HESI Exit Exam: 799 Essential Questions

Following discharge teaching, a male c. Review with the client the need to avoid foods that are rich in milk and cream. client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? a. Remind the client that it is also important to switch to decaffeinated coffee and tea. b. Suggest that the client also plan to eat frequent small meals to reduce discomfort c. Review with the client the need to avoid foods that are rich in milk and cream. d. Reinforce this teaching by asking the client to list a dairy food that he might select. The nurse observes an unlicensed b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of assistive personnel (UAP) positioning a pillows. newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? a. Ensure that the UAP has placed the pillows effectively to protect the client. b. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. c. Assume responsibility for placing the pillows while the UAP completes another task. d. Ask the UAP to use some of the pillows to prop the client in a side lying position. A male client with hypertension, who c. Stroke secondary to hemorrhage received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? a. Blindness secondary to cataracts b. Acute kidney injury due to glomerular damage c. Stroke secondary to hemorrhage d. Heart block due to myocardial damage An adolescent with major depressive a. Describes life without purpose disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up a. Describes life without purpose b. Complains of nausea and loss of appetite c. States is often fatigued and drowsy d. Exhibits an increase in sweating. A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan a. Further evaluation involving surgery may be needed b. A pelvic exam is also needed before cancer is ruled out c. Pap smear evaluation should be continued every six month d. One additional negative pap smear in six months is needed. a. Further evaluation involving surgery may be needed A client who recently underwent a b. Teach tracheal suctioning techniques tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? a. Explain how to use communication tools. b. Teach tracheal suctioning techniques c. Encourage self-care and independence. d. Demonstrate how to clean tracheostomy site. In assessing an adult client with a partial d. Document the assessment data rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client's respiratory rate is 14 breaths / minute. What action should the nurse implement a. Encourage the client to take deep breaths b. Remove the mask to deflate the bag c. Increase the liter flow of oxygen d. Document the assessment data During shift report, the central a. Respiratory apnea of 30 seconds electrocardiogram (EKG) 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. During a home visit, the nurse observed an elderly client with diabetes slip and fall. What action should the nurse take first? a. Give the client 4 ounces of orange juice b. Call 911 to summon emergency assistance c. Check the client for lacerations or fractures d. Asses clients blood sugar level c. Check the client for lacerations or fractures At 0600 while admitting a woman for a c. Inform the anesthesia care provider schedule repeat cesarean section (CSection), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? a. Ensure preoperative lab results are available b. Start prescribed IV with lactated Ringer's c. Inform the anesthesia care provider d. Contact the client's obstetrician. After placing a stethoscope as seen in the c. Listen with the bell at the same location picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first a. Side the stethoscope across the sternum. b. Move the stethoscope to the mitral site c. Listen with the bell at the same location d. Observe the cardiac telemetry monitor A 66-year-old woman is retiring and will c. Medicare no longer have a health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs? a. Woman, Infant, and Children program b. Medicaid c. Medicare d. Consolidated Omnibus Budget Reconciliation Act provision. A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? a. Fruit-flavored yogurt. b. Cheese and crackers. c. Cold cereal with skim milk. d. Toasted wheat bread and jelly d. Toasted wheat bread and jelly Following a lumbar puncture, a client d. I have a headache that gets worse when I sit up" voices several complaints. What complaint indicated to the nurse that the client is experiencing a complication? a. "I am having pain in my lower back when I move my legs" b. "My throat hurts when I swallow" c. "I feel sick to my stomach and am going to throw up" d. I have a headache that gets worse when I sit up" An elderly client seems confused and b. Obtain a clean catch mid-stream specimen reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement a. Auscultate for renal bruits b. Obtain a clean catch mid-stream specimen c. Use a dipstick to measure for urinary ketone d. Begin to strain the client's urine. The nurse is assisting the mother of a b. Foods sweetened with aspartame. child with phenylketonuria (PKU) to select foods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? a. Wheat products b. Foods sweetened with aspartame. c. High fat foods d. High calories foods. Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? a. Ask a more experience nurse to perform that scrub since it is the first time of the day b. Validate the nurse is implementing the OR policy for surgical hand scrub c. Inform the nurse that hand scrubs should be 3 minutes between cases. d. Direct the nurse to continue the surgical hand scrub for a 5-minute duration. d. Direct the nurse to continue the surgical hand scrub for a 5-minute duration. Which breakfast selection indicates that d. Bagel with jelly and skim milk. the client understands the nurse's instructions about the dietary management of osteoporosis? a. Egg whites, toast and coffee. b. Bran muffin, mixed fruits, and orange juice. c. Granola and grapefruit juice d. Bagel with jelly and skim milk. The charge nurse of a critical care unit is d. An 82-year-old client with Alzheimer's disease newly-fractures femur who has a informed at the beginning of the shift that Foley catheter and soft wrist restrains applied less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN) a. A 34-year -old admitted today after an emergency appendendectomy who has a peripheral intravenous catheter and a Foley catheter. b. A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race. c. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheter. d. An 82-year-old client with Alzheimer's disease newly-fractures femur who has a Foley catheter and soft wrist restrains applied A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurse implement first? a. Cleanse the foot with soap and water and apply an antibiotic ointment b. Provide teaching about the need for a tetanus booster within the next 72 hours. c. have the mother check the child's temperature q4h for the next 24 hours d. transfer the child to the emergency department to receive a gamma globulin injection a. Cleanse the foot with soap and water and apply an antibiotic ointment The mother of an adolescent tells the d. Stop using the ointment and encourage complete drying of the feet and clinic nurse, "My son has athlete's foot, I wearing clean socks. have been applying triple antibiotic ointment for two days, but there has been no improvement." What instruction should the nurse provide? a. Antibiotics take two weeks to become effective against infections such as athlete's foot. b. Continue using the ointment for a full week, even after the symptoms disappear. c. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration. d. Stop using the ointment and encourage complete drying of the feet and wearing clean socks. A 26-year-old female client is admitted to a. Palpitations and shortness of breath the hospital for treatment of a simple goiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences a. Palpitations and shortness of breath b. Bradycardia and constipation c. Lethargy and lack of appetite d. Muscle cramping and dry, flushed skin A client with a history of heart failure c. Obtain a list of medications taken for cardiac history. presents to the clinic with a nausea, vomiting, yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? a. Determine the client's level of orientation and cognition b. Assess distal pulses and signs of peripheral edema c. Obtain a list of medications taken for cardiac history. d. Ask the client about exposure to environmental heat. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies) a. S1 S2 b. S1 S2 S3 c. Murmur d. Pericardial friction rub. c. Murmur The nurse notes that a client has been a. Auscultate the client's bowel sounds receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete? a. Auscultate the client's bowel sounds b. Observe for edema around the ankles c. Measure the client's capillary glucose level d. Count the apical and radial pulses simultaneously A client is receiving a full strength a. Add equal amounts of water and feeding to a feeding bag and infuse at continuous enteral tube feeding at 50 50ml/hour ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? a. Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour b. Continue the full strength feeding after decreasing the rate of infusion to 25 ml/hr. c. Maintain the present feeding until diarrhea subsides and the begin the next new prescription. d. Withhold any further feeding until clarifying the prescription with healthcare provides. A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the nurse to ask? a. "Is there a history of female baldness in your family?" b. "Are you under any unusual stress at home or work?" c. "Do you work with hazardous chemicals?" d. "Have you noticed any changes in your fingernails?" d. "Have you noticed any changes in your fingernails?" After a third hospitalization 6 months ago, d. Capillary refill of 8 seconds a client is admitted to the hospital with ascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediate intervention by the nurse? a. Bruises on arms and legs b. Round and tight abdomen c. Pitting edema in lower legs d. Capillary refill of 8 seconds Following surgery, a male client with d. Advise the client that