HESI (Latest UPDATES STUDY) Exam Reviews Questions and Verified Answers 100% Correct Grade A

HESI (Latest UPDATES STUDY) Exam Reviews Questions and Verified Answers 100% Correct Grade A HESI (Latest 2024 / 2025 UPDATES STUDY) Exam Reviews | Questions and Verified Answers | 100% Correct | Grade A Restless client who is biting the endotracheal tube. - -1-While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse? Endotracheal cuff pressure greater than 25 cm H20. Decreased lung compliance during ventilation. Bilateral crackles with increased secretions. Restless client who is biting the endotracheal tube. Administer a nebulizer treatment. - -2-While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? Administer a nebulizer treatment. Increase oxygen to 6 liters/minute. Assist the client to lie back in bed. Call for an Ambu resuscitating bag. Initiate intravenous fluids as prescribed. - -3-After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X- ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? Remove the catheter and apply direct pressure for 5 minutes. Initiate intravenous fluids as prescribed. Secure the catheter using aseptic technique. Notify the healthcare provider of the need to reposition the catheter. Request a culture and sensitivity of the wound. - -4-While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take? Determine if the drainage has an unpleasant odor. Monitor the client's white blood cell count (WBC). Request a culture and sensitivity of the wound. Cleanse the wound with a sterile saline solution. Increase wall suction to eliminate fluctuation in water seal. - -5-A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer tothe intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? Increase wall suction to eliminate fluctuation in water seal. Give blood from the collection chamber as autotransfusion. Add sterile water to the suction control chamber. Manipulate blood in tubing to drain into chamber. Portosystemic shunting. - -6-A client admitted to the hospital with advanced liver failure related to chronic alcoholism is exhibiting ascites and edema. Which pathophysiological mechanisms should the nurse identify as responsible for the third spacing symptoms? (Select all that apply.) Portal hypertension. Sodium and water retention. Decreased serum albumin. Abnormal protein metabolism Portosystemic shunting. Administer prescribed antibiotics. - -7-The nurse is providing care for a client with a draining postoperative wound infected with methicillin- resistant Staphylococcus aureus (MRSA). Which is the most important action for the nurse to take? Encourage increased oral fluids. Provide high-protein snacks. Change the wound dressing. Administer prescribed antibiotics. Raisin bran muffins. Bowl of oatmeal. Cup of raspberries. - -8-A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu items should the nurse suggest? (Select all that apply.) Raisin bran muffins. Bowl of oatmeal. Cup of raspberries. Scrambled eggs. Bacon slices. Wear long sleeves and pants. - -9-When teaching a group of school-aged children how to reduce the risk for Lyme disease, which instruction should the camp nurse include?Wash hands frequently. Avoid drinking lake water. Do not share personal products. Wear long sleeves and pants. The client who is immobile on prescribed bedrest. - -10-Which client will benefit most from the application of pneumatic compression devices to the lower extremities? The client who is immobile on prescribed bedrest. has pressure ulcers on several toes. has diminished pedal pulse volume. is confused and tries to climb out of bed Use sunblock or protective clothing when outdoors - -11-A 4-year-old with acute lymphocytic leukemia (ALL) is receiving chemotherapy protocol that includes methotrexate, an antimetabolite. Which information should the nurse provide the parents about caring for their child? Use sunblock or protective clothing when outdoors Include the child on regular outings with the family Obtain any childhood vaccination that is not up-to-date Use diluted commercial mouthwash with mouth care Place a wedge under the client's hip. - -12-After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement?Instruct the client to take deep breaths. Place a wedge under the client's hip. Place the client in the Trendelenburg position. Remove the client's legs from the stirrups. Place a new pad and weigh the pad removed to determine blood loss. - -13-A grand multiparous client had a precipitous delivery in the emergency room 6 hours ago. The client was given oxytocin intramuscularly after birth. The nurse examines the client and observes the pad under her buttocks is full of blood. Which action should the nurse take first? Place a new pad and weigh the pad removed to determine blood loss. Massage the fundus and express clots. Start an IV and begin an oxytocin infusion. Clean the perineal area and encourage her to breastfeed. 67 - -14-A 9-year-old is receiving vancomycin 400 mg IV every 6 hours for a methicillin-resistant (Beta- lactam-resistant) Staphylococci aureus (MRSA) infection. The medication is diluted in a100 mL bag of saline with instructions to infuse over one and a half hours. How many mL/hour should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) Institute contact precautions for staff and visitors. Use standard precautions and wear a mask Monitor the client's white blood cell count. Send wound drainage for culture and sensitivity. - -15-A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? (Select all that apply.) Explain the purpose of a low bacteria diet. Institute contact precautions for staff and visitors. Use standard precautions and wear a mask Monitor the client's white blood cell count. Send wound drainage for culture and sensitivity. Renal and liver function tests. - -16-Which laboratory values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic crisis? Glucose and calcium levels. Blood and urine cultures. Electrolytes and hemoglobin. Renal and liver function tests. Begin manual ventilation immediately. - -17-An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. Which action should the nurse take first?Silence the alarm and call the technician. Monitor oxygen saturation levels every 5 minutes. Begin manual ventilation immediately. Call respiratory therapy. Muscle fiber degeneration. - -18-A 5-year-old child with a history of a waddling gait and frequent falls is brought into the hospital for diagnostic testing. When explaining the diagnostic testing to the parents, the nurseshould provide information based on which understanding of the underlying disease pathology?Systemic autoimmune vasculopathy. Muscle fiber degeneration. Impaired neuron function. Autonomic neuropathy. Facilitate a consultation for speech therapy. - -19-An older client is referred to a rehabilitation facility following a cerebrovascular accident (CVA). The client is aphasic with left-side paresis and is having difficulty swallowing. Which intervention is most important for the nurse to include in the client's plan of care? Multiple-Choice