ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide

ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide STUDY FOR EXIT HESI/ATI EXAM ALL HESI EXIT Questions and Answers Test Bank; A+ Rated Guide (2022) 271. A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take? (correct Answer- Administer the medication as prescribed with a glass of water 272. Which client should the nurse assess frequently because of the risk for overflow incontinence? A client Who is confused and frequently forgets to go to the bathroom 273. While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply) (correct AnswerMove obstacle away from client Monitor physical movements Observe for a patent airway Record the duration of the seizure 274. A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client's plan of care? (correct Answer- Observe for changes in level of consciousness. 275. An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client's ABG finding, which action is required? correct Answer- Increase ventilator rate. 276. The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide? (correct Answer- CPT should be performed more frequently, but at least an hour before meals. 277. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendationfor hypertension? 1 | P a g e(correct Answer- Baked pork chop, applesauce, corn on the cob, 2% milk, and key- lime pie 278. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client's plan of care? (correct Answer- Fingerstick glucose assessment q6h with meals Review with the client proper foot care and prevention of injury Coordinate carbohydrate controlled meals at consistent times and intervals Teach subcutaneous injection technique, site rotation and insulin management 279. Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse? (correct Answer- Muscle pain 280. While assessing a client's chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client's vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? (correct Answer- Provide supplemental oxygen Auscultate bilateral lung fields Reinforce occlusive CT dressing 281. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? (correct Answer- Ensure that the knot can be quickly released. 282. Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution? (correct Answer- Have the child lie with the ear up for one to two minute after installation. 283. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? (correct Answer- Restrict daily fluid intake. 284. The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next? (correct Answer- Leave the catheter in place and obtain a sterile catheter. 285. A client with coronary artery disease who is experiencing syncopal episodes is admitted 2 | P a g efor an electrophysiology study (EPS) and possible cardiac ablation therapy. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? (correct Answer- Prepare the skin for procedure. 286. Fallowing an outbreak of measles involving 5 students in an elementary school, which action is most important for the school nurse to take? (correct Answer- Restrict unvaccinated children from attending school until measles outbreak is resolved. 287. A preeclamptic client who delivered 24h ago remains in the labor and delivery recovery room. She continues to receive magnesium sulfate at 2 grams per hour. Her total input is limited to 125 ml per hour, and her urinary output for the last hour was 850 ml. What intervention should the nurse implement? (correct Answer- Continue with the plan of care for this client 288. The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? (correct Answer- Begin to show signs of improvement in affect 289. When assessing a multigravida the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? (correct Answer- Check for a destined bladder 290. A 12 year old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement? (correct Answer- Encourage popsicles and fluids of choice 291. An older male client arrives at the clinic complaining that his bladder always feels full. He complains of weak urine flow, frequent dribbling after voiding, and increasing nocturia with difficulty initiating his urine stream. Which action should the nurse implement? (correct Answer- Palpate the client's suprapubic area for distention 292. The nurse is preparing to administer 1.6 ml of medication IM to a 4 month old infant. Which action should the nurse include? (correct Answer- Divide the medication into two injection with volumes under 1ml 293. A client who had a below the knee amputation is experiencing severe phantom limb pain (PLP) and ask the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? (correct Answer- Research indicates that mirror therapy is effective in reducing phantom limb pain 3 | P a g e294. An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? (correct Answer- Notify healthcare provider to prepare for pericardiocentesis 295. A new member joins the nursing team spreads books on the table, puts items on two chairs, and sits on a third chair. The members of the group are forced to move closer and remove their possessions from the table what action should the nurse leader take? (correct Answer- Ask the new person to move belonging to accommodate others 296. The nurse is caring for a one week old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? (correct Answer- Poor feeding and vomiting Leakage of CSF from the incisional site Abdominal distention 297. The nurse is preparing a heparin bolus dose of 80 units/kg for a client who weighs 220 pounds. Heparin sodium injection, USP is available in a 3o ml multidose vial with the concentration of 1,000 USP units/ml. how many ml of heparin should the nurse administer? (Enter numeric value only) ( correct Answer- 8 298. In monitoring tissue perfusion in a client following an above the knee amputation (aka), which action should the nurse include in the plan of care? (correct Answer- Evaluate closet proximal pulse. 