HESI MILESTONE 2 EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+

1 HESI MILESTONE 2 EXAM | QUESTIONS & ANSWERS (VERIFIED) | LATEST UPDATE | GRADED A+ A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the RN to ask the client? Correct Answer: Do you hear sounds or voices that others do not hear? The schizophrenic client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning? Correct Answer: Ineffective denial related to situational anxiety The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? Correct Answer: Muscle twitches in the back and neck 32-year-old male client is admitted with paranoid schizophrenia Correct Answer: Reassure the client that he is safe and should rest. 2 What is schizophrenia? Correct Answer: it is a chemical imbalance in the brain that causes disorganized thinking: Dx: 2 or more S&S for over 6 mo (Positive= delusions, hallucinations, disorganized speech or Negative= 6 A's Anhedonia, Flat Affect, Apathy, Anergia, Algogia, Avolition) -Establish rapport and trust, ask about hallucinations, distract, lower environmental stimuli, monitor suicidal ideation, 1st or 2nd generation antipsych grief process/ therapeutic response Correct Answer: A. Encourage client to express anger in a supportive, nonthreatening environment. B. Discourage rumination. C. Assist client in giving up idealized perception of deceased; point out misrepresentations. D. Encourage interaction with others. E. Assist client with identification of support systems. F. Consult spiritual leader as indicated by client need and preference. G. Assist client toward a comfortable, peaceful death. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping 3 utensils on the floor and then refuses to eat. What action should the nurse implement? Correct Answer: Encourage finger foods, distraction, speak therapeutically 2 days after admission from alcohol withdrawal what should the nurse do? Correct Answer: Monitor HR and BP which action should the nurse implement first for a client experiencing alcohol withdrawal? Correct Answer: prepare the environment to prevent self injury: self A patient won't take oral meds that is going through alcohol withdrawal. The nurse starts giving saline lock per alcohol protocol and thiamine. What do you tell them that it will help with recovery? Correct Answer: Thiamine will replenish alcohol effects on the body (something to do with iron) A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysrhythmias. What would you give first? Correct Answer: Magnesium Patient having to get treated for benzodiazepine and methadone overdose. What do you use? 4 Correct Answer: Narcan When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide? Correct Answer: all clients are screened for domestic abuse because it is common in our society a mental health care worker caring for a client with escalating aggressive behavior. What action by the mental healthcare worker wards immediate interventions? Correct Answer: -attempting to physically restrain patient Violence handling Correct Answer: - Engage in dialogue to prevent escalation, intervene early in the cycle - Approach as non threatening, calm manner and convey empathy - Encourage the client to express their anger, build trust, anticipate need for meds, be consistent a 30 year old sales manager tells the nurse "i am thinking about a job change. i don't feel like i am living up to my potential." which of maslows developmental stages is the sales manager attempting to achieve Correct Answer: self actualization: 5 A client is admitted to the mental health unit and reports taking extra anti anxiety medication because, "I'm so stressed out. I just want to go to sleep." The RN should plan one-on-one observation of the client based on which statement? Correct Answer: "I don't want to walk. Nothing matters anymore." What is the most important goal for a client diagnosed with major depression who has been receiving an antidepressant medication for two weeks? Correct Answer: not attempt to commit suicide The nurse is obtaining the medical histories of new clients at a community-based primary care clinic. Which individual has the highest risk for experiencing elder abuse? Correct Answer: A 78 year old female on a fixed income who lives with her relatives Who is most prone to being abused (elder abuse)? Correct Answer: Females over 75 living with their families. While caring for an older client, the RN observes multiple bruises in Over the client's legs, arms, back, and gluteal areas. When the RN suspects elder abuse. What action should the RN take? Correct Answer: Measure and document size, shape and color of the bruised areas. 