Single-AnswerSelect your answer from the options on Initiate passive range of motion exercises. Use pictures and gestures to communicate. Facilitate a consultation for speech therapy. Arrange for daily home care assistance. New management's expectations. - -20-The nurse-manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employeeconcern?Employees' job security. Changes in job descriptions. Potential changes in employee benefits. New management's expectations. Document vital signs of clients in the medical record. - -21-After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to an unlicensed assistive personnel(UAP)? Document vital signs of clients in the medical record. Monitor an intravenous infusion rate on an established schedule. Irrigate a urinary catheter with normal saline. Begin wound care for a client after an appendectomy. Intensifying headache. - -22-The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should bereported to the healthcare provider immediately? Right ear hearing loss. Intensifying headache. Facial numbness. Difficulty with balance, Rubella. - -23-A client at 10-weeks gestation reports a maculopapular rash on the face, fever, malaise, sore throat, and lymphadenopathy. Which laboratory result should the nurse review?Gonorrhea. Toxoplasmosis. Rubella. Group B Streptococcus. During acute illness. - -24-The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes? Prior to exercising. Immediately after meals. During acute illness. Before going to bed. Ankle brachial index (ABI). - -25-The nurse notes that a client's legs become dusky-red whenever the client is sitting with both feet dangling. Which follow-up assessment should the nurse complete? Calf diameter. Joint range of motion. Ankle brachial index (ABI). Skin elasticity. Confusion, restlessness. - -26-The nurse includes assessment for fat embolism syndrome (FES) in the plan of care for a client with a fractured femur.Which findings should the nurse include that are often the earliest indication of a FES? Pulmonary crackles. Confusion, restlessness. Tachycardia, fever. Petechial rash. Remove resuscitation equipment from the room Gently close the eyes. Place a small pillow under the head. - -27-After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (Select all that apply.) Take out dentures and place in a labeled cup. Remove resuscitation equipment from the room Gently close the eyes. Place a small pillow under the head. Apply a body shroud. Go to the client's room and ask what happened. - -28-A female adolescent client is admitted to the hospital because she wrote a suicide note to her teacher at school. On the second day of hospitalization, the nurse asks the client tomeet with the treatment team. After the team meeting, the client leaves in tears and goes to her room. Which nursing intervention is best? Explore the client's goals and desire for treatment. Let the client rest quietly in her room for a while. Go to the client's room and ask what happened. Ask the treatment team about the client's behavior. Natural whole almonds. Plain, air-popped popcorn. - -29-During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the clients list should the nurse encourage? (Select all that apply.) Natural whole almonds. Plain, air-popped popcorn. Cheddar cheese cubes. Canned fruit in heavy syrup. Lightly salted potato chips. Cross legs at knee but not at ankle. Avoid prolonged standing or sitting. Use recliner for long periods of sitting. - -30-The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the client's discharge teaching plan? (Select all that apply.) Maintain the bed flat while sleeping. Cross legs at knee but not at ankle. Avoid prolonged standing or sitting. Use recliner for long periods of sitting. Continue wearing compression stockings. Ventricular arrhythmias. - -31-A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? Low blood glucose levels. Ventricular arrhythmias. Profound weight gain. Decreased urinary output. Utilize strict precautions when handling feces. - -32-An older adult woman with advanced Alzheimer's is admitted with severe nausea, vomiting, and diarrhea. The client's caregiver tells the nurse that the clienthas a history of irritable bowel syndrome, hepatitis A, and Methicillin-resistant Staphylococcus aureus (MRSA). Which intervention is most important for the nurse to implement? Perform hemoccult test on a sample of the client's stool. Clarify with the caregiver the exact location of the MRSA Utilize strict precautions when handling feces. Administer a prescribed PRN antiemetic. Initiate fluid resuscitation. - -33-The nurse is assessing a client with Addison's disease who is experiencing weakness, dizziness, disorientation. The nurse observes the client has dry oralmucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure, 94/44, heart rate 132 beats/minute, respirations 22 breaths/minute, and blood pressure 94/44 mmHg. Which intervention should the nurse implement first?Initiate fluid resuscitation. Obtain a blood sample for serum electrolytes. Assess extremity strength and resistance. Begin hourly finger stick glucose levels. Soft abdomen, absent bowel sounds, no bleeding on dressing. - -34-The nurse of a medical-surgical unit receives a report from a post-anesthesia care unit (PACU) nurse for a client who is being transferred following a righthemicolectomy. The PACU nurse reports, "The client has an intravenous (IV) infusion of 1000 mL lactated Ringer's infusing at 125 mL/hr into the left wrist with 300 ml. remaining. Prescriptions include morphine sulfate 2 mg IV every 2 to 4 hours for pain, last administered 30 minutes ago; ondansetron 4 mg IV every 8hours for nausea, last administered 15 minutes ago." Which additional information is most important for the nurse to obtain in the report? Peripheral pulses present with full range of motion of both legs. History of vomiting at home for 3 days prior to surgery. Soft abdomen, absent bowel sounds, no bleeding on dressing. Declining to take ice chips for complaints of dry mouth. Gradual onset of continuous eye pain and blurred vision - -35-The nurse is conducting a visual screening of a group of older adults. Which finding should the nurse report to the healthcare provider immediately? Cloudy opacity of the crystalline lens. Recent change in the ability to read and drive after dark. Gradual onset of continuous eye pain and blurred vision Gray-white circle around the iris of both eyes. Remain non-judgmental and assure the client of confidentiality. - -36-The nurse is caring for a client with the sexually transmitted infection (STI) human papillomavirus (HPV). The client reports having had prior sexuallytransmitted infections. Which response should the nurse provide? Provide counseling that most contraceptives protect against infection. Clarify that all STI's are transmitted through sexual intercourse. Remain non-judgmental and assure the client of confidentiality. Reassure that complications will not occur if the infection is treated. Altered peripheral tissue perfusion. Fatigue. Decreased cardiac output. Fluid