Hesi Fundamentals

HESI FUNDAMENTALS The nurse observes that a male client has removed the covering from an ice park applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin. Observe the appearance of the skin under the ice pack (The first action taken by the nurse should be to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can take the other actions.) The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor of 60 gtt/mL, how many drops per minute should the client receive? 124 gtt/min The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate w/ 30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? 83 gtt/min Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? Examining a chest x-ray obtained after the tubing was inserted Three days following a surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become much smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes (Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care. (D) A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use. B. Reposition the client on her side. (The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention (B) should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D)) A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory B. exhibits expressive dysphasia C. has a diminished attention span D. is disoriented to place and time D. is disoriented to place and time (The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate diminished attention span. (C). A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. What action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CKD. A. Commend the client for selecting a high biologic value protein. (Foods such as eggs and milk (A) are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids that are necessary for growth and cell repair. Orange juice is rich in potassium and should not be encouraged. The client has made a good diet choice so (D) is not necessary.) When assisting an 82 year old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the-- Upper torso (The center of gravity for adults is the hips. However, as the person grows older, a stooped posture is common because of the changes from osteoporosis and normal bone degeneration, and the knees, hips, and elbows flex. This stooped posture results in the upper torso becoming the center of gravity for older persons.) In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A. is to be expected, and progresses with age B. often follows relocation to new surroundings C. is a result of irreversible brain pathology D. can be prevented with adequate sleep B. often follows relocation to new surroundings (Relocation (B) often results in confusion among elderly clients-- moving is stressful for anyone. (A) is stereotypical judgement. Stress in the elderly often manifests itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion.) A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change B. states he will be able to complete the wound care regimen C. demonstrates the wound care procedure correctly D. has all the necessary supplies for wound care C. demonstrates the wound care procedure correctly (A return demonstration of a procedure (C) provides an objective assessment of the client's ability to perform a task, while (A and B) are subjective measures. (D) is important, but is less of a priority than the the nurse's assessment of the client's ability to complete wound care.) Upgrade to remove ads Only $3.99/month A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take?" C. "Do you feel that you are overweight?" D. "Will a clear liquid diet be okay after surgery?" B. "What vitamin and mineral supplements do you take?" (Vitamin and mineral supplements (B) may impact medications used during the operative period. (A and C) are appropriate questions for long-term dietary counseling. The nature of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the client's preference.) During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water. D. Encourage additional oral intake of juices and water. Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter B. Apply a skin protectant C. Encourage increased fluid intake D. Assess for bladder distention D. Assess the bladder for distention (Urinary retention is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of a client with urinary incontinence. (C) may worsen the bladder distention.) A client with acute hemorrhagic anemia is to receive four units of packed RBCs as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up C. Monitor vital signs q 15 min for the first hour. D. Ensure the accuracy of the blood type match. D. Ensure the accuracy of the blood type match. (ALL interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction.) A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, time-released capsules are not available, which dosing schedule should the nurse advise the client to follow? 8 AM, 4 PM, and midnight (Theophylline should be administered on a regular around the clock schedule to provide the best bronchodilating effect and reduce the potential for adverse effects.) A client is to receive 10 mEq of KCl diluted in 250 mL of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? 63 mL/hr When evaluating a client's plan of care, the nurse determines that a desire outcome was not achieved. Which action should the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the HCP to make changes. B. Note which actions were not implemented. (First, the nurse should review which actions in the original plan were not implemented (B) in order to determine why the original plan did not produce the desired outcome. Appropriate revisions can then be made, which may include revising the expected outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing actions were unsuccessful, or were unable to be implemented. (D) other members of the healthcare team may be necessary to collaborate changes once the nurse determines why the original plan did not produce the desired outcome. Which snack food is best for the nurse to provide a client with myasthenia graves who is at risk for altered nutritional status? A. chocolate pudding B. graham crackers C. sugar free gelatin D. apple slices A. chocolate pudding (The client with myasthenia graves is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding (A) are easy to swallow and require minimal chewing effort, and provide calories and protein. (C) does not provide any nutritional value. (B and D) require energy to chew and are more difficult to swallow than pudding.) The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol." B. "I need to avoid eating proteins, including red meat." C. "I will limit my intake of beef to 4 ounces per week." D. "My blood level of low density lipoproteins needs to increase." C. "I will limit my intake of beef to 4 ounces per week." (Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase.) An obese male client discusses with the nurse his plans to begin long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. "Be sure to have a complete physical examination before beginning your planned exercise program." B. "Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more." C. "Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class." D. "Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation." A. "Be sure to have a complete physical examination before your planned exercise program." (The most important teaching is (A), so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or stroke. (B, C, and D) are important instructions, but are of less priority than (A). ) The nurse is teaching a client proper use of an inhaler. When should the client administer the inhalerdelivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation C. At the end of three inhalers D. Immediately after inhalation B. During the inhalation. (The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as started in (A or D), and should deliver no more than two inhalations at a time (C).) An IV infusion terbutaline sulfate 5 mg in 500 mL of D5W, infusing at a rate of 30 mcg/min, is prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? 