6 Grief priority Correct Answer: Priority should be based on SHOCK! When checking a third grader's height and weight the school nurse notes that these measurements have not changed in the last year. The child is currently taking daily vitamins, albuterol, and methylphenidate for attention deficit hyperactivity disorder (ADHD). Which intervention should the nurse implement? Correct Answer: Refer child to the family healthcare provider A middle school male student was recently diagnosed with Attention-Deficit Hyperactivity Disorder (ADHD) and is having trouble with his grades. He is referred to the school nurse by the teacher because he continues to have learning problems. Which action should the school nurse take? Correct Answer: • Refer the child to the school counselor for educational testing A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the RN at bedtime. What action should the nurse implement? Correct Answer: Encourage the client to express her feelings regarding the upcoming procedure. 7 When preparing to administer a domestic violence screening tool to a female client, which statement should the nurse provide Correct Answer: all clients are screened for domestic abuse because it is common in our society A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first? Correct Answer: Do you have a plan in place when you are not safe? (SAFETY!!!) You're having a one on one session and nurse begins to get angry at patient. Correct Answer: terminate the session before the feelings escalate. A nurse is preparing a client for the termination phase of the nurse-client relationship. The nurse prepares to implement which nursing task appropriate for this phase? Correct Answer: Making appropriate referrals Which action should the nurse implement during the termination phase of the nurseclient relationship? Correct Answer: Help summarize accomplishments. Which features are prominent in anorexia nervosa? Correct Answer: Amenorrhea for 3 cycles; Perfectionism; Powerlessness; Rigid food rituals 8 After receiving treatment for anorexia, a student asks the school nurse for permission to work in the school cafeteria as part of the school's work study program. What action should the nurse take? Correct Answer: Recommend assignment to the receptionist's office. Bizarre social behavior Correct Answer: assess physical needs, suicide risk, ensure safety at all time - sit w/ client, silence, tell when leaving - limit stimuli / 1-1 interaction Which assessment finding should indicate to the nurse that a client with arterial HTN is experiencing a cardiac complication? Correct Answer: Shortness of breath on exertion When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are Correct Answer: Most likely related to low thyroid hormone levels and will improve with treatment. Diverticulosis signs and symptoms Correct Answer: LLQ abdominal pain (descending/sigmoid colon) Bloating/Gas 9 Fever Nausea/Vomiting Constipation alt. w/ diarrhea Anorexia A patient is ordered by the physician to take allopurinol (Zyloprim) for treatment of gout. You've provided education to the patient about this medication. Which statement by the patient requires you to re-educate them about this medication? Correct Answer: "This medication will help relieve the inflammation and pain during an acute attack" Allopurinol Correct Answer: -take after meals - avoid alcohol - purine-rich foods (red meat/shellfish/fructose drinks) - increase fluids - reduce stress DM poor compliance Correct Answer: Check feet Check visual acuity Check sensation 10 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 Correct Answer: Report weight gain of 2 pounds (0.9kg) in 24 hours A male pt calls the clinic and complains because he can't tie his shoes? What should the nurse do next? Correct Answer: Ask if the pt has gained weight in the past few days Osteoarthritis exercise Correct Answer: Aquatic exercise—improves function, decreases pain Remind client that excessive use of the involved joint aggravates pain and may accelerate degeneration The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to osteoarthritis? Correct Answer: Long distance runner since high school. A client with a small bowel obstruction is experiencing frequent vomiting. Which instructions are most important for the nurse to provide to the UAP who is completing morning care for this client? Correct Answer: Maintain a quiet environment 11 The nurse is caring for a client with a small bowel obstruction. The client is vomiting foul smelling fecal-like material. Which action should the nurse implement? Correct Answer: Give IV fluids with electrolytes. The nurse is assessing a client with a small bowel obstruction who was hospitalized 24 hours ago. Which assessment finding should the nurse report immediately to the healthcare provider? Correct Answer: Rebound tenderness in the upper quadrants The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of "Ineffective airway clearance related to thick pulmonary secretions." Which intervention is most important for the nurse to include in the client's plan