299. The leg of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personal (UAP) place a heating pad on the mottled areas, what action should the nurse take? (correct Answer- Remove the heating pads and place a soft blanket over the client's leg and feet. 300. A client who underwent an uncomplicated gastric bypass surgery is having difficult with diet management. What dietary instruction is most important for the nurse to explain to the client? (correct Answer- Plan volume-controlled evenly- space meal thorough the day 301. If the nurse is initiating IV fluid replacement for a child who has dry, sticky mucous membranes, flushed skin, and fever of 103.6 F. Laboratory finding indicate that the child has a sodium concentration of 156 mEq/L. What physiologic mechanism contributes to this finding? (correct Answer- Insensible loss of body fluids contributes to the hemoconcentration of serum solutes 302. During a Woman's Health fair, which assignment is the best for the Practical Nurse (PN) who is working with a register nurse (RN) (correct Answer- Prepare a woman for a bone density screening 303. An adult client present to the clinic with large draining ulcers on both lower legs that are characteristics of Kaposi's sarcoma lesions. The client is accompanied by two family member. 4 | P a g eWhich action should the nurse take? (correct Answer- Send family to the waiting area while the client's history is taking 304. An adult client is exhibit the maniac stage of bipolar disorder is admitted to the psychiatric unit. The client has lost 10 pounds in the last two weeks and has no bathed in a week "I'm trying to start a new business and "I'm too busy to eat". The client is oriented to time, place, person but not situation. Which nursing problem has the greatest priority? (correct Answer- Imbalance nutrition 305. The nurse is preparing a discharge teaching plan for a client who had a liver transplant. Which instruction is most important to include in this plan? (correct Answer- Avoid crowds for first two months after surgery. 306. The nurse is assessing a client's nailbeds. Witch appearance indicates further follow-up is needed for problems associated with chronic hypoxia? (correct Answer- Image 307. A client who had a percutaneous transluminal coronary angioplasty (PTCA) two weeks ago returns to the clinic for a follow up visit. The client has a postoperative ejection fraction ejection fraction of 30%. Today the client has lungs which are clear, +1 pedal edema, and a 5pound weight gain. Which intervention the nurse implement? (correct Answer- Assess compliance with routine prescriptions. 308. The RN is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? The client who is (correct Answer- Three days postoperative colon resection receiving transfusion of packed RBCs. 309. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be include in the discharge teaching? (correct Answer- Avoid straining at stool, bending, or lifting heavy objects. 310. The healthcare provider prescribes potassium chloride 25 mEq in 500 ml D_5W to infuse over 6 hours. The available 20 ml vial of potassium chloride is labeled, "10 mEq/5ml." how many ml of potassium chloride should the nurse add the IV fluid? (Enter numeric value only. If is rounding is required, round to the nearest tenth.) (correct Answer- 12.5 311. At 40 week gestation, a laboring client who is lying is a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? (correct Answer- Place a wedge under the client's right hip. 312. A client with a history of diabetes and coronary artery disease is admitted with shortness of breath, anxiety, and confusion. The client's blood pressure is 80/60 mmHg, heart rate 120 beats/minute with audible third and fourth heart sounds, and bibasilar crackles. The client's average urinary output is 5 ml/hour. Normal saline is infusing at 124 ml/hour with a secondary infusion of dopamine at mcg/kg/minute per infusion pump. With intervention should the nurse implement? (correct Answer- Titrate the dopamine infusion to raise the BP. 313. The nurse ends the assessment of a client by performing a mental status exam. Which statement correctly describes the purpose of the mental status exam? (correct Answer- Evaluate the client's mood, cognition and orientation. 314. An older adult resident of a long-term care facility has a 5-year history of hypertension. 5 | P a g eThe client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) (correct Answer- Administer a daily dose of lisinopril as scheduled. Provide a PRN dose of acetaminophen for headache 315. When conducting diet teaching for a client who is on a postoperative soft diet, which foods should eat? (Select all that apply) (correct Answer- Pasta, noodles, rice. Egg, tofu, ground meat. Mashed, potatoes, pudding, milk. A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma? (correct Answer- The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction. Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic symptoms. Although carteolol (B) is a beta blocking agent and an effective antihypertensive agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs, causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive pulmonary disorders. A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide? (correct Answer- Although the healthcare provider discontinued the propranolol, measures to prevent rebound cardiac excitation, such as progressively reducing the dose over one to two weeks (C), should be recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias. Abrupt cessation (A and B) of the beta-blocking agent may precipitate tachycardia and rebound hypertension, so gradual weaning should be recommended. (D) is not indicated. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make? (correct Answer- How long has the client been taking the medication? Drowsiness can occur in the early weeks of treatment with clonidine and with continued use becomes less intense, so the length of time the client has been on the medication (A) provides information to direct additional instruction. (B, C, and D) are not relevant. The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide? (correct Answer- Decrease the risk of bradycardia during surgery. 