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EXIT HESI
| Question | Answer |
|---|---|
| multiple organ dysfunction syndrome (MODS). Which system assessment should the nurse monitor as an indicator of MODS progression? | RENAL -- common manifestation in MODS is acute renal failure |
| While assessing the hair and scalp of an adult client, the nurse notes that the client has dry, brittle hair. Which information should the nurse obtain first? | CURRENT HAIR CARE REGIMEN |
| indwelling catheter to obtain a urine specimen | CLAMP DRAIN TUBE, LABEL SPECIMEN, PLACE IN BIO BAG, DOCUMENT |
| A nurse who adheres to the belief that life is sacred should be able to establish a therapeutic relationship most effectively with which client? | TERMINALLY ILL, DEPRESSED W/CANCER -- cancer was not a decision made by pt. |
| A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical abdominal wound. Which room is best for the nurse to assign this client? | PRIVATE ROOM ON MED UNIT |
| Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's respirations are six breaths per minute. What action should the nurse take first? | ATTEMPT TO AROUSE -- noninvasive measures first |
| (FHR) drops sharply from the baseline for 30 seconds during the peak of a contraction and then returns to the baseline before the end of the contraction. What action should the nurse implement at this time? | PLACE ON LEFT SIDE |
| Which clinical finding should the nurse identify in a client who is admitted with cardiac cirrhosis? | PERIPHERAL EDEMA |
| A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part of preoperative teaching, what information should the nurse provide? | STOOL IS EVENTUALLY EXPELLED FROM RECTUM |
| Which biological practices are federally regulated for healthcare workers? | STANDARD PRECAUTIONS, N95, BLOOD BORN PATHOGEN, RESOURCE CONSERVATION RECOVERY ACT |
| A male client is receiving (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What nursing action should the nurse implement first? | DESCRIBE PLACEMENT AND RATIONALE |
| A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response? | "I have known many clients with depression who have felt better after several weeks of treatment." |
| What assessment findings should the nurse identify before referring a client for further evaluation to rule out skin cancer? (Select all that apply.) | IRREGULAR BORED, ASYMMETRICAL LESION, COLOR VARIATIONS |
| The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan? | METHOD USED TO ASPIRATE DRUG FROM VIAL |
| Parents of a toddler tell the nurse that their child eats little at mealtime, sits at the table with the family only briefly, and wants snacks "all the time." What recommendation should the nurse provide? | GIVE TODDLER NUTRITIOUS SNACKS |
| Which contextual factors are considered external environmental influences in the framework for occupational health programs and services? (Select all that apply.) | ECONOMICS, TECHNOLOGY, LEGISLATION |
| Because the census is currently low in the Obstetrics (OB) unit, one of the nurses is sent to work on a medical-surgical unit for the day, or until the OB unit becomes busy. Which client assessment is best for the charge nurse to assign to the OB nurse? | ADULT W/COLON RESECTION YESTERDAY AND IV - nurse has experience in caring for abdominal wounds |
| Which outcome is best for the nurse to include in the plan of care for a client with impaired social interaction and obsessive-compulsive disorder? | Participates in one social or recreational activity each morning and afternoon. |
| Which client is at highest risk for chronic kidney disease (CKD) secondary to diabetes mellitus (DM)? | Type 1 DM and retinopathy and mild vision loss. |
| A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload? | Increase in size. |
| Which responsibility best describes the role of a nurse as manager? | Delivery of client care while meeting agency goals. |
| The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer? | A teacher who seeks information about her disease and wants to continue teaching. |
| cells increase in surface area or size by increasing the amount of contractile proteins, but the quantity of fibers remain constant | MYOCARDIAL HYPERTROPHY |
| Which responsibility best describes the role of a nurse as manager? | DELIVERY OF CLIENT CARE WHILE MEETING AGENCY GOALS |
| A young adult female comes to the health clinic to confirm a positive home pregnancy test. After determining the client's last menstrual period (LMP) as February 14, what expected date of birth (EDB) should the nurse calculate? | NOV 21 -- add 7 days to first day of LMP, subtract 3 months |
| N gele's rule for calculating EDB? | add 7 days to first day of LMP, subtract 3 months |
| A client is receiving a continuous bladder irrigation at 1000 ml/hour after a prostatectomy. The nurse determines the client's urine output for the past hour is 200 ml. What action should the nurse implement first? | STOP THE IRRIGATION FLOW DUE TO POSSIBLE OBSTRUCTION // PREVENT DISTENTION |
| The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase | URINE OUTPUT 55 ML/HR |
| He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement? | ENCOURAGE HIM TO HANG OUT WITH NON-SMOKERS WHILE ATTEMPTING TO QUIT |
| What is the most effective way to implement a teaching plan? | TEACH INFO THEY *WANT* TO LEARN FIRST |
| What is the underlying pathophysiologic process between free radicals and destruction of a cell membrane? | ENZYME RELEASE FROM LYSOSOMES |
| LYSOSOMES | "suicide bags" polyunsat fats bind to fatty acids in lysosome membrane, then the protein leaks out and the cell dies |