volume excess. - -37-An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problems should the nurse include in this client's plan of care? (Select all that apply.) Altered peripheral tissue perfusion. Fatigue. Fluid volume deficit. Decreased cardiac output. Fluid volume excess. Inspect your home for safety hazards. - -38-Which self-care measure is most important for the clinic nurse to emphasize when teaching a client who was recently diagnosed with osteoporosis? Inspect your home for safety hazards. Practice stress reduction techniques. Avoid contact with persons with infections. Use distraction techniques to reduce pain Complete blood count. - -39-A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider?Electromyography. Allergy test. Complete blood count. Skin biopsy. Rounded face. - -40-The nurse is caring for a toddler during a follow-up visit after corticosteroid treatment for minimal change nephrotic syndrome (MCNS). Which finding should the nurse recognize as an early sign of relapse? Tachypnea. Rounded face. Albuminuria. Increased thirst. Administer the prescribed analgesic on regular scheduled around the clock - -41-A client with bone cancer report pain of 10 on a scale of 0 to 10. Thirty minutes after the nurse medicates the client with IV pain medication, the client has no pain relief. Which intervention is most important for the nurse to include in the client's plan of care? Document any side effects the client experiences from the pain medication Assess client's pain more frequently to determine amount of ongoing pain Monitor and report break-through pain occurring between pain and medication Administer the prescribed analgesic on regular scheduled around the clock Deficient folate level. Low reticulocyte count. Macrocytosis. - -42-A client arrives to the emergency department after experiencing a syncopal episode. Laboratory results indicate a red blood cell (RBC) count of 1,5 x10°/uL(1.5 x 1012/L) and a hemoglobin of 7 g/dL (70 g/L). The client is diagnosed with pernicious anemia and receives a transfusion of packed red blood cells (PRBC). Which laboratory findings would the nurse expect to provide more pathophysiological evidence of pernicious anemia? (Select all that apply.) High serum B12. Elevated total iron-binding capacity. Deficient folate level. Low reticulocyte count. Macrocytosis. Halo around blood dropped on gauze. - -43-A client who is unconscious is brought by ambulance to the emergency department following an automobile accident. The nurse observes bleeding from thenose and the client's vital signs on arrival are: heart rate 100 beats/minute, respirations 16 breaths/minute, and blood pressure 130/76 mm Hg. Which assessment finding warrants immediate intervention by the nurse? Pupils 3 mm with sluggish response. Halo around blood dropped on gauze. Clots of blood forming within nares Blood pressure decreases to 110/64 mm Hg. Monitor abdominal girth. Note signs of swelling and edema. Report serum albumin and globulin levels. - -44-A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? (Select allthat apply.) Increase oral fluid intake to 1,500 mL daily. Monitor abdominal girth. Provide diet low in phosphorus. Note signs of swelling and edema. Report serum albumin and globulin levels. Family health history. Excessive aerobic exercise. History of hypertension. - -45-An adult male reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74mmHg. Which risk factors should the nurse explore further with the client? (Choose all that apply.) Family health history. Vegetarian diet. Homosexual lifestyle. Excessive aerobic exercise. History of hypertension. Begin with questions that are less sensitive in nature. - -46-Which is the best approach for the nurse to use when interviewing a client about sexual abuse? Get the most difficult questions over with first. Begin with questions that are less sensitive in nature. Share personal values to put the client at ease. Ask questions in a vague, non-specific format. Educate the client about the side effects of albuterol - -51-During the administration of albuterol per nebulizer, the client complains of shakiness. The client's vital signs are heart rate 120bpm, respirations 20 breaths/min, bp 140/88 mmhg. What action should the nurse take? Administer an anxiolytic Obtain 12 lead ECG Stop the albuterol administration and restart in 30 minutes Educate the client about the side effects of albuterol 12 - -47-The healthcare provider prescribes a low dose heparin protocol at 18 units/kg/hour for a client with a possible pulmonary embolism. This client weighs 144 pounds. The availablesolution is labeled, Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the pump to deliver how many mL/hr? (Enter numeric value only. If rounding is required, round to the nearest whole number.) Experiences facial swelling after eating crab. - -48-The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? Experiences facial swelling after eating crab. Drank a glass of water in the past 2 hours. Reports left chest wall pain prior to admission. Verbalizes a fear of being in a confined space. Risk for decreased cardiac output related to bleeding. - -49-The nurse is planning care for a client who has had a suprapubic resection of the prostate gland. Which nursing problem has the highest priority for this client's care?Pain related to inability to use patient-controlled analgesia. Risk for deficient fluid volume related to NP status. Impaired physical mobility related to multiple drainage devices Risk for decreased cardiac output related to bleeding. Maintain strict intake and output. - -50-The nurse is caring for a client with pneumonia who now develops initial signs of septic shock and multi-organ failure. The healthcare provider prescribessepsis protocol. Which intervention is most important for the nurse to include in the plan of care? Maintain strict intake and output. Assess warmth of extremities. Keep head of bed raised 45 degrees. Monitor blood glucose level. Speak directly facing the client. - -52-A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options? Talk loudly into the affected ear. Speak directly facing the client. Repeat information to the client. Write information on a whiteboard. Liquid brown drainage from stoma. - -53-A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nursereport to the healthcare provider immediately? Stomal output of 40 mL in last hour. Red edematous stomal appearance. Liquid brown drainage from stoma. Mucous strings floating in the drainage. Neutrophil count. - -54- While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? Serum albumin Neutrophil count. Hematocrit. Serum blood glucose (BG) level. Have the child lie with the ear up for one to two minutes after instillation. - -55- Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic is also prescribed for pain and inflammation. Which instruction should the nurse emphasize concerning the instillation of the antipyrine/benzocaine otic solution?Keep the medication refrigerated between administrations. Place the dropper on the upper outer