of care? Correct Answer: Increase fluid intake to 3,000 ml/daily Pneumonia Treatment/Prevention Correct Answer: oxygen therapy, hydration, bed rest, positioning to facilitate breathing, deep breathing, humidified air, chest physiotherapy, suctioning prn, A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen with a Venturi mask at a rate of 3 L/min. Prior to initiating oxygen therapy, the patient appeared anxious with gray skin, a respiratory rate of 24 breaths/min, and an oxygen 12 saturation of 87%. After 15 minutes of oxygen therapy, the nurse observes the patient resting with closed eyes, pink coloration, a respiratory rate of 12 breaths/min, and an oxygen saturation of 95%. Which action by the nurse is correct? Correct Answer: Decrease the oxygen to 2 L/min to improve respiratory rate What are the nutritional needs of this client throughout recovery? Correct Answer: Acute phase: NPO, IV fluids • Recovery phase: no fiber or foods that irritate the bowel • Maintenance phase: high-fiber diet with bulk-forming laxatives A client is admitted to the hospital with a diagnosis of severe acute diverticulitis. Which nursing intervention has the highest priority Correct Answer: Place the client on NPO status. A nurse is caring for a client who has heart failure and has been taking digoxin 0.25 mg daily. The client refuses breakfast and reports nausea. Which of the following actions should the nurse take first? Correct Answer: Check the client's vital signs. The healthcare provider prescribes digitalis (Digoxin) for a client diagnosed with congestive heart failure. Which intervention should the nurse implement prior to administering the digoxin? Correct Answer: Assess the serum potassium level 13 A 77-year-old female client is admitted to the hospital. She is confused and has had no appetite for several days. She has been nauseated and vomited several times prior to admission. She is currently complaining of a headache. Her pulse rate is 43 beats/min. The nurse is most concerned about the client's history related to what medication? Correct Answer: Digitalis (Lanoxin) The nurse is administering a dose of digoxin to a patient with heart failure (HF). The nurse would become concerned with the possibility of digitalis toxicity if the patient reported which symptom? Correct Answer: Anorexia, nausea, vomiting, blurred or yellow vision, and cardiac dysrhythmias are all signs of digitalis toxicity IV fluids hypertonic Correct Answer: Hypertonic solutions exert an osmotic pressure greater than that of the ECF. When normal saline solution or lactated Ringer solution contains 5% dextrose, the total osmolality exceeds that of the ECF Saline 3% or 5% 3% NaCl 5% Nacl D10W 'D20W 14 D50W D5LR Rheumatoid arthritis pain Correct Answer: movement causes pain, rather than relieving pain. Rheumatoid arthritis occurs bilaterally. E. Morning stiffness F. Bilateral inflammation of joints PUD NGT Correct Answer: During surgery stomach contents are drained by NG tube - Confirmation that obstruction is the cause of pt discomfort us done by assessing the amount of of fluid aspirated a residual of 400 mL indicated obstruction prostatic hyperplasia Correct Answer: Decreased force in the stream of urine is an early symptom of benign prostatic hyperplasia - urgency - nocturia - hesitancy - decreased/intermittent stream - incomplete emptying - less than 50-100mL's 15 Assessment: palpate the bladder BPH - don't give antihistamines - do not give decongestant, anticholinergics, antidepressants Type I DM tight control Correct Answer: glucose checks at home - A1C should be 4-6% *** LESS THAN 7% Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? Correct Answer: Reduce risks factors for infection A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD? Correct Answer: The client smokes 1 to 2 packs of cigarettes per day. IBD - peritonitis Correct Answer: - Fluid, colloid, and electrolyte replacement is the major focus - Antibiotic therapy 16 The mother of a child recently diagnosed with asthma asks the nurse how to help protect her child from having asthmatic attacks. To avoid triggers for asthmatic attacks, which instructions should the nurse provide the mother? (Select all that apply) Correct Answer: Close car windows and use air conditioner Avoid sudden changes in temperature Keep away from pets with long hair Stay indoors when grass is being cut Ulcerative colitis bloody diarrhea Correct Answer: Patients with ulcerative colitis may experience as many as 10-20 liquid, bloody stools per day Arterial insufficiency diabetic Correct Answer: arterial insufficiency symptoms -weak pedal pulses -shiny and cool skin -intermittent claudication - aching/cramping - induced fatigue Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)? 