| Designated funds are received to address the healthcare needs of a community's vulnerable populations. Which group qualifies for this funding? | SURVIVORS OF VIOLENCE FROM 5 YRS AGO |
| a female client who is delusional told the nurse that her healthcare provider needs to be released from her case because they are going to get married on her birthday. Which statement made by the client today indicates that the client is less delusional? | "I don't talk about things like that anymore." |
| A client with terminal pancreatic cancer is receiving hospice care at home and reports increasing shortness of breath and associated anxiety. Which prescription should the nurse implement first? | MORPHINE 5 TO 10 MG AS NEEDED |
| When assessing a client's interior eye structures with an ophthalmoscope, which action should the nurse use? | ADJUST THE DIOPTERS |
| Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a preschool setting? | ENSURE HEP A VACCINE |
| The nurse is assessing a client 12 hours after a spinal cord injury at C7 level. Which finding is most important for the nurse to report to the healthcare provider? | SPO2 IS 88% WITH SHALLOW SLOW RESPS |
| A 60-year-old homeless man who complains of a cough, late-afternoon fever, and night sweats has a 10 mm induration after receiving a purified protein derivative (PPD) skin test. Which action should the nurse implement? | REFER FOR DIAGNOSTIC EVAL |
| When assessing an intravenous (IV) solution infusing by gravity, the nurse observes that the IV fluid continues to flow when pressure is applied above the catheter tip. What action should the nurse implement? | GATHER SUPPLIES NEEDED TO D/C IV |
| The nurse inflates the cuff on a tracheostomy tube to minimal occlusion pressure for a client who is breathing spontaneously. Which action should the nurse follow? | INJECT AIR UNTIL NO AIR IS HEARD OVER LARYNX |
| minimal pressure (minimal occlusion volume technique) | inject air into the tracheostomy tube cuff while auscultating with a stethoscope placed over the larynx (over the cuff) during inhalation |
| The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? | RETAKE BP IN SAME ARM, DEFLATING SLOWLY |
| distended bladder, hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction? | Obstruction at the urinary bladder neck. |
| The nurse begins a physical assessment of an 8-month-old. The child is sitting contentedly on the mother's lap, chewing on a toy. Which action should the nurse implement first? | AUSCULTATE HEART AND LUNGS |
| A male client on a psychiatric unit becomes extremely agitated and begins to smash his head against doors. He seems frightened, and his verbalizations suggest he is experiencing distorted sensory perceptions. What action should the nurse take first? | RESTRAIN UNTIL CALM |
| A client with acute pancreatitis is admitted to the medical unit. During the nurse's admission interview, which assessment has the highest priority? | INTENSITY OF PAIN |
| A nurse is caring for a male client with paranoid schizophrenia who believes that his antipsychotic medications are poison. Which intervention is best for the nurse to implement? | APPROACH CLIENT WITH MED 30 MIN LATER |
| A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle? | 90 |
| Which action should the nurse take first when performing tracheostomy care? | OXYGENATE 100% |
| The nurse is analyzing the waveforms of a client’s electrocardiogram. What finding indicates a disturbance in electrical conduction in the ventricles? | QRS INTERVAL OF 0.14 SEC |
| normal duration of the QRS | 0.04 - 0.12 |
| T WAVE | 0.16 |
| PR INTERVAL RANGE | 0.12 - 0.20 |
| QT | 0.31 - 0.38 |
| A child with nephrotic syndrome is receiving prednisone (Deltasone). Which priority nursing diagnosis should the nurse include in the plan of care? | RISK FOR INFECTION |
| STEROID USE | RISK FOR INFX DUE TO ALTERED IMMUNE MECHANISMS NEEDING STEROID THERAPY |
| Which action should the nurse implement when implementing a physical assessment of an older client? | Arrange the exam sequence to minimizes position changes. |
| Duplex scanning confirms the presence of a deep venous thrombosis for a client with swelling and pain of the lower leg. While the client is receiving continuous heparin infusion, what actions should the nurse implement? | Avoid any intramuscular medications to prevent localized bleeding. |
| The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the nurse implement? | Assess and document skin condition around the incision and IV site at each shift. |
| A client who is 12 hours post total thyroidectomy develops stridor on exhalation. What is the nurse's first action? | CALL FOR EMERGENCY ASSISTANCE |
| Which type of management style is a case management model for nursing care delivery? | PT FOCUSED AND PRIMARY NURSING |
| Which client is at greatest risk for multiple organ dysfunction syndrome (MODS)? | An older client with intestinal obstruction and septic shock. |
| MODS | decreased organ reserve, comorbidities, and massive inflammatory or immune dysfunction, such as septic shock, or clients who have experienced various ischemia-reperfusion events related to trauma or surgical complications |
| To treat cystitis, a 14-day course of treatment with cephalexin (Ceclor) is prescribed for a client residing in a long-term care facility. Which action is most important for the nurse to take prior to administering the first dose of this medication? | Determine if the client has ever had a hypersensitivity reaction to penicillins. |
| A new mother asks the nurse why her infant son has yellow liquid coming out of his eyes. Which explanation is correct? | "An antibiotic ointment is placed in each newborn's eyes to prevent infection." |