180 The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxoltn is available in 5 mg tablets. How much should the nurse plan to administer? 1 1/2 tablets The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2ml. How many millileters should the nurse administer? 1.5 mL Heparin 20,000 units in 500 mL D5W at 50 mL/hour has been infusing for 5.5 hours. How much heparin has the client received? 11,000 units The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 mL/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10% dextrose and water at 54 mL/hour. D. Obtain a stat blood glucose level and notify the HCP. C. Infuse 10% dextrose and water at 54 mL/hour. (TPN is discontinued gradually to allow the client to adjust decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood-glucose level (D) and the HCP cannot do anything about this situation.) Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. (Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording such a finding the nurse should describe the appearance (B) rather than simply naming the condition. (A) identifies vesicles-- fluid filled blisters--an incorrect description given the symptoms listed. (C) identifies papule-- solid elevated lesions, again not correctly identifying the symptoms. (D) identifies petechiae-- pinpoint red to purple skin discolorations that do not itch, again an incorrect identification.) At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." B. "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." C. "It is OK if you don't want to talk about your surgery. I will be available when you are ready." D. "I will ask a woman who has had a mastectomy to come by and share her experiences with you." C. "It is OK if you don't want to talk about your surgery. I will be available when you are ready." ( (C) displays sensitivity and understanding without judging the client. (A) is judgmental in that it is telling the client how she feels and is also insensitive. (B) would give the client a chance to talk, but is also demanding and demeaning. (D) displays a positive action, but, because the nurse's personal support if not offered, this response could be interpreted as dismissing the client and avoiding the problem.) The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? Skim milk, turkey salad, roll, and vanilla ice cream The nurse prepares a 1000 mL IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter . The nurse should regulate the IV to administer approximately how many drops per minute? 21 An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastronomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone B. Fowler's C. Sim's D. Supine B. Fowler's (The client should be positioned in a semi-setting (B) position during feeding to decrease occurrence of aspiration. A gastronomy tube, known as PEG tube, due to placement by a percutaneous endoscopic gastronomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk for aspiration.) Which action is the most important to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first. C. Keep gloved hands above the elbows. (Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is not necessary to ensure asepsis (D).) The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens. A. Avoid any type of sprays, powders, and perfumes. A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. "In 8 weeks you will be able to bend at the waist to reach items on the floor." B. "Place a pillow between your knees while lying in bed to prevent hip dislocation." C. "It is safe to use a walker to get out of bed, but you need assistance when walking." D. "Take pain medication 30 minutes after your physical therapy sessions." B. "Place a pillow between your knees while lying in bed to prevent hip dislocation." (The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at risk of dislocation for 6 months to a year following the procedure. Hip precautions to prevent dislocation include placing a pillow between the knees to maintain abduction of the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek assistance for both standing and walking until they are stable on a walker or cane (C), and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather than waiting until the pain level is high after their therapy.) The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again. D. Re-oxygenate the client before attempting to suction again. A client's infusion of normal saline infiltrated earlier today, and approximately 500 mL of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding stronger pain medications. What initial action is most important for the nurse to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area. B. Measure the pulse volume and capillary refill distal to the infiltration. (Pain and diminished pulse volume (B) are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast) or internal pressure (usually form subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity. (A) should not be pursued until physical causes of the pain are ruled out. (C) is less of a priority than determining the effects of the edema on circulation and nerve function. Further assessment of the client's ecchymosis can be delayed until the signs of edema and compression that suggest compartment syndrome have been examined (D).) The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A. Remain calm with the client and record abnormal results in the chart. B. Notify the medication nurse immediately if the pulse or blood pressure is low. C. Report the results of the vital signs to the nurse. D. Reassure the client that the vital signs are normal. C. Report the results of the vital signs to the nurse. (Interpretation of the vital signs is the responsibility of the nurse, so the UAP should report vital sign measurements of to the nurse (C). (A, B, and D) require the UAP to interpret the vital signs, which is beyond the scope of the UAP's authority.) Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat. D. "The body's receptors adapt over time as they are exposed to heat." ( (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide false information. (C) is not based on knowledge of physiology and is unsafe action that may harm the client.) When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse. A. Loosen the right wrist restraint. (The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression-- the restraints.) An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgement? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred. C. The nurse who transferred the client to the chair when the fall occurred. (The four elements of malpractice are: breach of duty owed, failure to adhere to the recognized standard of care, direct causation of injury, and evidence of actual injury. The hip fracture is the actual injury and the standard of care was "frequent monitoring." (C) implies the duty was owed and the injury occurred while the nurse was in charge of the client's care. There is no evidence of negligence in (A, B, and D). ) The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure. B. Reassess the client's blood pressure using a larger cuff. (The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A). Though (C and D) are likely indicated, these actions do not have the priority of (B).) An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position. D. Gently life the client when moving into a desired position. (To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should NOT be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip.) The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client w/ left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot. ( (D) uses the client's stronger side, the right side, for weight-bearing during the transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of transfer and include the use of poor body mechanics by the caregiver.) An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request. D. Notify the HCP of the family's request. (The nurse should first communicate with HCP (D). Hospice care is provided for clients with a limited life expectancy which must be identified by the HCP. (A) is not necessary at this time. Once the HCP provides the transfer to hospice care, the nurse can collaborate with the hospice staff and HCP to determine (B and C) should be implemented.) After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals. A. Determine the etiology of the problem. (Before planning care, the nurse should determine the etiology, or cause, of the problem (A), because this will help determine (B, C, and D). ) What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. B. A decreased flow rate could result in the formation of a thrombosis. (Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handing a leg or foot with an IV (C) is probably not anymore difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, that is not the most important reason for using the upper extremities. Pain (D) is not a consideration. ) The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water. B. Flush the tube with water. (The NGT should be flushed before, after, and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed.) A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. (To ensure that a therapeutic level of medication is maintained, the nurse should administer dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug.) While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion. A. Acknowledge that she is supporting the arm correctly. (The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the best of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support for the joint while still allowing for joint movement.) An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. It is important that you continue your medication while learning to meditate. B. Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C. Obtain your healthcare provider's permission before starting meditation. D. Complementary therapy and western medicine can be effective for you. A. "It is important that you continue your medication while learning to meditate." (The prolonged practice of meditation may lead to reduced need for antihypertensive medications. However, the medications must be continued (A) while the physiologic response to meditation is monitored. (B) is not as important as continuing the medication. The HCP should be informed, but permission is not required to mediate (C). Although, it is true that the complimentary therapy might be effective (D), it is essential that the client continue with antihypertensive mediations until the effect of mediation can be measured.) The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer. B. A lactating woman nursing her 3-day-old infant. (A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein but do NOT have the increased metabolic protein demands of lactation.) A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. B. Blood transfusions are forbidden. When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices. C. Many complimentary healing practices can be used in conjunction with conventional practices. (Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complimentary healing practices can be used in conjunction with conventional medical practices (C), rather than interfering (A) with conventional practices, causing adverse effects (B), or replacing conventional medical care (D). ) A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities. A. Give an around-the-clock schedule for administration of analgesics. (The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain.) A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe. A. Assist the ambulating client back to the bed. (An oxygen saturation below 90% indicates inadequate oxygen. First, the client should be assisted to return to bed (A) to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood, so (B) is contraindicated. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation (C), but first the client should return to the bed to rest. Oxygen saturation levels at different sites should be evaluated AFTER the client returns to bed (D). ) A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator. D. Request and document the name of the certified translator. (A certified translator should be requested to ensure the exchanged information is reliable and unaltered. To adhere to legal requirements in some states, the name of the translator should be documented (D). Client information that is translated is private and protected under HIPAA rules, so (A) is not the best action. Although an emergency situation may require extenuating circumstances (B), a translator should be provided in most situations. Family members may skew info and not translate the exact information, so (C) is not preferred.) An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distention. A. Inquire about the source and type of pain (Different cultural groups often have their own terms for health conditions. African-Americans clients may refer to pain as "the miseries." Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain (A). (B, C, and D) are important, but do not focus on "miseries" (pain).) The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering. B. Continue asking the mother questions about the child. (Eye contact is culturally-influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child (B). (A, C, and D) are not indicated.) The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. "Hot" remedies restore balance after surgery, which is considered a "cold" condition. D. "Hot" remedies restore balance after surgery, which is considered a "cold" condition. Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference. B. Weight in kilograms or pounds (Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.) A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A. Administer the medication more rapidly using the same IV site. B. Initiate an alternate site for the IV infusion of the medication. C. Notify the HCP before administering the next dose. D. Give the client a PRN dose of aspirin while the medication infuses. B. Initiate an alternate site for the IV infusion of the medication. (A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site should be initiated (B) before administering the next dose. Rapid administration (A) of intravenous cephalosporins can potentiate vessel irritation and increase the risk of thrombophlebitis. (C) is not necessary to initiate an alternate IV site. Although aspirin has antiinflammatory actions, (D) is not indicated.) On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs a cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? battery (civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing a procedure against the client's wishes can potentially poise a legal issue, such as battery (B) even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request.) A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A. HCP notified of failure to collect specimens for prescribed blood studies. B. Blood specimens not collected because client no longer wants blood tests performed. C. HCP notified of client's refusal to have blood specimens collected for testing. D. Client irritable, uncooperative, and refuses to have blood collected. HCP notified. C. HCP notified of client's refusal to have blood specimens collected for testing. At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed D. Immediately after the assessments are completed. A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery was recommended for the client. What is the best plan to obtain consent for surgery for this client? D. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met? A. Expresses concern about the meaning and importance of life. B. Remains angry at God for the continuation of the illness. C. Accepts that punishment from God is not related to illness. D. Refuses to participate in religious rituals that have no meaning. C. Accepts that punishment from God is not related to illness. (Acceptance that she is not being punished by God indicates a desired outcome (C) for some degree of resolution of spiritual distress. (A, B, and D) do NOT support the concept of grief, loss, and cultural/spiritual acceptance.) During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? B. Use the stethoscope bell over the valvular areas of the anterior chest. A nurse is preparing to give medications through a nasogastric feeding tube. Which action should prevent complications during administration? A. Mix each medication individually B. Use sterile gloves for the procedure C. Monitor vital signs before giving medications D. Mix all medications together to facilitate administration A. Mix each medication individually (Medications should be mixed separately (A) to prevent clumping.) During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? Close-ended questions (Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use close-ended questions (C) that focus on common signs and symptoms about the client's health problem. (A, B, and D) are used when therapeutically interacting and should be used after specific information is obtained from the client) The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment. A. The client voluntarily signed the form. (The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client signature is authentic, and that the client is otherwise competent to give consent. It is the HCP responsibility to ensure the client fully understands the procedure.) An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A. Generalized dry skin B. Localized dry skin on lower extremities C. Red flush over entire skin surface. D. Rashes in axillary, groin, and skin fold regions. D. Rashes in the axillary, groin, and skin fold regions. (Immobility, constant contact with bed, clothing, and excessive heat and moisture in areas where are flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers.) During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters. C. Degree of flexion and extension of the client's knee joint. (The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flees the joint to measure the degrees of flexion and extension on the protractor (C). A doppler is used to measure blood flow (A). Calipers are used to measure body fat (B). A tape measure is used to measure circumference of body parts (D).) The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe. C. Frontal Lobe (The frontal lobe (C) of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. (A) is an afferent relay center in the brain that directs impulses to the cerebral cortex. (B) regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as pituitary. (D) is the location of sensory and motor functions. ) An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level. C. Reposition the client in a Sim's position with the client's weight on the anterior ilium. (The left sided Sim's position allows the enema solution to follow the anatomical course of the intestines and allows the best overall results, so the UAP should reposition the client in the Sim's position, which distributes the client's weight to the anterior ilium (C). (B and D should be implemented once the client is positioned.) A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain next? A. Sexual activity patterns B. Nutritional history C. Leisure activities D. Financial stressors B. Nutritional history (Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first.) A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 mL/hour. The client's eight-hour urine output is 400 mL, BUN is 15 mg/dL, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A. Notify HCP and request to change the IV infusion to hypertonic D10W B. Decrease in the infusion rate of the current IV and report to the HCP C. Document in the medical record that these normal findings are expected outcomes D. Obtain potassium chloride 20 mEq in anticipation of prescription to to present IV C. Document in the medical record that these normal findings are expected outcomes.. During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A. Listen and show interest as the client expresses these feelings. B. Reinforce that this behavior means they were not true friends. C. Ask the HCP for psychiatric consult. D. Continue with the assessment and tell the client not to worry. A. Listen and show interest as the client expresses these feelings. (When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings (A). (B) is not a therapeutic option and the nurse does not know the dynamics of their relationships. (C) is not indicated at this time. (D) is non-therapeutic and offers false hope.) The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? CLIENT (HCP, fam, previous medical records-- secondary sources)