17 Correct Answer: The nurse should instruct the client to not lie down for about 2 hours after eating to prevent reflux. Minimize symptoms by wearing loose and comfortable clothes Pre op labs which is abnormal Correct Answer: WBC count higher than 5,000-10,000/mm3 = possible infection Seizure unconscious patient Correct Answer: Make sure suction is available While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply) Correct Answer: a. Move obstacle away from client b. Monitor physical movements d. Observe for a patent airway e. Record the duration of the seizure A pt is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions? Correct Answer: monitor urinary stream for decrease in urinary output 18 A patient returns to the medical-surgical unit after having extracorporeal shock wave lithotripsy (ESWL). What is an appropriate nursing intervention for the postprocedural care of this patient? Correct Answer: Strain the urine to monitor the passage of stone fragments General anesthesia - post anesthesia car Correct Answer: systolic under 90 = immediately reportable unless baseline!! Thrombocytopenia labs Correct Answer: under 50,000 /LOW PLATELET COUNT normal PT/PTT prolonged Bleeding time Thrombocytopenia: Low platelet count Bleeding and petechiae usually do not occur with platelet counts greater than 50,000/mm3, although excessive bleeding can follow surgery or other trauma. When the platelet count drops to less than 20,000/mm3, petechiae can appear, along with nasal and gingival bleeding, excessive menstrual bleeding, and excessive bleeding after surgery or dental extractions. When the platelet count is less than 5000/mm3, spontaneous, potentially fatal central nervous system or GI hemorrhage can occur Sickle cell first sign of crisis Correct Answer: pain - fatigue 19 - swollen hands and feet - dehydration **give oxygen, fluids, pain med, infection prevention A child with possible Duchenne muscular dystrophy ( MD) undergoes an electromyogram (EMG). Following the procedure, the child's parents tell the nurse that the child is complaining of sore muscle. How should the nurse respond? Correct Answer: Offer reassurance that muscle soreness following this procedures is temporary and does not indicate a problem The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, "How can our son have this disease? We are wondering if we should have any more children." What information should the nurse provide to parents? Correct Answer: This is an inherited X-linked recessive disorder, which primarily affects male children in the family A 4-year-old boy was recently diagnosed with Duchenne muscular dystrophy (DMD). Which characteristic of the disease is most important for the nurse to focus on during the initial teaching? Correct Answer: Lower legs become progressively weaker, causing waddling, unsteady gait Duchenne muscular dystrophy 20 Correct Answer: Duchenne muscular dystrophy appears in early childhood (ages 3 to 5 years) (children appear normal at birth until signs and symptoms of the disease manifest). By the age of 9 to 11 years old, the child loses the ability to walk independently. Life expectancy generally in the third decade Febrile seizures teaching Correct Answer: febrile seizures: reassure parents febrile seizures will go away use seizure precautions, call 911 if lasts more than 5 minutes The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider? Correct Answer: Weight gain of 2.2 lbs (1kg) in last 48 hours Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease? Correct Answer: Susceptibility to respiratory infection In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? Correct Answer: Diminished femoral pulses 21 RSV distress Correct Answer: RSV: Private room, not airborne - transferred via hand (no mask is needed) - Standard precautions. Cool mist via tent. Do not expose other children to RSV, it is very contagious even without direct contact Look for nasal flaring Pyloric stenosis symptoms Correct Answer: olive shaped mass may be visible Mass in the upper right abdominal quadrant, shaped like an olive. S/s:- RUQ sausage shaped mass - vomiting/ Note Degree of forcefulness of vomiting episodes - bloody mucus stool fever weight loss The 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated? Correct Answer: Weak cry without any tears. The nurse is assessing an infant with pyloric stenosis. Which pathophysiological mechanism is the most likely consequence of this infant's clinical picture? Correct Answer: metabolic alkalosis (from the forceful vomiting) 22 The nurse is preparing a child with an intussusception for a prescribed barium enema. What is the main purpose of conducting this procedure prior to surgical intervention? Correct Answer: Reduce the invaginated bowel segment. The nurse is caring for an infant scheduled for reduction of intussusceptions. The day before the scheduled procedure the infant passes a soft-formed brown stool. Which intervention should the nurse