| A client is receiving a continuous IV infusion and intermittent IV antibiotics. The nurse should plan to collaborate with the case manager regarding which aspect of this client's care? | Evaluation of the need for continued IV antibiotics to achieve the desired outcomes. |
| large quantity of acetaminophen (Tylenol). The nurse should prepare for which treatment to be implemented? | Acetylcysteine (Mucomyst) 140 mg/kg. |
| male client with acute leukemia is admitted for blood transfusions because his hemoglobin is 6 gm/dl. O2 82%. The nurse increases the O2 per nasal cannula from 3 to 4 liters per minute. What intervention should the nurse implement next? | Start the first transfusion of blood. |
| Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa? | Consume at least 50% of all meals. |
| Which type of delivery of nursing care is organized around tasks? | Functional nursing. |
| The nurse is caring for a client with ulcerative colitis and formulates a nursing diagnosis of, "Impaired skin integrity related to diarrhea." What client behavior demonstrates that the teaching regarding perianal care is effective? | Cleans perianal area with mild soap and water after each diarrhea stool. |
| The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement? | Defibrillate at 200 joules. |
| A client at 13-weeks gestation is scheduled for an amniocentesis in one week. The nurse knows that the primary reason for conducting this procedure is to obtain what information? | PRESENCE OF GENETIC DISORDERS |
| A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question? | ATROPINE |
| mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear sounds over the other lung fields. Based on these assessment findings, which action should the nurse take? | SUCTION ENDOTRACHEAL TUBE AND AUSCULTATE |
| (CKD) and severe anemia refuses blood transfusions. The healthcare provider prescribes epoetin alfa. Which action should the nurse explain to the client about the medication's therapeutic response? | STIMS ERYTHROPOIESES IN BONE MARROW TO INCREASE CIRCULATING ERYTHROCYTES |
| Epoetin alfa | biological response modifier that is used to stimulate the formation of red blood cells |
| Two hours after the vaginal delivery of a 7-pound, 3-ounce infant, a client's fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first? | PALPATE ABOVE SYMPHYSIS FOR BLADDER |
| During the physical assessment, which finding should the nurse recognize as a normal finding? | REGULAR PULSATION AT THE EPIGASTRIC AREA WHEN CLIENT IS SUPINE |
| An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? | STAGE 3 |
| A client is being admitted to the medical unit from the emergency department after having a chest tube inserted. What equipment should be brought to this client's room? | Rubber-tipped clamps. |
| A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having? | OBSESSIVE |
| The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture? | SERUM POTASSIUM 5.5, TOTAL CALCIUM 6 MG |
| Prior to a cardiac catheterization, which activity should the nurse have the client practice? | Valsalva's maneuver and coughing. |
| The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select? | A Buretrol attachment -- restrict the total volume of IV fluids that a client receives |
| A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid? | Dried prunes. |
| "Imbalanced nutrition: more than body requirements?" | Inadequate lifestyle changes in diet and exercise. |
| The scope of professional nursing practice is determined by rules promulgated by which organization? | STATE BOARD OF NURSING |
| The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next? | Mark the drainage on the dressing and take vital signs. |
| An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client? | Tricyclic antidepressants. |
| The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? | "Wanting the drug is all that matters to an addict." |
| right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? | Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning. |
| A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client? | A nurse with Marfan's syndrome who is postmenopausal. |
| In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition? | Increased thirst. |
| A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse? | Administer isoniazid (INH) daily for 6 to 9 months. |
| When engaging in planned change on the unit, what should the nurse-manager establish first? | Staff members are aware of the need for change. |
| A male client who lives in an area endemic with Lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide? | Look for early signs of a lesion that increases in size with a red border, clear center. |
| The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement? | Administer the dose as prescribed. |
| Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia? | Lethargy or irritability. |
| The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function? | Change in level of consciousness. |
| Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse? | Implements health programs for construction workers. |
| Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication? | Increase daily intake of raw fruits and vegetables. |
| A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map? | Multidisciplinary group. |
| The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? | An African-American client may have slightly yellow sclerae. |
| The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace which her healthcare provider has prescribed. Which instruction would be accurate? | Remove the brace one hour each day for bathing only. |
| periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse // What assessment finding would be consistent with a basilar skull fracture? | Rhinorrhoea or otorrhoea with Halo sign. |
| To assess a client’s pupillary response to accommodation, a nurse should perform which activity? | Ask the client to look at a distant object and then at an object held 10 cm from the nose. |
| arterial occlusion from a clot | common postoperative complication after valve replacement |
| Addisonian crisis | Hypotension, rapid weak pulse, and rapid respiratory rate. |
| Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma? | Metoprolol tartrate (Lopressor). |
| A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, an exhibiting signs of restlessness. Which action should the nurse take fist? | auscultate breath sounds |
| no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client's medical history? | Frequency of laxative use for chronic constipation |
| Which assessment finding is indicative of a developing epidural hematoma? | Altered consciousness within the first 24 hours after injury. |
| 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? | Culture for sensitive organisms. |
| 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? | Determine if the sensation feels uncomfortable. |
| A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? | COUNSEL FOR CANCER RISKS |
| one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site? | DELTOID |
| A client diagnosed with calcium kidney stones has a history 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? | ALLOPURIONOL **allopurinol diminishes aluminum hydroxide and increases gout! |
| The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation? | Brain damage with CP is not progressive but does have a variable course. **CP is non-progressive |
| A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? | SEND STOOL SAMPLE FOR GUAIAC TEST |
| infant returns w/gastrostomy tube for trachea esophageal fistula- the mom wonders when tube feeding can begin...? | STOMACH CONTENTS AND AIR MUST BE DRAINED FIRST |
| trachea esophageal fistula (TEF) | abnormal connection between your trachea and esophagus. |
| A confused client has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)? | ASSIST W/ADLs |
| An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication? | THE CLIENTS MANUAL DEXTERITY **how well can they admin gtts |
| A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note | HIGH PROTEIN |
| A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to | CHECK FREQUENTLY FOR SWOLLEN FEET |
| During the beginning shift assessment of a client with asthma and is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding? | RAPID SHALLOW RESPIRATIONS W/INTERMITTENT WHEEZES |
| A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because it? | REDUCES POTENTIAL FOR SHOCK |
| When teaching new parents to prevent Sudden Infant Death Syndrome (SIDS) what is the most important practice the nurse should instruct them to do? | PLACE INFANT IN SUPINE OR SIDE LYING FOR SLEEP |
| A child with Tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention to | ASSESSMENT OF O2 |
| When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority? | RISK FOR INJURY: HEMORRHAGE |
| While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality? | IRREGULAR HIP SYMMETRY |
| The nurse is planning care for a client with increased intracranial pressure. The best position for this client is | SEMI-FOWLERS |
| When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility? | AMENORRHEA |
| A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis | ELEVATED CPK (creatinine phosphokinase) |
| diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect? | mental confusion |
| In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test? | unchanged urine specific gravity |
| A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize | admin of thyroid hormone will prevent problems |
| The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure? | encourage ROM and ambulation |
| To prevent a Valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would | admin stool softeners every day as ordered |
| Valsalva maneuver | Involves forceful exhalation and can test cardiac and autonomic nervous function |
| The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? | SHALLOW RESPIRATIONS |
| A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? | FETAL HEART TONES LOCATED IN UPPER RIGHT QUADRANTS |
| PO dressing, red swollen wound with moderate yellow/green drainage and foul odor, positive MRSA, most important action for nurse to take? | REQUEST WOULD CULTURE AND SENSITIVITY |
| The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL is alert and diaphoretic. What action should the charge nurse take? | GIVE OJ |
| The nurse identifies an electrolyte imbalance, crackles on auscultation and an elevated blood pressure in a client with progressive heart disease. Which intervention should the nurse include in the plan of care? | MEASURE ANKLE CIRCUMFERENCE |
| overweight, heart failure client shopping list | pain air popped popcorn & natural whole almonds |
| Which intervention is most important for the nurse to include in the plan of care for a client who is being mechanically ventilated and is receiving continuous enteral feedings? | Maintain the head of the bed elevated at 45 degrees |
| Which type of leukocyte is involved with allergic responses and the destruction of parasitic worms? | eosinophils |
| complex hand washing rituals // cleanliness concerns // which clinical manifestation? | compulsion |