assignments are not based on client requests antisocial personality disorder frequently requests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? a. Ask the client to explain why he constantly request the nurse b. Encourage the client to verbalize his feelings about the nurse c. Reassure the client that his request will be met whenever possible. d. Advise the client that assignments are not based on client requests A client with cervical cancer is d. Place the implant in a lead container using long-handled forceps hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take? a. Call the radiology department b. Reinsert the implant into the vagina c. Apply double gloves to retrieve the implant for disposal. d. Place the implant in a lead container using long-handled forceps The client with which type of wound is most likely to need immediate intervention by the nurse? a. Laceration b. Abrasion c. Contusion d. Ulceration a. Laceration The nurse is planning care for a client b. Monitor blood pressure frequently admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care? a. Record urine output every hour b. Monitor blood pressure frequently c. Evaluate neurological status d. Maintain seizure precautions When caring for a client who has acute a. To reduce abdominal pressure on the diaphragm respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? a. To reduce abdominal pressure on the diaphragm b. to promote retraction of the intercostal accessory muscle of respiration c. to promote bronchodilation and effective airway clearance d. to decrease pressure on the medullary center which stimulates breathing When assessing a mildly obese 35-yearold female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. What is the most likely explanation for failure to locate the gallbladder by palpation? a. The client is too obese b. Palpating in the wrong abdominal quadrant c. The gallbladder is normal d. Deeper palpation technique is needed c. The gallbladder is normal A woman with an anxiety disorder calls c. Inform her that some antianxiety medications are safe to take while her obstetrician's office and tells the breastfeeding nurse of increased anxiety since the normal vaginal delivery of her son three weeks ago. Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? a. Describe the transmission of drugs to the infant through breast milk b. Encourage her to use stress relieving alternatives, such as deep breathing exercises c. Inform her that some antianxiety medications are safe to take while breastfeeding d. Explain that anxiety is a normal response for the mother of a 3-week-old. An older male client with a history of type d. Start an intravenous (IV) infusion of normal saline 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? a. obtain a serum potassium level b. administer the client's usual dose of insulin c. assess pupillary response to light d. Start an intravenous (IV) infusion of normal saline A client who received multiple c. The additive effect of multiple medications has caused the blood pressure to antihypertensive medications experiences drop too low. syncope due to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication? a. Increased urinary clearance of the multiple medications has produced diuresis and lowered the blood pressure b. The antagonistic interaction among the various blood pressure medications has reduced their effectiveness c. The additive effect of multiple medications has caused the blood pressure to drop too low. d. The synergistic effect of the multiple medications has resulted in drug toxicity and resulting hypotension. Which client is at the greatest risk for a. An adult client who cannot sleep due to constant pain. developing delirium? a. An adult client who cannot sleep due to constant pain. b. an older client who attempted 1 month ago c. a young adult who takes antipsychotic medications twice a day d. a middle-aged woman who uses a tank for supplemental oxygen Which intervention should the nurse a. Reduce risks factors for infection include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? a. Reduce risks factors for infection b. Administer high flow oxygen during sleep c. Limit fluid intake to reduce secretions d. Use diaphragmatic breathing to achieve better exhalation Which location should the nurse choose a. A business and professional women's group. as the best for beginning a screening program for hypothyroidism? a. A business and professional women's group. b. An African-American senior citizens center c. A daycare center in a Hispanic neighborhood d. An after-school center for NativeAmerican teens A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling "very tired". Which nursing intervention is most important for the nurse to implement? a. Measure vital signs b. Auscultate breath sounds c. Palpate the abdomen d. Observe the skin for bruising a. Measure vital signs A male client reports the onset of c. Serum calcium numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider? a. capillary glucose b. urine specific gravity c. Serum calcium d. white blood cell count What explanation is best for the nurse to b. The technique