ear canal and instill the medication slowly. Have the child lie with the ear up for one to two minutes after instillation. Warm the medication in the microwave for 10 seconds before instilling. Encourage the client to describe the pain. - -56- A client who is seen in the clinic with possible neuropathic pain of the right leg rates the pain as a 7 on a 10-point scale. Which action should the nurse take? Measure the client's capillary glucose. Elevate the client's foot and leg on two pillows. Ask the client to dorsiflex the right foot. Encourage the client to describe the pain. Apply antiembolism stockings. - -57- 56-A client with rapid respirations and audible rhonchi is admitted to the intensive care unit because of a pulmonary embolism (PE). Low-flow oxygen by nasal cannula and weight based heparin protocol is initiated. Which intervention is most important for the nurse to include in this client's plan of care? Monitor deep vein blood flow using Doppler. Evaluate daily blood clotting factors. Maintain strict bed rest. Apply antiembolism stockings. Implement toileting program. Apply a barrier cream to perianal areas. Offer beverages at frequent intervals. - -58- The family of an older woman reports that they are no longer capable of caring for her at home. While performing the admission assessment at a long-termcare facility, the nurse determines that the client is incontinent of urine, has dry mucous membranes, and has a large bruise on the coccyx. Which interventions should the nurse include in the plan of care? (Select all that apply.) Report suspicion of elder abuse. Implement toileting program. Thicken liquids and provide pureed foods. Apply a barrier cream to perianal areas. Offer beverages at frequent intervals. Question the client about the frequency of falls in recent months. - -59- The nurse is performing a functional assessment on an older client who lost five pounds (2.27 Kg) of weight since the last visit 12 weeks ago, and who reportsa decrease in energy and appetite. Which action should the nurse include during the assessment? Assist the client with clarifying values about end-of-life care options. Request to have the client lie as still as possible for the assessment. Ask the client how often episodes of sundowning are experienced. Question the client about the frequency of falls in recent months. 0.6 - -60-The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL. vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.) Pull up a chair and sit bedside the client's bed - -61- While taking vital signs, a critically ill male client grabs the nurse's hand and asks the nurse not to leave. What action is best for the nurse to take? Pull up a chair and sit bedside the client's bed Reassure the client that the nurse will return after all vital signs are taken Allow the client to hold the nurse's hand until the vital signs can be completed Tell the client that he must release the nurse's hand Explain that the client will start to lose consciousness and the body systems will slow down. - -62- -An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse? Reassure the spouse that the healthcare provider will notify when to call the children. Offer to discuss the client's health status with each of the adult children. Gather information regarding how long it will take for the children to arrive. Explain that the client will start to lose consciousness and the body systems will slow down. Altered consciousness within the first 24 hours after injury. - -63- A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the Emergency Department, and is transferred to the neurological unit to be monitored for symptoms of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? Altered consciousness within the first 24 hours after injury. Fever, nuchal rigidity and opisthotonos within hours. Cushing reflex and cerebral edema after 24 hours. Headache and pupillary changes 48 hours after head injury. NOT SURE - -64- A client with an asymptomatic abdominal aneurysm visits the health clinic for a routine visit. Which action is most important for the nurse to include in assessing the client?Observe skin for bruising. Measure blood pressure. Palpate for ankle edema. Auscultate bowel sounds. Complaint of increased pain and pressure. Change in the quality of the peripheral pulses. Loss of sensation to the left lower extremity. - -65- When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? (Select all that apply.)This item can have multiple correct answers. Refer to question instructions for answering information. Complaint of increased pain and pressure. Change in the quality of the peripheral pulses. Loss of sensation to the left lower extremity. Sloughing tissue around wound edges. Weeping serosanguineous fluid from wounds. Discuss alternative ways to support the client's birth plan. - -66- A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction, but refuses the prescribed oxytocin infusion because she wants to have a "natural"delivery. Which action is most important for the nurse to implement? Explain the indications for induction related to post-term pregnancy. Discuss alternative ways to support the client's birth plan. Discuss the character of labor from endogenous vs exogenous oxytocin. Ask the healthcare provider to discuss the issue with the client. Request that the mother leave the room. - -67- A gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutesWhile assessing the client, the client's mother enters the labor suite and says in a loud voice, "I've had 8 children and I know she is in labor. I want her to have her cesarean section right now!" Which action should the nurse take?Request security to remove her from the room. Request that the mother leave the room. Tell the mother to stop speaking for the client. Notify the charge nurse of the situation. Observe aspiration site. - -68- A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure? Observe aspiration site. Assess body temperature. Measure urinary output. Monitor skin elasticity. Institute a daily fluid restriction while the client is in the hospital. - -69- The nurse is assessing a client with pulmonary edema who is reporting two pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies crackles in all lung fields and use of accessory muscles. Which action should the nurse include in the client's plan of care?Administer the prescribed amiodarone immediately. Institute a daily fluid restriction while the client is in the hospital. Arrange a prescribed electrophysiology study (EPS) for the client. Assess the client's commitment to their daily exercise regimen Verify nutrition and hydration status - -70- A family member accompanies client with schizophrenia to the mental health unit. The family member describes to the nurse the client experienced a prolonged psychotic episode that lasted for three days. Which action should the nurse implement first?Assess if warning signs were observed Verify nutrition and hydration status Review the list of medications taken at home Explore possible triggers to the episode Instructions regarding a restricted protein diet. - -71- A client with chronic renal insufficiency is preparing for discharge from the hospital. Which information is most important for the nurse to include in this client'sdischarge teaching? Need for maintaining good oral hygiene. Strategies to promote independent self-care. Use of topical applications to manage pruritus. Instructions regarding a restricted protein diet. 1-Rub hands palm to palm. 2- Interlace the fingers. 