the ED and transferred to ICU. the nurse notes that the suction control chamber is bubbling at the -10 cm mark, with fluctuation in the water seal, a hour 75ml of bright red blood is measured in the collection chamber. which intervention should the nurse implement? a. Add sterile water to the suction control chamber. b. Give blood from the collection chamber as autotransfusion c. Manipulate blood in tubing to drain into chamber. d. Increase wall suction to eliminate fluctuation in water seal.
a. Add sterile water to the suction control chamber.
A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain? a. Cardiac rhythm and heart rate. b. Daily intake of foods rich in potassium. c. Hourly urinary output d. Thirst ad skin turgor.
a. Cardiac rhythm and heart rate. Hypokalemia is a side effect of potassium-wasting diuretics, such as Lasix, and manifest as muscle weakness, hypotension, tachycardia, and cardiac dysrhythmias, so changes in the child's heart rate and cardiac rhythm should be reported to the healthcare provider. Although BCD can affect the serum potassium level, the most important finding is the effect of hypokalemia on the child's cardiac rate and rhythm.
The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? a. Convey to the client that birth is imminent. b. Prepare the client for spinal anesthesia c. Empty the client's bladder using a straight catheter d. Prepare the coach to accompany the client to delivery
a. Convey to the client that birth is imminent. The second stage of labor occurs when the client is fully dilated, and the fetus is crowning, so completing preparations and informing the client that birth is imminent, so A is the first action. B is usually administered immediately prior to delivery. C is usually performed prior of after delivery D is not the priority action at this time.
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. Determine if the sensation feels uncomfortable. b. Decrease the strength of the electrical signals. c. Remove electrodes and observe for skin redness. d. Check the amount of gel coating on the electrodes.
a. Determine if the sensation feels uncomfortable.
The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) a. Ease the client to the floor b. Loosen restrictive clothing c. Note the duration of the seizure
a. Ease the client to the floor b. Loosen restrictive clothing c. Note the duration of the seizure
An older adult male reporting abdominal pain is admitted to the hospital from a long term care facility. It has been seven days since his last bowel movement, and his abdomen is distended, and he just vomited 150 milliliters of dark brown emesis. In what order should the nurse implement these interventions? a. Elevate the head of bed b. Complete focus assessment c. Offer PRN pain medication d. Send emesis sample to the lab
a. Elevate the head of bed c. Offer PRN pain medication b. Complete focus assessment d. Send emesis sample to the lab
After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.) a. Apply oxygen via nasal cannula b. Administer PRN nebulizer treatment. c. Obtain 12 lead electrocardiogram. d. Monitor continuous oxygen saturation. e. Give PRN dose of regular insulin
b. Administer PRN nebulizer treatment. c. Obtain 12 lead electrocardiogram. d. Monitor continuous oxygen saturation. Rationale: A nebulizer treatment may improve the wheezing. Chest tightness is most likely to coughing, but a 12-lead electrocardiogram is needed to assess for cardiac ischemia. Oxygen saturation monitors for adequate oxygenation.
An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries? a. Decrease morbidity in the elderly population b. Decrease prevalence of glaucoma in the population. c. Increase mortality in the elderly population d. Increased incidence of glaucoma in the population.
b. Decrease prevalence of glaucoma in the population.
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
b. Glucose Rationale: Cushing syndrome, caused by excess corticosteroids causes hyperglycemia and the client's serum glucose level should be monitor for this side effect.
The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) a. evaluate the patient for sleep disturbances b. Weigh the client and report any weight gain. c. Report any client complaint of pain or discomfort. d. evaluate effectiveness of medication adherence e. Note and report the client's food and liquid intake during meals and snacks
b. Weigh the client and report any weight gain. c. Report any client complaint of pain or discomfort. e. Note and report the client's food and liquid intake during meals and snacks
The healthcare provider changes a client's medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement? a. Continue to administer the medication via the IV route b. Give half the prescribed oral dose until the provider is consulted. c. Administer the medication via the oral route as prescribed. d. Consult with the pharmacist regarding the error in prescription.
c. Administer the medication via the oral route as prescribed. Rationale: Bioavailability refers to the percentage of drug available in the systemic circulation. An increase in dosage is necessary to provide a therapeutic effect for oral medications with significantly reduce bioavailability.
In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis? a. Impaired gas exchange related to narrowing of small airways b. Death anxiety related to concern about prognosis c. Anxiety related to fear of suffocation. d. Ineffective coping related to knowledge deficit about COPD
c. Anxiety related to fear of suffocation. A common problem with clients who have COPD is anxiety. These clients cannot aerate their bodies, so they feel a perpetual state of suffocation which is worse during exacerbation of their COPD. A classic descriptor of COPD id impaired gas exchange (A). Because the client has typically adapted to impaired gas exchange over a long period of time, and the nurse has assessed a change in her appearance (A) is not the primary diagnosis at this time. Based on the data presented (B and D) are not the best diagnoses in this situation.