is intended to maintain straight spinal alignment. provide a client who asks the purpose of using the log-rolling technique for turning? a. working together can decrease the risk for back injury b. The technique is intended to maintain straight spinal alignment. c. Using two or three people increases client safety. d. turning instead of pulling reduces the likelihood of skin damage A client receiving chemotherapy has d. Baked apples topped with dried raisins severe neutropenia. Which snack is best for the nurse to recommend to the client? a. Plain yogurt with sweetened with raw honey b. Peanuts in the shell, roasted or unroasted. c. Aged farmer's cheese with celery sticks d. Baked apples topped with dried raisins Which action should the school nurse take first when conducting a screening for scoliosis? a. Compare dorsal measurement of trunk b. Extend arms over head for visualization c. Inspect for symmetrical shoulder height. d. Observe weight-bearing on each leg. c. Inspect for symmetrical shoulder height. An unlicensed assistive personnel (UAP) c- Assign a practical nurse (LPN) to determine if an apical radial deficit is present. assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/ minutes. What action should the charge nurse implement? a- Instruct the UAP to count the client apical pulse rate for sixty seconds b- Determine if the UAP also measured the client's capillary refill time. c- Assign a practical nurse (LPN) to determine if an apical radial deficit is present. d- Notify the health care provider of the abnormal pulse rate and pulse volume. After a sudden loss of consciousness, a b. Encourage a low-carbohydrate and high-protein diet female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan? a. Describe the signs and symptoms of hypoglycemia. b. Encourage a low-carbohydrate and high-protein diet c. Reinforce the need to continue outpatient treatment d. Suggest wearing a medical alert bracelet at all time. Which instruction should the nurse d. Eat small meal throughout the day to avoid a full stomach. 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. 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. Hypokalemia b. Ketonuria. c. Peripheral edema d. Elevated blood pressure a. Hypokalemia A 10 year old who has terminal brain c. "The heart will stop beating & you will stop breathing." cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? a. "Your mother & father will be here soon. Talk to them about that." b. "Why do you want to know about what will happen to your body when you die?" c. "The heart will stop beating & you will stop breathing." d. "Are you concerned about where your spirit will go?" The nurse is preparing to administer an d. Determine which side of the body is weak. 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 foods preferences b. Auscultate the client's breath sounds c. Obtain and record the client's vital signs d. Determine which side of the body is weak. The nurse who is working on a surgical d. Abdominal-perineal resection 2 days ago with no drainage on dressing who has unit receives change of shift report on a fever and chills. group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse? a. Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing. b. Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jacksonpratt drain. c. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collection container d. Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. The nurse is caring for a client who had gastric bypass surgery yesterday. Which intervention is most important for the nurse to implement during the first 24 postoperative hours? a. Insert an indwelling urinary catheter b. Monitor for the appearance of an incisional hernia c. Instruct the client to eat small frequent meals d. Measure hourly urinary output. d. Measure hourly urinary output. When preparing to discharge a male b. Schedule an appointment for an out-patient psychosocial assessment. client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells the nurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? a. Administer anti-anxiety medication prior to providing discharge instructions b. Schedule an appointment for an outpatient psychosocial assessment. c. Obtain a blood cortisol level after last dose of synthetic ACTH d. Encourage the healthcare provider to delay the client's discharge. An adult female client tells the nurse that d. Explore client's readiness to discuss the situation. though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? a. Report the finding to the police department b. Discuss treatment options for abusive partners c. Determine the frequency and type of client's abuse d. Explore client's readiness to discuss the situation. In caring for a client with Cushing b. Glucose syndrome, which serum laboratory value is most important for the nurse to monitor? a. Lactate b. Glucose c. Hemoglobin d. Creatinine Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client a. Have partner screened for human immunodeficiency virus b. Report a sudden onset arthralgia to the healthcare provider c. Decrease intake of high-fat-foods, caffeine, and alcohol d. Use two forms of contraception while taking this drug. d. Use two forms of contraception while taking this drug. A client in the emergency center b. Divalproex. demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it is most important for the nurse to review the laboratory value for which medication? a. Olanzapine b. Divalproex. c. Lorazepam d. Fluoxetine A male client who is admitted to the b. Serum lithium level of 1.6 mEq/L or mmol/l (SI) mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? a. Blood alcohol level of 0.09% b. Serum lithium level of 1.6 mEq/L or mmol/l (SI) c. Six hours of sleep in the past three days. d. Weight loss of 10 pounds (4.5 kg) in past month. A client was admitted to the cardiac b. Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per observation unit 2 hours ago complaining nasal cannula. of chest pain. On admission, the client's EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? a. Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock b. Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. c. Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzymes levels. d. Notify the healthcare provider of the client's increase chest pain a call for the defibrillator crash cart. The nurse is developing a teaching a. Literacy level program for the community. What population characteristic is most influential when choosing strategies for implementing a teaching plan? a. Literacy level b. Prevalent learning style c. Median age d. Percent with internet access. A client is being discharged with a a. Eat approximated the same amount of leafy green vegetables daily so the prescription for warfarin (Coumadin). amount of vitamin K consumed is consistent. What instruction should the nurse provide this client regarding diet? a. Eat approximated the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. b. Avoid eating all foods that contain any vitamin K because it is an antagonist of Coumadin. c. Increase the intake of dark green leafy vegetables while taking Coumadin d. Eat two servings of raw dark green leafy vegetables daily and continue for 30 days after Coumadin therapy is completed. A client who had a small bowel resection a. Maintain contact transmission precaution acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention. a. Maintain contact transmission precaution b. Review white blood cell (WBC) count daily c. Instruct visitors to gown and wash hands d. Collect serial stool specimens for culture A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take? a. Provide oxygen 100% via facemask b. Check peripheral tendon reflexes c. Give another IV dose of morphine d. Administer Naloxone IV d. Administer Naloxone IV Which intervention is most important for b. Place the client on fall precautions the nurse to include in the plan of care for an older woman with osteoporosis? a. Evaluate the client's orientation to time and place b. Place the client on fall precautions c. Encourage the client to drink milk with meals d. Assess the client's breath sounds daily. Based on the information provided in this d. Continue to monitor the progress of labor. client's medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) a. Apply oxygen 10 l/mask b. Stop the oxytocin infusion c. Turn the client to the right lateral position. d. Continue to monitor the progress of labor. A client with intestinal obstructions has a b. Serum potassium level of 3.1 mEq/L or mmol/L (SI) nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding is most important for the nurse to report to the healthcare provider? a. Gastric output of 900 mL in the last 24 hours b. Serum potassium level of 3.1 mEq/L or mmol/L (SI) c. Increased blood urea nitrogen (BUN) d. 24-hour intake at the current infusion rate. Which type of Leukocyte is involved with c. Eosinophils allergic responses and the destruction of parasitic worms? a. Neutrophils b. Lymphocytes c. Eosinophils d. Monocytes The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat a. Vanilla-flavored yogurt b. Low fat chocolate milk. c. Calcium fortified juice d. Cinnamon applesauce d. Cinnamon applesauce Several months after a foot injury, and b. Assist the client in developing a goal of managing the pain. adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond? a. Explain the healing from injury can take many months b. Assist the client in developing a goal of managing the pain. c. Encourage the client to verbalize her fears about the pain d. Complete an assessment of the client's functional ability. One day following an open reduction and b. Neurovascular and circulation compromise related to compartment syndrome. internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk? a. Reduce pulmonary ventilation and oxygenation related to fat embolism. b. Neurovascular and circulation compromise related to compartment syndrome. c. Wound infection and delayed healing to fractured bone protrusion. d. Venous stasis and thrombophlebitis related to postoperative immobility. The nurse is completing a head to be b. Clear fluid leaking from the nose. assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse? a. Sluggish pupillary