3- Dry hands with paper towel. 4- Turn off the water faucet. - -72- When washing soiled hands, the nurse first wets the hands and applies soap. The nurse should complete additional actions in which sequence? (Arrange from first action on top to last action on bottom.) TURN OFF THE WATER INTERLACE THE FINGERS RUB HANDS PALM TO PALM DRY HOUNDS WITH PAPER TOWEL Identify the client's plans to tell sexual partner(s) about the positive HIV status. - -73- After receiving a positive human immunodeficiency virus (HIV) blood test result, a client requests the nurse not to tell their partner about the results. Which action should the nurse take? Respect the client's wishes and keep the results confidential from the partner. Identify the client's plans to tell sexual partner(s) about the positive HIV status. Determine if there is a partner notification law for the state. Attempt to convince the client of the importance of notifying the partner. Plan to apply pressure over the site for several minutes. - -74- In preparing to discontinue a client's saline lock, the nurse notes that the client is receiving an antiplatelet medication. Which action should the nurse implement?Encourage the client to drink additional oral fluids. Leave the saline lock in place and notify the charge nurse. Plan to apply pressure over the site for several minutes. Prepare a warm pack to apply after removing the lock. Instruct the client to keep hands under the sterile field - -76- The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety? Assess for discomfort when procedure is completed. Instruct the client to keep hands under the sterile field Pour cleansing solution onto the sterile cloth field. Verify that the client has given informed consent. Inform the client that gradual tapering must be used to discontinue the medication. - -75- An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feelingbetter after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide? Inform the client that gradual tapering must be used to discontinue the medication. Tell the client that the medication's side effects will most likely dissipate over time. Tell the client to discuss the medication side effects with the healthcare provider. Remind the client that feeling better is the therapeutic effect of the medication. Submit a sentinel event report to the research committee. Arrange inservice training through the education department. Obtain informed consent from clients who will receive care. - -77- A group of nurses implement a pilot study to evaluate a proposed evidence-based change to providing client care. Evaluation indicates successful outcomes and the nurses want to integrate the change throughout the facility. Which actions should be taken? (Select all that apply.) Submit a sentinel event report to the research committee. Invite data review by the quality improvement department. Propose clinical practice guidelines to the nursing committee. Arrange inservice training through the education department. Obtain informed consent from clients who will receive care. Cardiology unit supervisor. - -78- After having coronary artery bypass surgery, a client develops a deep venous thrombosis in the left leg. Which nurse should be responsible for coordinating the progression of this client's care?Cardiology unit supervisor. Nurse case manager. Adult nurse practitioner. Risk management nurse. Flaring of the nares. - -79- A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever and cough for the last two days. Which finding should alert the nurse that the child is in acute respiratory distress? A resting respiratory rate of 35 breaths/min. Diaphragmatic respirations. Flaring of the nares. Bilateral bronchial breath sounds. 1.4 - -80- A client who weighs 65 kg receives a prescription for lorazepam 44mcg/kg intravenously to be administered 20 minutes before a scheduled procedure. The medication is available in 2mg/ml vial. How many ml should the nurse administer? 2+ pitting edema in the extremities. - -81- The parents bring their one-year-old child with a ventricular septal defect (VSD) to the clinic for a well child visit. Which assessment finding should the nurse report to the healthcare provider immediately?Expected weight and growth curve for an infant. Respirations of 26 breaths/minute at rest. Heart rate of 105 beats/minute. 2+ pitting edema in the extremities. A history of having Helicobacter pylori infection. - -82- The nurse is caring for a client with a paralytic ileus who presents with severe, colicky abdominal pain, nausea, vomiting, and abdominal distention. Which pathophysiologic mechanism supports the client's clinical presentation? A history of having Helicobacter pylori infection. Ulceration of protective duodenal mucosal lining. Intestinal volvulus that occurred during surgery. Esophagitis due to reflux of gastric contents. Monitor for hives and pruritus. - -83- An older adult client is receiving a second unit of blood when the nurse enters the room and finds the client sitting up in bed. The client is dyspneic and seemsconfused. Lung auscultation reveals crackles in the bases of both lungs. Vital sign measurement reveals a rapid, bounding pulse and elevated blood pressure. After discontinuing the transfusion, which intervention should the nurse implement? Monitor for hives and pruritus. Send the blood bag and blood tubing to the blood bank. Obtain a urine specimen. Keep the IV access line intact for diuretic administration. Encourage the client to verbalize his frustrations. - -84-A nurse working on the psychiatric intensive care unit (PIC) observes a male client pacing and hitting the wall with his fist. Which intervention should the nurse implement first? Restrain the client to prevent self injury. Isolate the client until he is calm. Encourage the client to verbalize his frustrations. Medicate the client with a prescribed PRN sedative. Physical soothing - -85- The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain? Supine positioning Simultaneous injections Physical soothing Verbal reassurance Lactulose. - -86-A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies anelevated serum ammonia level. Based on this finding, which prescription is most important for this client to receive? Lactulose. Furosemide. Loperamide. IV human albumin. Serum potassium level of 3.1 mEq/L (3.1 mmol/L). - -87- A client with intestinal obstruction has a nasogastric tube to low intermittent suction and is receiving an IV of Lactated Ringer's at 100 mL/hour. Which finding is most important for the nurse to report to the healthcare provider?Increased blood urea nitrogen (BUN). Gastric output of 900 mL in the last 24 hours. 