implement? Correct Answer: Notify the healthcare provider of the passage of brown stool. A healthcare provider informs the charge nurse of a labor and delivery unit that a client is coming to the unit suspected abruptio placentae. What findings should the charge nurse expect the client to demonstrate? Correct Answer: A. dark,red vaginal bleeding D. increased uterine irritability F. Rigid abdomen placenta abruption s/s Correct Answer: severe abdominal and back pain uterine rigidity bright red or dark vaginal bleeding maternal hypovolemia 23 -A client who is at 32 wks calls the HCP b/c she is experiencing dark red vag bleeding. She is admitted to the ED, where the nurse determines the FHR to be 100bpm. The client's abd is rigid & boardlike, & she is complaining of severe pain. What action does the nurse take first? Correct Answer: -Use their knowledge base to differentiate b/w abruption & previa -IMMEDIATELY NOTIFY HCP, & NO ABD OR VAG MANIPULATION OR EXAMS -ADMIN O2 BY FACEMASK -MONITOR FOR BLEEDING AT IV SITE & GUMS B/C OF ↑ RISK FOR DIC -EMERGENCY C-SECTION REQUIRED b/c uteroplacental perfusion to the fetus is being compromised by early sep. of the placenta from the uterus While in labor at 39 weeks' gestation, a primigravida develops a temperature of 38.2°C (100.7°F), and fetal tachycardia is noted at 170 beats per minute. The student nurse asks the experienced nurse what this could indicate. How should the experienced nurse respond? Correct Answer: A temperature of 38.2°C (100.7°F) may indicate an infection such as chorioamnionitis, and the practitioner should be notified. Prolapsed Cord: Care Correct Answer: Care Includes: Knee to Chest position OR Trendelenburg PATIENT IS IN DELIVERY, NURSE NOTICES PRESENCE OF UMBILICAL CORD PROTRUDING THROUGH VAGINA. WHAT WOULD YOU DO? 24 Correct Answer: Knee-to-chest position or Trendelenburg's, oxygen, call physician A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? Correct Answer: supine with the foot of the bed elevated. need to aleviate pressure on the prolapsed cord. Shoulder dystocia actions Correct Answer: McRoberts' maneuver and suprapubic pressure (need step stool) Variable deceleration actions Correct Answer: Change maternal position. 2. Stimulate fetus if indicated. 3. Discontinue oxytocin (Pitocin) if infusing. 4. Administer oxygen (O2) at 10 L by tight facemask. 5. Perform a vaginal examination to check for cord prolapse. 6. Report findings to physician and document. Pt has variable deceleration. What is nursing action? Correct Answer: Turn her on her side Nurse discovers the postpartum client has a boggy uterus and is on the left side 25 Correct Answer: fundal massage and administer uterotonic to increase uterine contraction. - give oxytocin A hospitalized child stiffens and starts to seize as the nurse enters the room. What actions should the nurse take? (Select all apply) Correct Answer: • Turn client to the side if possible • Pad side rails with available pillows and blankets• Monitor duration and progress of the seizure Mother brings infant complaining of vomiting and diarrhea to ER that's been breastfeeding and introducing formula - Correct Answer: Ask what kind of water are you mixing with formula How is symmetric IUGR diagnosed Correct Answer: By serial ultrasound, which is the reason for 1st trimester ultrasound Engorgement Teaching Correct Answer: Avoid nipple stimulation Do not express milk Place ice packs for 15 minute 26 Tight fitting bra or binder A new mother reports breast engorgement and nipple pain on day 2 after the delivery of a healthy newborn. The mother tells the nurse, "I'm not sure that breastfeeding the baby is for me." What should the nurse advise the mother to do to help relieve discomfort and encourage persevering with breastfeeding? Correct Answer: Inform the mother that breastfeeding the newborn more frequently will help treat these symptoms. A client who is 3 days postpartum and breastfeeding asks the nurse how to reduce breast engorgement. Which instruction should the nurse provide? Correct Answer: Breastfeed the infant every 2 hours The nurse is teaching the parents of a 5-year-old child with cystic fibrosis about respiratory treatments. Which statement indicates to the nurse that the parents understand? Correct Answer: Administer aerosol therapy followed by postural drainage before meals. A 17-year-old male student with cystic fibrosis talks with the school nurse about his disease and wonders how it will affect getting married and having children. Which relevant information would the nurse include in this discussion? 