response to light b. Clear fluid leaking from the nose. c. Complaint of severe headache d. Periorbital ecchymosis of right eye. A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff's sign). Which pathophysiological mechanism supports this response a. Arterial Constriction b. Temporary vasodilation c. Poor temperature control d. Severe dehydration. b. Temporary vasodilation While assessing a radial artery catheter, b. Promptly remove the arterial catheter from the radial artery. the client complains of numbness and pain distal to the insertion site. What interventions should the nurse implement? a. Determine of aspirin was given prior to radial artery catheter insertion. b. Promptly remove the arterial catheter from the radial artery. c. Irrigate the arterial line using a syringe with sterile saline d. Administer a PRN analgesic and assess numbness in 30 mints A client is admitted with an epidural c. Rapid onset of decreased level of consciousness. hematoma that resulted from a skateboarding accident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? a. Slow increasing intracranial pressure (ICP) b. Decerebrate posturing c. Rapid onset of decreased level of consciousness. d. Coup contrecoup signs The nurse finds a client at 33 weeks b. Position a firm wedge to support pelvis and thorax at 30-degree tilt. gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? a. Apply oxygen by mask after opening the airway b. Position a firm wedge to support pelvis and thorax at 30-degree tilt. c. Give continuous compression with a ventilation ratio at 20:3 d. Apply less compression force to reduce aspiration When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most important for the nurse to include in the client's discharge teaching plan? a. Report any signs of cloudy urine output. b. Seek counseling for body image concerns c. Follow instruction for self-care toileting d. Frequently empty bladder to avoid distension. a. Report any signs of cloudy urine output. For the past 24 hours, an antidiarrheal d. Tented skin turgor. agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? a. Loss of appetite b. Serum K 4.0 mEq/or mmol/dl (SI) c. Loose, runny stool d. Tented skin turgor. After repositioning an immobile client, the c. Apply light pressure over the area. nurse observes an area of hyperemia. To assess for blanching, what action should the nurse take? a. Note the skin color around the area b. Measure the degree of... c. Apply light pressure over the area. d. Palpate the temperature of the area. The nurse enters a client's room and b. Reposition the restraint tie onto the bedframe. observes the client's wrist restraint secured as seen in the picture. What action should the nurse take? a. Use a full knot to secure the restrain tie. b. Reposition the restraint tie onto the bedframe. c. Raise the button side rail of the client's bed d. Document that the restrain is secured. A female client with acute respiratory c. Diminished left lower lobe sounds. distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2. Which assessment finding warrants immediate intervention by the nurse? a. Premature atrial contractions (PAC) b. Hemoccult-positive nasogastric fluid c. Diminished left lower lobe sounds. d. Increasing endotracheal secretions. Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to the healthcare provider a. This output is not sufficient to cleat nitrogenous waste b. Oliguria signals tubular necrosis related to hypoperfusion c. Low urine output puts the client at risk for fluid overload d. An increased urine output is expected after splenectomy b. Oliguria signals tubular necrosis related to hypoperfusion A nurse-manager is preparing the d. Skills of staff and client acuity curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective? a. Client geographic location and age b. Number of staff and number of clients c. Weekend and weekday staff availability d. Skills of staff and client acuity When performing postural drainage on a d. Explain that the client may be placed in five positions client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? a. Perform the drainage immediately after meals b. Instruct the client to breath shallow and fast c. Obtain arterial blood gases (ABG's) prior to procedure d. Explain that the client may be placed in five positions A client presents in the emergency room b. Inability to close the affected eye, raise brow, or smile with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facial muscles. What symptoms suggest that the client has most likely experience a Bell's palsy rather than a stroke? a. Slow onset of facial drooping associated with headache b. Inability to close the affected eye, raise brow, or smile c. A flat nasolabial fold on the right resulting in facial asymmetry. d. Drooling is present on right side of the mouth, but not on the left. The nurse is teaching a client how to b. Keeps the irrigating container less than 18 inches above the stoma perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching? a. Turns to left the side to instill the irrigating solution into the stoma b. Keeps the irrigating container less than 18 