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? (correct Answer- Drugs with anticholinergic properties, such as tricyclic antidepressants (C), can exacerbate urinary retention associated with opioids in the older client. Although tricyclic antidepressants and antihistamines with opioids can exacerbate urinary retention, the concurrent use of (A and B) with opioids do not. Nonsteroidal antiinflammatory agents (D) can increase the risk for bleeding, but do not increase urinary retention with opioids (D). A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I 6 | P a g ehave been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide? (correct Answer- Provide antiinflammatory response. A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor? (correct Answer- Acetaminophen and alcohol are both metabolized in the liver. This places the client at risk for hepatotoxicity, so monitoring liver (A) function is the most important assessment because the combination of acetaminophen and alcohol, even in moderate amounts, can cause potentially fatal liver damage. Other non-narcotic analgesics, such as n onsteroidal anti- inflammatory drugs (NSAIDs), are more likely to promote adverse renal effects (B). Acetaminophen does not place the client at risk for toxic reactions related to (C or D). 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? (correct Answer- Administer the dose as prescribed. Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the ventricular rate, and is used to treat atrial flutter, so (A) should be implemented, based on the client's heart rate and blood pressure. (B and C) are not indicated. (D) delays the administration of the scheduled dose. A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care? (correct Answer- One chronic and one acute illness. Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide? (correct Answer- Stimulate contraction of the uterus. Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit? (correct Answer- Supervised and guided visits with infant. A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent? (correct Answer- The client is a minor and cannot legally sign his own consent unless he is an emancipated minor, so the consent should be obtained from the guardian for this client, which is the custodial parent (B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has been adopted by the stepparent (C). The non-custodial parent does not need to co-sign this form (D). During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first? (correct Answer- Identify the problem. The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short-term goal is best for this client? (correct Answer- Eat 50% of six small meals each day by the end of one week. A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any more contact with the hospital. How should the nurse respond? (correct Answer- The chart is the property of the facility, but the client has a legal right to the information in it, even if he is 7 | P a g eleaving AMA, so a copy of the record (D) should be provided. The client does not lose his legal rights to his medical record if he leaves AMA (A). The medical record is confidential, but the hospital protects the client's privacy by not allowing unauthorized access to the record, so the hospital may provide the client with a copy (B). The hospital must maintain records of the care provided and should not release the original record (C). The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment? (correct Answer- In developing organizational skills, medication administration is based on a prescribed schedule that is time-sensitive in the delivery of nursing care and should be the priority in scheduling nursing activities in a daily assignment. Although suctioning a client's tracheostomy takes precedence in providing care, the client's PRN need is less amenable to a preselected schedule. (B and C) can be scheduled around time-sensitive delivery of care. What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period? (correct Answer- Primary nursing (B) is a model of delivery of care where a nurse is accountable for planning care for clients around the clock. Functional nursing (D) is a care delivery model that provides client care by assignment of functions or tasks. Team nursing (A) is a care delivery model where assignments to a group of clients are provided by a mixed-staff team. Case management (C) is the delivery of care that uses a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs and promote quality cost-effective outcomes. Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict? (correct Answer- Dealing with the issues which are concrete, not personalities (A) which include emotional reactions, is one of seven important key behaviors in managing conflict. (B, C, and D) do not resolve the conflict when diverse opinions are expressed emotionally. The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome? (correct Answer- The nurse should evaluate the client's outcome by observing the client's performance of each expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective, which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid intake. The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem? (correct Answer- Activity intolerance related to postoperative pain. A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement? (correct Answer- Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented for clients in isolation with contact precautions, it is most important that air flow from the room is minimized when the client has TB. (B) should be implemented when the client leaves the isolation environment. A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next? (correct Answer- Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate, so the medication should be administered (C) because the client's apical pulse is greater than 60. (A, B, and D) are not indicated at this time. 8 | P a g eThe nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation? (correct Answer- Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred to as a goiter, and a bruit may be auscultated over the goiter due to an increase in glandular vascularity which increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C). A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture? (correct Answer- Rhinorrhoea or otorrhoea with Halo sign. Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt abdominal injuries. The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder? (correct Answer- This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease (A), which is an autoimmune condition affecting the thyroid. (B, C, and D) are not associated with these symptoms. The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding? (correct Answer- Ptosis is the term to describe an eyelid droop that covers a large portion of the iris (A), which may result from oculomotor nerve or eyelid muscle disorder. The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take? (correct Answer- The child is overweight for height, so assessment of the child's daily diet (C) should be determined. The child does not need (A or B), both of which will increase the child's weight. Poor nutrition (D) is commonly seen in underweight children, not overweight. A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.) (correct Answer- 61 The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day; or 10 to 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24. 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24 hours = 61 mL/hour The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take? (correct Answer- Withhold the medication and contact the healthcare provider. Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than 100 beats/minute, digoxin should be withheld and the healthcare provider should be notified (D). 9 | P a g eAssessing the respiratory rate (A) is not indicated before administering Lanoxin. (B and C) place the infant at further risk for digoxin toxicity. The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include? (correct Answer- Wear the brace over a T-shirt 23 hours per day. Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Early treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature, under the neck, and against the iliac crest, so it should be worn for 23 hours per day over a T- shirt (D) which reduces friction and chafing of the skin. (A, B, and C) reduce the effectiveness of the brace. A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond? (correct Answer- "To protect you because you can get an infection very easily." The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy? (correct Answer- "I will keep the baby's eyes covered when the baby is under the light." Neonatal jaundice is related to subcutaneous deposition of fat-soluble (indirect) bilirubin, which is converted to a water-soluble form when the skin is exposed to an ultraviolet light, so the infant's eyes should be protected (C) by closing the eyes and placing patches over them before placing the baby under the phototherapy light source. The baby's position should be changed about every two hours, not (A), so that the light reaches all areas of the body to promote conversion to a water-soluble form of bilirubin, which is excreted in the urine. The infant can be removed from the light for feedings and diaper changes, but should receive phototherapy exposure for 18 hours a day (B). The baby should be naked or dressed in only a diaper to expose as much skin as possible to the light (D). A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement? (correct Answer- Apply a water soluble lubricant to the lips, oral mucosa and nares. To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the mucous membranes moist (D). (A) is a petroleum-based product and should not be used because it is flammable. (B and C) should not be given to the client with a nasogastric tube to suction because it can cause further distension and interfere with fluid and electrolyte balance. 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? (correct Answer- Serum potassium of 5.5 mEq and total calcium of 6 mg/dl. In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vitamin D, calcium absorption is impaired, and serum calcium decreases, which stimulates the release of PTH causing resorption of calcium and phosphate from the bone. A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia (C). (A) is reflective of a non-renal cause, such as dehydration or liver pathology. (B) is more indicative of infection. Renal failure causes anemia and hyperphosphatemia, not (D). Which information should the nurse give a client with chronic kidney disease (CKD)? (correct Answer- Avoid salt substitutes. 10 | P a g eA client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so (C) should be taught. Hypocalcemia is a complication of CKD and calcium supplements are often needed, not (A). Anemia related to CKD is treated with iron, folic acid, and erythropoietin, not (B). Although (D) is a common dietary recommendation, it not an essential part of client teaching for CKD. A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide? (correct Answer- This anti- estrogen drug inhibits malignancy growth. Tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit the growth-stimulating effects (C) of estrogen by blocking estrogen receptor sites on malignant cells. A side effect of tamoxifen is hot flashes (A), which is related to the decreased estrogen. Tamoxifen is used for women with estrogen receptor-positive breast cancer, not all women (B), and is classified as a hormonal agent, not (D), used to suppress malignant cell growth. A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client? (correct Answer- A nurse with Marfan's syndrome who is postmenopausal. Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer? (correct Answer- Use a sanitary napkin instead of a tampon. Clients should avoid the use of tampons for 3 to 6 weeks (D) after the procedure to reduce the risk of infection. A heavy, watery vaginal discharge is expected during this time, so (A) is unnecessary. Sexual intercourse should be avoided for up to 6 weeks, so (B) is inaccurate. (C) is not a side effect of the procedure but may indicate human papillomavirus or a cancerous lesion and should be reported. Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers? (correct Answer- Case manager. The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider? (correct Answer- Recalls drinking a glass of juice after midnight. The risk of aspiration while under general anesthesia is increased when the stomach is not empty prior to a surgical procedure, so the client's intake of juice (B) after midnight should be reported the healthcare provider. Preoperative fear and anxiety (A) are common and should be further explored by the nurse. (C) should be communicated using allergy identification tags on the client's records and bracelets on the client's wrist. (D) is a common and expected side effect of perioperative medications. The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide? (correct Answer- Early adolescence is a developmental stage of normal experimentation. The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement? (correct Answer- Ask the spouse to step out for a few minutes. 