27 Correct Answer: He is likely to have infertility problems and further evaluation The nurse is caring for a 6-month-old infant who has been diagnosed with hydrocephalus. Which of the following signs best indicates ↑ ICP in this child? Correct Answer: high pitched cry Which information is most important for the nurse to provide parents about long-term care for their child with hydrocephalus and a VP shunt? Correct Answer: Shunt malfunction or infection requires immediate treatment. A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epiphysis (SFCE). What focus should the nurse include in this child's plan of care? Correct Answer: Pin and incisional care after surgery The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client? Correct Answer: Remove the brace 1 hour each day for bathing only. post-op interventions for scoliosis Correct Answer: neuro assess 28 -log roll 5 days -iv fluids and pain meds -NPO, mouth care -NG tube, bowel sounds -assist with ambulation -body jacket for bone fusion A postpartum client who is Rh-negative refuses to receive Rho(D) immune globulin (RhoGAM) after delivery of an infant who is Rh-positive. Which information should the nurse provide this client? Correct Answer: RhoGam prevents maternal antibody formation for future Rh-positive A one-day-old neonate develops a cephalhematoma. The nurse should closely assess the neonate for which common complication? Correct Answer: Jaundice A client with hemophilia has a very swollen knee after falling from bicycle riding. Which of the following is the first nursing action? Correct Answer: apply ice pack and compression dressings to the knee A toddler with hemophilia is being discharged from the hospital. Which teaching should the nurse include in the discharge instructions to the mother? Correct Answer: apply padding to sharp edges 29 A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained.The child's color becomes blue and respiratory rate increases to 44 bpm.Which of the following actions would the nurse do first? Correct Answer: place the child in knee-to-chest position During a follow up clinical visit a mother tells the nurse that her 5 month old son who had surgical correction for tetralogy of fallot has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement? Correct Answer: Auscultate heart and lungs while infant is held Chronic kidney disease & metabolic acidosis Correct Answer: kidneys fail, no longer reabsorb HCO3 (bicarb), serum bicarbonate decrease = acidosis occurs ** sodium bicarb administration Pulmonary edema first action Correct Answer: dangle the legs RN is caring for client w DX of HF who suddenly experiences dyspnea & RN suspects pulmonary edema. RN immediately: Correct Answer: Answer: Places client in high fowlers 30 feet hanging over edge of bed The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating? Correct Answer: Normal sinus rhythm and complaining of chest pain normal sinus rhythm Correct Answer: 60-100 bpm P wave always in front P:QRS ratio 1:1 Diabetes insipidus Correct Answer: Dry Inside diabetes insipidus (DI) = makes you want to SIP water Diabetes insipidus - dysuria, dysphagia, low urine specifity gravity, wgt loss, NA+ is high, high blood sugar -Caused by a deficiency of production of ADH or a decreased renal response to ADH. -Clinical Manifestations: Polydipsia and Polyuria. -Diagnostic Studies: Water deprivation test (pt deprived of water for 8-12 hrs and then given desmopressin acetate subcut or nasally), Measure level of ADH after an analog of ADH is given PE report findings 31 Correct Answer: INCREASE D-DIMER!!! Glaucoma signs and symptoms Correct Answer: loss of peripheral vision halo around lights reddened sclera mild aching headache ** tonometry diagnose between the two (open and closed angle) IOP pressure - 30mmhg is glaucoma Guillain barre assess Correct Answer: watch for shallow/rapid breathing, ask if cold/stomach flu in last month CVA expressive aphasia Correct Answer: sg assessment: inability to speak/understand language (Left Side = Language) A patient is admitted to the ER with expressive aphasia. To further assess the patient, the nurse should include which of the following techniques: Give them picture charts to communicate Cardiomyopathy care plan 32 Correct Answer: A. Monitor vital signs at least every 4 hours for changes. B. Monitor apical HR with vital signs to detect dysrhythmias, or abnormal heart sounds such as S3 or S4. C. Assess for hypoxia. 1. Restlessness 2. Tachycardia 3. Angina F. Elevate head of bed to assist with breathing. G. Observe for signs of edema. 1. Weigh daily. 