inches above the stoma c. Instills 1,200 ml of irrigating solution to stimulate bowel evacuation d. Inserts irrigating catheter deeper into stoma when cramping occurs The nurse should teach the client to observe which precaution while taking dronedarone? a. Stay out of direct sunlight b. Avoid grapefruits and its juice c. Reduce the use of herbal supplements d. Minimize sodium intake. b. Avoid grapefruits and its juice A client who sustained a head injury c. Confusion and papilledema following an automobile collision is admitted to the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? a. Increased Glasgow coma scale score. b. Nuchal rigidity and papilledema. c. Confusion and papilledema d. Periorbital ecchymosis. The nurse is caring for a client receiving d. Confirm the necessity for continued use of the CVC. continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection? a. Remind staff to follow protective environment precautions b. Gently flush the catheter lumen with sterile saline solution c. Cleanse the site and change the transparent dressing. d. Confirm the necessity for continued use of the CVC. During an annual physical examination, an d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)? a. An increased thirst with frequent urination b. Blood glucose range during past two weeks was 110 to 125 mg/dl or 6.1 to 7.0 mmol/L(SI) c. Two-hour postprandial glucose tolerance test (GTT) is 160 mg/dL or 8.9 mmol/L (SI) d. Repeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). A new mother tells the nurse that she is unsure if she will be able to transition into parenthood. What action should the nurse take? a. Provide reassurance to the client that these feeling are normal after delivery b. Discuss delaying the client's discharge from the hospital for another 24 hrs. c. Determine if she can ask for support from family, friend, or the baby's father. d. Explain the differences between postpartum blues and postpartum depression. c. Determine if she can ask for support from family, friend, or the baby's father. A client who was admitted yesterday with c. Stop the normal saline infusion. severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Which intervention should the nurse implement first? a. Establish the second IV site b. Asses the IV for blood return c. Stop the normal saline infusion. d. Discontinue the 24-gauge IV An elderly female is admitted because of d. Ensure proper alignment of the leg in traction. a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking her left hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan care? a. Evaluate her response to narcotic analgesia b. Asses the skin under the traction moleskin c. Place a pillow under the involved lower left leg d. Ensure proper alignment of the leg in traction. An Unna boot is applied to a client with a b. Document the ongoing wound healing. venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nurse take in response to this finding? a. Immediately apply a pressure dressing b. Document the ongoing wound healing. c. Irrigate the wound with sterile saline d. Obtain a capillary INR, measurement At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is the priority nursing diagnosis for this client? a. Knowledge deficit b. Anxiety c. Anticipatory grieving d. Pain (acute) b. Anxiety The nurse note a visible prolapse of the c. Elevate the presenting part off the cord. umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should the nurse implement immediately? a. Administer oxygen by face mask at 6L/mint b. Transport the client for a cesarean delivery c. Elevate the presenting part off the cord. d. Place the client to a knee-chest position. A client who had a right hip replacement a. Reassess readiness for SNF transfer. 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursing facility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider? a. Reassess readiness for SNF transfer. b. Obtain specimens for culture analysis c. Confer with family about home care plans d. Arrange physical therapy for strengthening. An older male comes to the clinic with a c. Assess the surroundings for noise and distractions. family member. When the nurse attempts to take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first a. Ask the family member to answer the questions. b. Provide a printed health care assessment form c. Assess the surroundings for noise and distractions. d. Defer the health history until the client is less anxious. The nurse caring for a client with acute renal fluid (ARF) has noted that the client has voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need? a. Treatment for acute uremic symptoms within 24 hours b. Change to a regular diet c. Large amounts of fluid and electrolyte replacement. d. Unrestricted sodium intake c. Large amounts of fluid and electrolyte replacement. Which intervention should the nurse include in the plan of care for a child with tetanus? a. Open window shades to provide natural light b. Reposition side to side every hour. c. Minimize the number of stimuli in the room. d. Encourage coughing and deep breathing c. Minimize the number of stimuli in the room.