11 | P a g eThe nurse determines that a client's body weight is 105% above the standardized height- weight scale. Which related factor should the nurse include in the nursing problem, "Imbalanced nutrition: more than body requirements?" (correct Answer- Inadequate lifestyle changes in diet and exercise. The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding? (correct Answer- Purplish-red pinpoint lesions of the skin. The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? (correct Answer- An African-American client may have slightly yellow sclerae. During the physical assessment, which finding should the nurse recognize as a normal finding? (correct Answer- Regular pulsation at the epigastric area when the client is supine Recognizing normal findings in the physical exam is a necessity. The regular and recurrent expansion and contraction of an artery produced by waves of pressure caused by the ejection of blood from the left ventricle as it contracts is a normal finding (A). (B, C, and D) are abnormal findings that require further assessment. 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? (correct Answer- Change in level of consciousness. Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS), which includes verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness (D), as indicated by responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. (A, B, and C) are late signs of altered cerebral function. When documenting assessment data, which statement should the nurse record in the narrative nursing notes? (correct Answer- S1 murmur auscultated in supine position. 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? (correct Answer- Obsessive The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take? (correct Answer- Tell the receptionist to have the healthcare provider return the phone call. 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. The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes? (correct Answer- Participants can identify at least three coping strategies to use during labor. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation? (correct Answer- Secondary prevention (B) attempts to halt the progression of the disease process, in 12 | P a g ethis case, an escalation in the battering, by educating the client about prevention strategies. The nurse has identified client injuries that create a suspicion of battering and domestic violence. Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio? (correct Answer- A self-evaluation that identifies how the nurse has met professional objectives and goals. When engaging in planned change on the unit, what should the nurse-manager establish first? (correct Answer- Staff members are aware of the need for change. 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? (correct Answer- Multidisciplinary group. The scope of professional nursing practice is determined by rules promulgated by which organization? (correct Answer- State's Board of Nursing. 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? (correct Answer- Pressure ulcers develop over skin surfaces usually covering bony prominences and are caused by external pressure that impedes blood flow, causing ischemia of the skin and underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 (C) because it is a full thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. (A) is a nonblanchable pressure point over intact skin. (B) is a partial thickness ulcer, such as a ruptured blister or shallow open ulcer with a pink wound bed. (D) is a full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar, and often includes undermining and tunneling. After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first? (correct Answer- Based on Maslow's hierarchy of needs and the need to address airway, breathing, and circulation (ABCs), the client with a new onset of difficulty breathing (A) should be assessed first. (B, C and D) do not have the priority of (A). When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care? (correct Answer- Coordinating and educating about multidisciplinary services. Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer? (correct Answer- 1.5 mL. A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid? (correct Answer- A serving of dried prunes (D) contains more than 300 mg of potassium, and should be avoided. The richest dietary sources of potassium are unprocessed foods (especially fruits), many vegetables, and some dairy products, so the client should avoid these food groups. Servings of foods containing less than 150 mg of potassium, such as (A, B, and C), are good choices for a low potassium diet. A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? (correct Answer- Hypotension, rapid weak pulse, and rapid respiratory rate. 13 | P a g eThe nurse plans to suction a male client who has just undergone 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? (correct Answer- Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning. A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client? (correct Answer- Nasal cannula. Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time? (correct Answer- Encourage the use of an incentive spirometer. A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care? (correct Answer- Ask client to describe triggers of anger. 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? (correct Answer- Wanting the drug is all that matters to an addict. The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? A client with (correct Answer- Spinal cord injuries (C) place the client at high risk for the development of neurogenic distributive shock. The development to watch for in (A) is cardiogenic shock, in (B) is hemorrhagic shock, and in (D) is hypovolemic shock. Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? (correct Answer- You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan? (correct Answer- Avoid sharing towels and washcloths with siblings. The school nurse is reviewing health risks associated with extracurricular activities of grade- school children. Regular participation in which activity places the child at highest risk for developing external otitis? (correct Answer- Swimming lessons in an indoor pool. The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands? (correct Answer- A pregnant woman. The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? (correct Answer- Frequent blood pressure checks, including readings taken by automated machines, are recommended. A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? (correct Answer- Monitor for 14 | P a g eincreased blood pressure and pulse. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. What intervention should the nurse implement? (correct Answer- Confront the client about the consequences of the behavior. 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? (correct Answer- Increased thirst. (A) is a primary factor in monitoring effectiveness of treatment for diabetes insipidus. A child with diabetes insipidus does not want to eat, and only wants to drink; in fact he or she may even drink water from toilets and vases. The anterior fontanel usually closes at about 18 months of age; therefore, (B) is not an appropriate measure of dehydration for a 3-year-old. The skin of a child with diabetes insipidus is usually warm and dry, not (C). (D) is not characteristic of diabetes insipidus, but is characteristic of hypothyroidism, Cushing syndrome, or nephrotic syndrome. A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement? (correct Answer- Demonstrate the wound care procedure to the PN while the PN assists A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse can lessen the symptoms of this "TET spell?" (correct Answer- The child should be placed on his or her back in the knee-to-chest position (B) to increase blood vessel resistance. The increased pressure reduces the rush of blood through the septal hole and improves blood circulation. During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client? (correct Answer- Taking medication, with community follow-up. The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema? (correct Answer- History of inflammatory bowel disorders. A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem? (correct Answer- Denial related to the loss of a loved one. A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse- manager take? (correct Answer- Report the incident to the immediate supervisor. A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take? (correct Answer- Stop the code immediately. A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate? (correct Answer- It will identify someone that can make decisions for your health care if you are in a coma or vegetative state. 15 | P a g eWhich documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? The client (correct Answer- reports decrease in pain. After eye drops are instilled, which instruction should the nurse provide to the client? (correct Answer- Close your eyelids. 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? (correct Answer- A Buretrol attachment. Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess? (correct Answer- Tolerance of exertion. Lasix 20 mg PO is prescribed for a client at 0600. The medication is available in a scored tablet of 40 mg. Before breaking the tablet, what action should the nurse take? (correct Answer- Perform hand hygiene Which assessment finding should make the nurse suspect that a 21-year-old male client is taking anabolic steroids? (correct Answer- Describes working hard to develop muscles. Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication? (correct Answer- A common side effect of antipsychotic medications is constipation, and increasing high-fiber foods in the diet (A) can help to alleviate this problem. Prior to the discharge of a healthy 4-day-old newborn, the nurse is collecting the blood specimens to screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test? (correct Answer- Assess the newborn's feeding patterns of formula or breast milk which has "come in." Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse? (correct Answer- Implements health programs for construction workers. The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond? (correct Answer- Confidentiality. 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? (correct Answer- Rubber-tipped clamps. A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide? (correct Answer- Headache and hyperirritability are common. 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? (correct Answer- Mark the drainage on the dressing and take vital signs. Drainage on a surgical dressing should be described by type, amount, color, consistency, and odor, and the surgeon should be notified of any excessive or abnormal drainage and significant 16 | P a g echanges in vital signs. To determine that the drainage on an abdominal surgical dressing is usual and not an indication of hemorrhage, marking the 6 cm drainage on the dressing (A) assists in determining an increase in the amount which is supported with any changes in vital signs that indicates possible internal bleeding. (B) is premature. Removing the initial dressing may disturb the surgical site and increase the risk of hemorrhage and infection (C). (D) is compared with the previous amount of drainage marked on the dressing, so (A) is necessary. The nurse is planning care for a client who is having abdominal surgery. To achieve desired postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such as turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include? (correct Answer- Administer analgesics prior to encouraging progressive activities and ambulation. To assess a client's pupillary response to accommodation, a nurse should perform which activity? (correct Answer- Ask the client to look at a distant object and then at an object held 10 cm from the nose. 