2. Monitor I&O. 3. Measure abdominal girth; observe ankles and fingers A client sustains a complex comminuted fracture of the tibia with soft tissue injuries after being hit by a car while riding a bicycle. Surgical placement of an external fixator is performed to maintain the bone in alignment. Postoperatively it is most essential for the nurse to? Correct Answer: Perform a neurovascular assessment of both lower extremities One day following an open reduction and 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 findings, what is the client's greatest risk? 33 Correct Answer: Neurovascular and circulation compromise related to compartment syndrome The nurse is caring for a client with a fractured right elbow. Which assessment finding has the highest priority and requires immediate intervention? Correct Answer: Deep unrelenting pain in the right arm Stroke broca's area Correct Answer: Stroke in Broca's area of left cerebral cortex Answer: Listen patiently - expressive aphasia usually occurs -paralyzed on right side A patient has Broca's aphasia. Which lobe of the brain does the nurse anticipate to have been affected by a stroke? Correct Answer: The frontal lobe of the brain is related to reasoning, planning, parts of speech, movement, emotions, and problem solving Acute pancreatitis assessment Correct Answer: rigid board like abdomen A nurse is caring for a client with acute pancreatitis. Which elevated laboratory test result is most indicative of acute pancreatitis 34 Correct Answer: Serum amylase When providing dietary teaching to the client with hepatitis, the nurse includes which information? Correct Answer: A. The client feels full easily and should have four to six small meals daily. B. To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia. C. Fluids are restricted with ascites caused by cirrhosis; not all clients with hepatitis progress to cirrhosis. D. Abstention from alcohol is necessary until the liver enzymes return to normal Cirrhosis ascites dyspnea Correct Answer: As the ascites increases, the client is likely to experience dyspnea because the fluid build-up puts pressure on the diaphragm A female pt was in an MVC and admitted with a fractured L femur. Nurse assessment include diminished pulses. What should the nurse do next? SATA Correct Answer: Verify pedal pulses with a Doppler Monitor L leg for pain, pulselessness, pallor,paralysis Evaluate the app of the splint to the L leg 35 Pt with Addison's has started taking hydrocortisone in a divided dose. What should the nurse do next? Correct Answer: Monitor pt's glucose If Hypoglycemia occurs during Addison's crisis, what should the nurse do? Correct Answer: Administer IV glucose Chemo side effects Correct Answer: • Nausea and vomiting • Bone marrow suppression • Alopecia • Weight gain or loss • Anorexia • Fatigue • Decline infunctional status • Mucositis • "Chemo" Brain The nurse formulates the nursing diagnosis of Urinary retention related to sensorimotor deficit for a client with multiple sclerosis. Which nursing intervention should the nurse implement? Correct Answer: Teach the client techniques of intermittent self-catheterization. 36 Meningitis first step Correct Answer: Antibiotics - penicillin (ampicillin) AND cephalosporin o Corticosteroids After the diagnosis of meningitis is confirmed, isolation is required for 24 to 72 hours after the institution of antibiotic therapy. The client with acute renal failure has a serum potassium of 6.0 mEq/L. The nurse would plan which of the following as a priority action? Correct Answer: place the client on a cardiac monitor The client hemodialyzed suddenly becomes short of breath and complains of chest pain. The client is tachycardic, pale and anxious. The nurse suspects air embolism. The priority action for the nurse is to Correct Answer: discontinue dialysis and notify the physician End of life plan of care Correct Answer: Pain management is a priority in end-of-life care because untreated or undertreated pain consumes energy; interferes with function; affects quality of life and social interactions; and contributes to sleep A nurse is caring for a client who has Cushing's syndrome. Which of the following clinical manifestations should the nurse expect to observe? (Select all that apply.) Correct Answer: 1) Buffalo hump 37 2) Purple striations 3) Moon face The nurse is developing a plan of care for a client with Cushing's syndrome. The nurse documents a client problem of excess fluid volume. Which nursing actions should be included in the care plan for this client? Select all that apply. Correct Answer: Answer: Monitor daily weight. Monitor intake and output. Assess extremities for edema When conducting discharge teaching for a client who has had a mechanical valve replacement, which information should the nurse plan to include? Correct Answer: The client will need to take an antibiotic before dental procedures. ANTIBIOTIC PROPHYLAXIS FOR DENTAL PROCEDURES!! The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? Correct Answer: The client's pain rating A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and 38 amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? Correct Answer: Sensory pattern, area, intensity, and nature of the pain. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the UAP who is assisting with a bed bath? Correct Answer: Take measures to promote as much comfort as possible