| The 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? | Brings a heavy can close to body before lifting & Widens stance while working near the sink |
| Widens stance while working near the sink | eat small meals throughout the day to avoid full stomach |
| The nurse assesses a child in 90-90 skeletal traction. Where should the nurse assess for signs of compartment syndrome? | toes of injured foot or distal point to injured limb |
| 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? | neutrophil count |
| A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. NA 129, Glucose 54, K+ 5.3, nurse anticipates what med? | hydrocortisone |
| To prevent medication errors by an older client who is sometimes confused, which intervention by the home health nurse is likely to be most effective? | provide education verbally and written |
| 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 client's compliance with self care? | have the client vocalize the instructions provided |
| An adult male was diagnosed with stage IV lung cancer three weeks ago, wife wonders when death is imminent? | loss of consciousness and body systems will slow down |
| total gastrectomy // NG tube, rec LR 75 ml/hr., 300 ml blood loss in container, 155 HR, 78/48 BP, reports to surgeon, then...? | increase infusion of LR solution **attempt to reverse fluid loss |
| Which information is a priority for the RN to reinforce to an older client after intravenous pylegraphy? | Measure the urine output for the next day and immediately notify the health care provider if it should decrease. |
| A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is | WEEKLY WEIGHT |
| A client has been diagnosed with Zollinger-Ellison syndrome.Which information is most important for the nurse to reinforce with the client? | It is critical to report promptly to your health care provider any findings of peptic ulcers |
| ZOLLINGER-ELLISON SYNDROME | A condition where the body produces an excess of the gastrin hormone that causes stomach to produce too much acid. This causes peptic ulcers and diarrhea. |
| A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client’s blood pressure is increasing. Which action should the nurse take first? | TURN HER TO THE LEFT |
| The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? | COLD, PALE LOWER LEG |
| The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? | 103 FEVER |
| A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? | Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception |
| A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? | the flow of life is believed to flow through major pathways or nerve clusters in your body |
| The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? | Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent |
| Kawasaki Disease | causes swelling (inflammation) in children in the walls of small to medium-sized blood vessels that carry blood throughout the body. |
| A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? | side lying on left with head of bed elevated to 10 degrees |
| A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? | minimal drainage into the urinary collection bag |
| nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client’s pulse and respirations, what should be the function of the second nurse? | participate with compressions or breaths |
| The nurse assesses a 72 year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? | jugular vein distention |
| A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication | can predispose to dysrhythmias |
| A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? | pupils fixed and dilated **neuro signs, think eyes and consciousness |
| A 14 year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? | I went to the health care provider last week for a cold and I have gotten worse." |
| Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? | pale mucosa of eyelids and lips |
| The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is | pupil responses |
| Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? | A preschooler with intermittent episodes of alertness |
| The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be | Pale, thin arms and legs, uninterested in surroundings |
| As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? | hair loss |
| While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius | give Tylenol as ordered since this is normal during this time |
| A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be | assess for dyspnea or stridor |
| Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? | I went to the bathroom and my urine looked very red and it didn’t hurt when I went. |
| A middle aged woman talks to the nurse in the health care provider’s office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? | Fibroids that cause no problems still need to be taken out. |
| An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? | Stay with client and observe for airway obstruction |
| The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal | S3 ventricular gallop |
| Which of these observations made by the nurse during an excretory urogram indicate a complicaton? | The client’s entire body turns a bright red color |
| excretory urogram | intravenous pyelogram (PIE-uh-low-gram) is an X-ray exam of the urinary tract. Also called an excretory urogram, this exam allows your care team to see the parts of your urinary tract and how well they work |
| A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? | "The tube will remove excess air from your chest." |
| spontaneous pneumothorax | air in the lung |
| hemothorax |
Created by:
jemerson