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? (correct Answer- Administer isoniazid (INH) daily for 6 to 9 months. Prior to a cardiac catheterization, which activity should the nurse have the client practice? (correct Answer- Valsalva's maneuver and coughing. A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take? (correct Answer- Keep the client in bed in the supine position. The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA). Which intervention should the nurse include in the plan of care? (correct Answer- Progressive leg exercises to obtain 90-degree flexion A client with chronic osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide? (correct Answer- The infection has walled off into an area of infected bone creating a barrier to antibiotics. A sequestrum (dead bone) is separated from the living bone and has no blood supply, so neither antibiotics nor white blood cells can reach the infected area (D). (A and B) do not address the encasement of the necrotic tissue. Although a sinus tract may occur, (C) does not address the purpose of the surgery. After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatoid arthritis returns to the clinic for a follow-up visit. Which laboratory finding should the nurse review for a therapeutic response? (correct Answer- An elevated erythrocyte sedimentation rate (ESR) is indicative of active inflammation, so the nurse should determine if the ESR has normalized (D) 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? (correct Answer- Look for early signs of a lesion that increases in size with a red border, clear center. 17 | P a g eThe client should look for the early signs of localized Lyme disease known as erythema migrans, a skin lesion that slowly expands to form a large round lesion with a bright red border and clear center (B) at the site of the tick bite. What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies? (correct Answer- Recognizes the value of a client's input into their own health care. Alternative and complementary therapies offer human-centered care based on philosophies that recognize the value of the client's input and honor cultural and individual beliefs, values, and desires (C). The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices? (correct Answer- Individual beliefs. The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement? (correct Answer- Immunizations that decrease occurrences of many contagious diseases Primary prevention involves health promotion and disease prevention activities to decrease the occurrence of illness and enhance general health and quality of life, such as immunization (A). A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide? (correct Answer- Five to seven days after menses cease. Due to the effect of cyclic ovarian changes on the breast, the best time for breast self- examination (BSE) is 5 to 7 days after menstruation stops (D) because physiologic alterations in breast size and activity reach their minimal level after menses. A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond? (correct Answer- "Tell me about your undergarments so we can discuss how you can have your examination comfortably. A young adult female arrives at the emergency center with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings? (correct Answer- Young adult female presents with periorbital ecchymosis on right side, 3 cm laceration on left parietal area, approximately 1 cm deep with tissue bridging. States her boyfriend is abusive During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection. The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women? (correct Answer- Chlamydia. Chlamydia (B) is the most common and fastest spreading sexually transmitted infection (STI) in American women, with an estimated 3 million new cases each year A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide? (correct Answer- Avoid tight-fitting clothing and do not use bubble-bath or bath salts. 18 | P a g eA female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LMP) was February 14. The client wants to know the expected date of birth (EDB). How should the nurse respond? (correct Answer- November 21. Using Nägele's rule to calculate EDB, subtract 3 months and add 7 days to the first day of the last normal menstrual period. 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? (correct Answer- Palpate above the symphysis for the bladder. Two hours after giving birth, the uterus should be firm, in the midline, and below the umbilicus. If the fundus is high, dextroverted and boggy, urinary retention is likely distending the bladder, so palpating for a full bladder above the symphysis (B) should be implemented first. The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who is in the first trimester of pregnancy. Which action should the nurse prepare the client for? (correct Answer- Preparing for other diagnostic testing. The triple marker screen measures maternal serum levels for alpha-fetoprotein (AFP), human chorionic gonadotropin (HCG), and estriol, which screens for indications of possible fetal defects. An elevated result may be a false indicator, so other tests are indicated (B). Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple? (correct Answer- Diagnostic testing may indicate a fetal problem that could be treated prior to delivery. Which finding should the nurse identify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia? (correct Answer- Hyperbilirubinemia causes severe brain damage, encephalopathy (kernicterus), that results from the deposition of unconjugated bilirubin in brain cells. Prodromal clinical manifestations of central nervous system involvement include decreased activity, a loss of interest in feeding, and lethargy or irritability (C). Which approach should the nurse use when preparing a toddler for a procedure? (correct Answer- Demonstrate the procedure using a doll. Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach? (correct Answer- Give one hour before or two hours after a meal. A male client with a history of chronic back pain that was managed with opiate analgesics calls the nurse after having back surgery. The client reports that the back pain is finally gone, but after stopping the pain medication, the client has been having severe diarrhea and painful muscle cramps. Which assessment information should the nurse obtain next? (correct Answer- When did the symptoms begin after the last dose of opiate analgesic? Moderate to severe opiate withdrawal manifests with moderate to severe vomiting, diarrhea, muscle cramps, and elevated blood pressures greater than 110 systolic or 70 diastolic.