24 hour intake at the current infusion rate. Serum potassium level of 3.1 mEq/L (3.1 mmol/L). Ask the client if she has an allergy to shellfish. - -88-A female client is scheduled for an intravenous pyelography (IVP) today. The nurse instructs the client that the x-ray visualizes the kidneys, ureters, and bladder. Which information is most important for the nurse to gather before the client goes for the x-ray? Ask the client if she has an allergy to shellfish. Find out if the client can lie prone for the x-ray. Inquire if she has taken her regularly scheduled medications. Determine the last time the client had a bowel movement. Raise head of bed until at a 90 degree angle. - -89- A client diagnosed with pancreatitis is complaining of severe epigastric pain and intense nausea. After the nurse administers a narcotic analgesic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement?Raise head of bed until at a 90 degree angle. Reinforce bed rest until analgesic is effective. Position bedside table for client to lean across. Place bed in reverse trendelenburg position. An 8 year old who lives in housing project - -90-The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? An adolescent who works part time in a paint factory A 10 year old who has type 1 diabetes mellitus An 8 year old who lives in housing project A 2 year old who plays an aging outdoor playground equipment Fluid volume deficit. - -91- The nurse identifies several nursing problems for a client with tetraplegia who is experiencing fecal incontinence and diarrhea. The client's spouse is the primary caregiver. In planning care, which identified nursing problem has the highest priority? Caregiver role strain Bowel incontinence. Fluid volume deficit. Impaired bed mobility. Widespread maculopapular rash. - -92-The nurse is assessing a client who received a hematopoietic stem cell transplant 4 weeks ago. Which assessment finding indicating graft-versus-host disease should the nurse report to the healthcare provider? Widespread maculopapular rash. Decreased urinary output. High blood pressure. Change in level of consciousness. 2.7 - -93-The healthcare provider prescribes dobutamine 3mcg/kg/min intravenously for a client who weighs 60kg. The iv bag contains dobutamine 1000mg in dextrose 5% water (D5w) 250 ml. The nurse should program the infusion pump to deliver how many ml/hour? Pain scale. - -94- A client with metastatic cancer who was taking hydromorphone by mouth at home is now receiving the medication intravenously while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete? Respiratory rate. Blood pressure. Level of consciousness Pain scale. "What are the voices saying?" - -95- A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client? "Which medication works best?" "When do you hear voices?" "What are the voices saying?" "How do you cope with the voices?" Is it possible that you will be in direct contact with the children at the school? - -96- A female adult who is undergoing chemotherapy tells the nurse that she plans to volunteer at the elementary school this winter. Which question is best for the nurse to ask this client? Do you realize that you will be exposed to many different kinds of germs? Is it possible that you will be in direct contact with the children at the school? Are you aware that you do not have a fully functioning immune system?Have you considered that you are putting yourself at risk for developing infections? An office worker who requires hemodialysis for chronic kidney disease (CKD). - -97-The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic hepatitis B immunizations? A restaurant chef who was diagnosed one year ago with hepatitis A An office worker who requires hemodialysis for chronic kidney disease (CKD). A sales person who travels internationally and eats food in foreign countries. A child daycare worker who has a history of Type 2 diabetes mellitus. Change the client's position. - -98- The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the inputflow. Which actions should the nurse implement first? Check the client's blood pressure and serum bicarbonate. Irrigate the dialysis catheter. Change the client's position. Continue to monitor intake and output with next exchange. Initiate seizure precautions. - -99- A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication? Measure urinary output every hour. Initiate seizure precautions. Monitor serum potassium frequently. Assess pupillary response to light hourly. Explain to mother that the finding is due to increased androgen - -100- When assessing a newborn girl with salt-wasting congenital adrenal hyperplasia due to 21 hydroxylase deficiency, the nurse notes that the infant has an enlarged clitoris. Which intervention should the nurse implement? Explain to mother that the finding is due to increased androgen Observe and palpate newborn's breast tissue for enlargement Assess for signs of fluid retention and bilateral pedal edema Review transcutaneous bilirubin levels with a bilirubinometer Prepare for rapid sequence intubation. - -101- A male client admitted with chronic pulmonary obstruction disease (COP) exacerbation is receiving assisted ventilation with continuous positive airway pressure (CPAP). His vital signs are: temperature 98.8 °F (37.1 °C), heart rate 118 beats/minute, respirations 46 breaths/minute, blood pressure 176/92 mmHg. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurseimplement? Increase the oxygen delivery by 10%. Prepare for rapid sequence intubation. Administer PRN nebulizer treatment. Complete neurological assessment. Increasing confusion of the client. - -102- A client is brought to the emergency department after falling from of a ladder and is showing signs of confusion and disorientation. The spouse states theclient appeared to have lost consciousness. The nurse is provided with a list of current medications and healthcare power of attorney. When reporting to the healthcare provider using BAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?Currently prescribed medications. Client's healthcare power of attorney. Increasing confusion of the client. Myalgia in wrists and hands. - -103- The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding should the nurse recognize as a possible complication? BUN 20 mg/dL (7.14 mmol/L). Hyperactive bowel sounds. Anxiety and sighing. Myalgia in wrists and hands. Antiembolism stockings on, leg exercises performed hourly. - -104- Which computer documentation indicates that activities to prevent postoperative venous stasis were performed correctly? Leg exercises not performed because of placement of anti embolism hose. Antiembolism stockings removed hourly during leg exercises. Client demonstrates ability to move all extremities well. Antiembolism stockings on, leg exercises performed hourly. Hydrocortisone 100 mg IV every 6 hours until systolic BP reaches 110 mmHg. - -105- The nurse is assessing a male client with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The healthcare provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed? Hydrocortisone 100 mg IV every 6 hours until systolic BP reaches 110 mmHg. Regular insulin drip to keep blood glucose around 100 mg/dL (5.55 mmol/L). Hypotonic saline solution at 100 mL/hr until all edema disappears. Potassium chloride 20 mEq IV to infuse over two hours until confusion resolves Position the arm in a sling for discharge. - -106- A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assesses the client's vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement? Position the arm in a sling for discharge. Check neurovascular status of the distal digits Change the dressing if drainage increases. Administer a nonsteroidal anti-inflammatory drug for pain. Demonstrate use of a tucked-chin position while eating. - -107- The home health nurse makes a home visit to a male client with amyotrophic lateral sclerosis (ALS). The client is sitting upright while feeding himself and coughs frequently during the meal. What action should the nurse implement?Encourage the use of assistive feeding devices. Assist the client to lie down and turn to the side. Demonstrate use of a tucked-chin position while eating. Recommend the use of supplemental liquid feedings Ensure placement of the gastrostomy tube with an abdominal x-ray. - -108- An infant born with esophageal atresia and tracheoesophageal fistula receives a prescription for enteral feedings after corrective surgery. To promote normal growth and development of the infant, which action should the nurse include in the plan of care? Speak to the healthcare provider about instituting physical therapy. Use sterile technique during feedings. Ensure placement of the gastrostomy tube with an abdominal x-ray. Offer a pacifier for non-nutritive sucking. Oral antihistamine. Topical corticosteroid. - -109- A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply.) Oral antihistamine. Topical scabicide. Transdermal analgesic. Topical alcohol rub. Topical corticosteroid. Contract dermatitis Allergic rhinits - -110- Which conditions are most likely to respond to treatment with antihistamines? Select all that apply Otitis Media Contract dermatitis Myocarditis Allergic rhinits Bronchitis Keep clear of smoke and exhaust fumes. - -111- The nurse is preparing discharge instructions for a client who was hospitalized with a severe exacerbation of asthma. Which instruction is most important for the nurse to review with the client? Increase the daily intake of clear fluids. Keep clear of smoke and exhaust fumes. Avoid extreme environmental temperatures. Take the prescribed cortisone accurately. Decreased post-voiding dribbling. - -112- The healthcare provider prescribed finasteride 5 mg by mouth daily for a client with benign prostatic hyperplasia (BPH). In evaluating the effectiveness of this drug, the nurse should assess for which outcome? Increased sperm count. Relief from urinary tract infection. Decreased post-voiding dribbling. Enhanced libido. .Third degree heart block. - -113- A female client with a history of hypertension and diabetes mellitus is admitted with uncontrolled atrial fibrillation. The healthcare provider performed synchronized cardioversion and prescribed a STAT dose of dronedarone 400 mg by mouth. Which assessment finding warrants immediate intervention by the nurse? Paroxysmal atrial fibrillation. Third degree heart block. Elevated mean arterial pressure. Premature ventricular beats. Use distraction and therapeutic communication skills. - -114- An older client with Alzheimer's disease is confused and asking the nurse to call their mother who is deceased. Which nonpharmacological interventionshould the nurse implement? Use distraction and therapeutic communication skills. Reduce the client's interaction with others during day. Awaken the client for reality checks every 4 hours at night. Clarify reality with the client about delusional thoughts. Turn on overhead lights while giving instructions. - -115- An older client presents to the emergency department with abdominal pain due to constipation. The nurse is providing a list of high-fiber foods to the client thatthe healthcare provider has recommended. Which action should the nurse implement when reviewing the list of foods? Provide handouts written at a 12th grade reading level. Stand behind the client to avoid intimidation. Turn on overhead lights while giving instructions. Use background music to promote relaxation. Leave the client's room and return later in the day. - -116- When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tellsthe nurse in a loud voice to leave the room. Which action should the nurse take? Leave the client's room and return later in the day. Explain that insulin is a life-saving drug for the client. Refer client to the social worker for support therapy. Encourage client to implement relaxation techniques. Provide a wide variety of meal choices. - -117- After years of struggling with weight management, a middle-age man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care? Apply sequential compression stockings. Provide a wide variety of meal choices. Monitor for urinary incontinence Observe for signs of depression. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client. - -118- Unlicensed assistive personnel (UP) is assigned to a client with flu-like symptoms who has been placed on droplet precautions. The UAP requests a change in assignment, stating she has not yet been fitted for a particulate filter mask. Which action should the nurse take? Send the UP to be fitted for a particulate filter mask immediately so she can provide care to this client. Advise the UP to wear a standard face mask to obtain vital signs, and then get fitted for a filter mask before providing personal care Before changing assignments, determine which staff members have fitted particulate filter masks. Instruct the UAP that a standard face mask is sufficient to be able to provide care for the assigned client. Average client scores improved on specific risk factor knowledge tests. - -119- The nurse implements a primary prevention program for sexually transmitted diseases in a nurse managed health center. Which outcome indicates that the program was effective? Average client scores improved on specific risk factor knowledge tests. More than half of at-risk clients were diagnosed early in their disease process. Clients who incurred disease complications promptly received rehabilitation. New screening protocols were developed, validated, and implemented. Ask the client for a description of the exercise schedule that is being followed - -120- A client who has been running three miles a day for two months tells the nurse the goal is to lose weight and sleep better. The client describes frustration of still having trouble falling asleep at night. Which action should the nurse implement?Advise the client that lifestyle changes often take several weeks to be effective Determine the amount of weight the client has lost since increasing activity Ask the client for a description of the exercise schedule that