The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicate the program is effective? a. At-risk clients received an increased number of routine health screenings. b. Clients reported having new confidence in making healthy food choices. c. Clients who incurred disease complications promptly received rehabilitation. d. Client relapse rate of 30% in a 5-year community-wide anti-smoking campaign.
c. Clients who incurred disease complications promptly received rehabilitation.
A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goosebumps". The nurse should asses for which trigger? a. Loud hallway noise. b. Fever c. Full bladder d. Frequent cough.
c. Full bladder Rational: a pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder. The other options are unlikely to produce the manifestation of autonomic hyperreflexia.
A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching? a. Engage in physical exercise immediately after eating to help decrease cholesterol levels. b. Walk briskly in cold weather to increase cardiac output c. Keep nitroglycerin in a light-colored plastic bottle and readily available. d. Avoid all isometric exercises but walk regularly.
d. Avoid all isometric exercises but walk regularly. Isometric exercise can raise blood pressure for the duration of the exercise, which may be dangerous for a client with cardiovascular disease, while walking provides aerobic conditioning that improves ling, blood vessel, and muscle function. Client with angina should refrain from physical exercise for 2 hours after meals, but exercising does not decrease cholesterol levels. Cold water cause vasoconstriction that may cause chest pain. Nitroglycerin should be readily available and stored in a dark-colored glass bottle not C, to ensure freshness of the medication.
A client is receiving mesalamine 800mg po TID Which assessment is most important for the nurse to perform to assess the effectiveness of the medication? a. Pupillary response b. Oxygen saturation c. Peripheral pulses d. Bowel patterns
d. Bowel Patterns Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [large intestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation.
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? a. Spironolactone b. Potassium c. Ampicillin sodium parental d. Digoxin.
d. Digoxin. This infant is demonstrating early signs of heart failure due to an increase right ventricular workload caused by a left to right shunt through the VSD, son an inotropic, such as digoxin should be administered first to improve the efficiency of myocardial contractility. Next a high ceiling diuretic to reduce fluid volume and workload of the heart. If hypokalemia occurs as result of potassium-wasting diuretic, should be given to reduce the risk of digoxin toxicity.
A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include? a. Swaddle the infant in a blanket for sleeping b. Place the infant in a prone position whenever possible c. Prop the baby up on soft pillows and blankets d. Ensure that the infant's crib mattress is firm.
d. Ensure that the infant's crib mattress is firm.
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day refuses to take a bath and refuses to eat which nursing intervention should the nurse implement first? a. Assess the client's ability to communicate with the other staff members b. Arrange a meeting with the family to discuss the client's situation c. Administer the client's antidepressant medication as prescribed. d. Establish a structured routine for the client to follow.
d. Establish a structured routine for the client to follow.
An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? a. Obtain a medical history b. Record pain evaluation c. Assess blood glucose d. Identify pills in the bag.
d. Identify pills in the bag. Rationale: Comorbidity places the client at risk for multiple drug interaction and side effects, and the client's gout therapy may need to be modified. A review of the medication in the bag (D) is the most important way to analyze the client's polypharmacy. And therapeutic response for comorbidities. Obtain a medical history (A), pain evaluation (B), and assessing blood glucose level (C) should be done in a timely manner.
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the finding to the surgeon. Which action should the nurse implement first? a. Measure and document the client's urinary output. b. Request the client's reserved unit if packed red blood cells. c. Prepare the placement of a central venous catheter. d. Increase the infusion rate of Lactated Ringer's solution.
d. Increase the infusion rate of Lactated Ringer's solution.
During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? a. Keep a daily weight record b. Obtain weight at the same time every day c. Limit intake of dietary salt. d. Report weight gain of 2 pounds (0.9kg) in 24 hours
d. Report weight gain of 2 pounds (0.9kg) in 24 hours
When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant? a. Crying b. Straining on stool c. Vomiting d. Sitting upright.
d. Sitting upright. The anterior fontanel closes at 9 months of age and may bulge when venous return is reduced from the head, but a bulging anterior fontanel is most significant if the infant is sitting up and may indicated an increase in cerebrospinal fluid. Activities that reduce venous return from the head, such as crying, a Valsalva maneuver, vomiting or a dependent position of the head, cause a normal transient increase in intracranial pressure.
A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? a. Decrease urinary output b. Low blood glucose level c. Profound weight gain d. Ventricular arrhythmias.
d. Ventricular arrhythmias.
A nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? SATA. a. Leans forward to pull from the high shelf b. bends from the waist to pick trash off the floor c. locks knees while preparing food on the counter d. brings the heavy can close to body before lifting e. Widens stance while working near the sink.
d. brings the heavy can close to body before lifting e. Widens stance while working near the sink.