is being followed Encourage the client to exercise every day to eliminate bedtime wakefulness Explain the use of the vaccination to reduce risk for Herpes zoster. - -121- An older adult female asks the clinic nurse about getting a Herpes vaccination because she gets cold sores on her mouth when she is sick or stressed. Howshould the nurse respond? Explain the use of the vaccination to reduce risk for Herpes zoster. Describe the use of the vaccination to treat Herpes simplex Type 2. Arrange for skin testing to evaluate if the client is a candidate for the vaccine. Confirm that a consent form is signed before administering the vaccination. vanilla frozen yogurt vegetable juice - -122- When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? (Select all that apply.) Vanilla frozen yogurt. Creamy peanut butter. Clear beef broth. Vegetable juice. Canned fruit cocktail. .Ask if they they can obtain financial help from their family or friends. - -123- The community health nurse is making a postpartum home visit to a new mother who has four children, including the newborn. The mother tells the nurse that her husband recently lost his job, and the electric company has terminated their service. What action should the nurse take first? Initiate a social services referral to assess for potential abuse. Initiate a consult to obtain infant formula via a national agency. Discuss with the family what they see as their current needs. Ask if they they can obtain financial help from their family or friends. Amenorrhea. - -124- The nurse is assessing an adolescent female diagnosed with anorexia nervosa who is admitted to the unit with severe malnutrition and electrolyte imbalance. Which pathological process results from the adolescent's consistent maladaptive behavior? Amenorrhea. Sinus tachycardia. Menstrual cramps. Hypertension Replace fluids intravenously based on intake and output. - -125- A client who experienced a blunt trauma to the abdomen is admitted to the intensive care unit following surgery for an exploratory laparotomy which revealeda contused right kidney and lacerated spleen. Which intervention is most important for the nurse to include in the plan of care? Turn every 2 hours around the clock from side-to-side. Assess skin condition and turgor for breakdown. Replace fluids intravenously based on intake and output. Record the amount of daily wound drainage Cervix 50% effaced and 1 cm dilated. - -126- The nurse is assessing a primigravida at 37-weeks gestation who believes she is in labor. Which assessment finding necessitates admission to the labor anddelivery unit? Positive fern test. Burning on urination. Systolic blood pressure elevation. Cervix 50% effaced and 1 cm dilated. Allow the child to play with an empty syringe without the needle. - -127- A 4-year-old child who fell off a tricycle is admitted to the hospital for observation. Which action should the nurse implement to facilitate the child's cooperation during the admission assessment? Have the parent hold the child's arms during the head to toe assessment. Ask the child to blow out the pen light and turn it off to simulate success. Allow the child to play with an empty syringe without the needle. Explain the function of each organ during the steps of the assessment. Elevated HCO3 (bicarbonate). - -128- An older client who has a history of diabetes mellitus is admitted with pneumonia and has a serum glucose level of 625 mg/dL (34.69 mol/L). Which finding is an indicator that the client is experiencing hyperosmolar hyperglycemia syndrome (HHS) rather than diabetic ketoacidosis (DKA)? Glucose 250 mg/dL (13.88 mmol/L). Large amount urine ketones. Elevated HCO3 (bicarbonate). Higher than normal arterial pH Obtain psychiatric and medical admission records Review list of home medications including dosages. - -129- An adult client with a history of schizophrenia is admitted with diabetic ketoacidosis (DKA). Which nursing interventions should the nurse implement duringthe admission process for this client? (Select all that apply.) Obtain psychiatric and medical admission records Review list of home medications including dosages. Initiate the process for an involuntary commitment admission. Determine the client's understanding of how to manage their diabetes. Hold psychiatric medications until glucose is regulated. Auscultate for irregular heart rate - -130- The nurse identifies an electrolyte imbalance, elevated BP, and exhibited changes in mental status for a client with CKD. Which is the most important action for the nurse to take? Auscultate for irregular heart rate Monitor daily sodium intake Measure ankle circumference Document abdominal growth Instruct the nurse to use a transparent dressing over the site. - -131- The charge nurse observes a new nurse preparing to insert an intravenous (IV) catheter. The new nurse has gathered supplies, including intravenous catheters, an intravenous insertion kit, and a 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take? Plan to observe the secured IV site after the insertion procedure. Instruct the nurse to use a transparent dressing over the site. Confirm that the nurse has gathered the necessary supplies. Remind the nurse to tape the gauze dressing securely in place. Provide a bedside commode for toileting. - -132- The nurse is developing a plan of care for a client with cardiomyopathy. Which intervention should the nurse include to reduce cardiac workload? Assist with ambulation in the hallway. Teach to sleep in a side-lying position Encourage active range of motion exercises. Provide a bedside commode for toileting. Evaluate the client's response to bladder training efforts. - -133- An older client arrives to the clinic describing a new onset of urinary incontinence. Which intervention should the nurse implement? Obtain a clean, voided urine specimen for analysis. Evaluate the client's response to bladder training efforts. Encourage increased fluid intake for 24 hours. Provide protective undergarments for the client. Respiratory acidosis. - -134- A client with a long history of chronic bronchitis and emphysema arrives to the emergency department with dyspnea. The nurse reviews the client's arterial blood gas (ABG) results of: pH: 7.25, PCO, 62 mmHg (8.25 kPa), HCO; 28 mEq/L (28 mmol/L), PO2 70 mmHg (9.31 KPa). Which acid base disturbance should the nurse determine the client is experiencing? Respiratory acidosis. Respiratory alkalosis. Metabolic alkalosis. Metabolic acidosis. *photo will be seen in the question during the exam - -The nurse determines that 850 mL of serosanquineous drainage is in the Pleura-vac® chest drainage system of a client who is 12 hours postoperative for the removal of a lung tumor Which location on the chest collection unit indicates this finding? (Click the chosen location. To change, click on the new location.) Use an auto-injection pen to control the rate of administration. - -136- The healthcare provider prescribes epinephrine (1:10,000) 0.1 mg intravenously for a client with a severe allergic reaction. To reduce the risk for overdose, wh