NURS 203HESI Final Exam | 2022 latest update

NURS 203HESI Final Exam | 2022 latest update NURS 203HESI Final Exam 1- A client with multiple sclerosis is receiving beta – 1b interferon every other day. To assess for possible bone marrow suppression caused by the medication, which serum laboratory test findings should the nurse monitor? (Select all that apply) a- Platelet count b- White blood cell count (WBC) c- Sodium and potassium d- Red blood cell count (RBC) e- Albumin and protein 2- A male client with hypercholesterolemia wants to change his diet to help reduce his cholesterol levels. When breakfast items should the nurse encourage the client to eat? (Select all that apply) a- Sausage patties and eggs b- Whole wheat toast and jam c- Bagels and cream cheese d- Toaster pastries and milk e- Blackberries and oatmeal 3- 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) a- Take out dentures and place in a labeled cup b- Apply a body shroud c- Place a small pillow under the head d- Remove resuscitation equipment from the room e- Gently close the eyes 4- A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement? a- Tell the client to have a complete blood count (CBC) drawn b- Instruct the client to seek medical attention immediately c- Encourage him to take the medication at night with a snack d- Explain that these are common side effects of the medication 5- An older adult male is admitted with complications related to chronic obstructive Pulmonary Disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? a- Restrict daily fluid intake b- Eat meals at the same time daily c- Maintain a low protein diet d- Limit the intake of the high calorie foods 6- A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective? a- Granulating tissue in foot ulcer b- Full volume of pedal pulse c- Reduced level of pain d- Improved visual activity. 7- The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long- term control of diabetes? a- The fating blood sugar was 120 mg/dl this morning. b- Urine ketones have been negative for the past 6 months c- The hemoglobin A1C was 6.5g/100 ml last week d- No diabetic ketoacidosis has occurred in 6 months. 8- A heparin infusion is prescribed for a client who weights 220 pounds. After administering a bolus dose of 80 units/kg. The nurse calculates the infusion rate for the heparin sodium at 18 units/kg/hour. The available solution is Heparin Sodium 25,000 units in 5% Dextrose Injection 250 ml. The nurse should program the infusion pump to deliver how many ml/hour. (Enter numeric value only. If rounding to the nearest whole number.) 18 9- The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first? a- Assess extremity strength and resistance b- Report a sodium level of 132 mEq/L or mmol/L (SI units) c- Measure and record the cardiac QRS complex d- Check current finger stick glucose 10- The nurse assesses an older adult who is newly admitted to a long term care facility. The client has dry, flaky skin and long thickened fingernails. The clients has a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)? a- Soak and file fingernails b- Offer fluids frequently c- Monitor skin elasticity d- Ambulate in the hallway 11- A client is receiving lidocaine IV at 3 mg/minute. The pharmacy dispenses a 500 ml IV solution of normal saline (NS) with 2 grams of lidocaine. The nurse should regulate the infusion pump to deliver how many ml/hr? (Enter numeric value only. If rounding to the nearest whole number.) 45 12- The nurse is demonstrating wound care to a client following abdominal surgery. In what order should the nurse teach the technique? (Arrange from first action on top to last action on bottom) Remove old dressing using clean gloves. Discard gloves with old dressing Moisten sterile gauze with normal saline. Clean wound from least contaminated area to most contaminated area” Apply sterile gauze dressing to wound area Secure dressing with tape 13- The healthcare provider explains through an interpreter the risks and benefits of a scheduled surgical procedure to a non-English speaking female client. The client gives verbal consent and the healthcare provider leaves, instructing the nurse to witness the signature on the consent form. The client and interpreter then speaker together in the foreign language for an additional 2 minutes until the interpreter concludes, “She says it is OK.” What action should the nurse take next? a- Clarify the client’s consent through the use of gesture and simple terms b- Have the interpreter co-sign the consent to validate client understanding c- Ask for full explanation from the interpreter of the witnessed discussion d- Have the client sign the consent and the nurse witness the signature 14- A client is admitted to a mental health unit after attempting suicide by taking a handful of medications. In developing a plan of care for this client, which goal has the highest priority? a- Signs a no-self-harm contract. b- Sleep at least 6 hours nightly. c- Attends group therapy every day d- Verbalizes a positive self-image. 15- After receiving report, the nurse can most safely plan to assess with client last? a- An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac b- An adult client with no postoperative drainage in the Jackson- Pratt drain with the bulb compressed c- An older client with a distended abdomen and no drainage from the nasogastric tube d- An adult client with rectal tube draining clear pale red liquid drainage 16- The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance? a- Wearing gloves when interviewing the client b- Encouraging the client to join a support group c- Shaking the client's hand during an introduction. d- Allowing the client to ventilate feelings 17- A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? • Fetal heart tones located in upper right quadrant • Biophysical profile results showing oligohydramnios • Regular contractions occurring every 10 minutes • Sterile vaginal exam reveling 3 cm dilatation 18- The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching? • Do not read without direct lighting for 6 weeks • Avoid straining at stool, bending, or lifting heavy objects. • Irrigate conjunctiva with ophthalmic saline prior to installing antibiotic ointment. • Limit exposure to sunlight during the first 2 weeks when the cornea is healing. 19- After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, “God has abandoned me. What did I do to deserve this?” Based on this response, the nurse decides to include which nursing problem in the client’s plan of care? • Ineffective coping • Spiritual distress • Acute pain • Complicated grieving 20- Un infant is unresponsive and gasping for breath. Prior to starting CPR, which site should the nurse palpate for a pulse? 21- 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 action should be taken? (Select all that apply) a- Invite data review by the quality improvement department b- Submit a sentinel event report to the research committee c- Propose clinical practice guidelines to the nursing committee d-Obtain informed consent from clients who will receive care e-Arrange inservice training through the educational department 22- The mother of a school age child calls the school to ask when her daughter can return to school after treatment for Pediculosis capitis. What is the nurse best response? (nits liendra) • When the classroom epidemic subsides • Two weeks after the last treatment • As soon as the itching stops • After the treatment kills all the live lice 23- A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a- Review the heart rhythm on cardiac monitors b- Check urinary catheter for obstruction c- Auscultated bilateral breath sounds d- Give PRN dose of lorazepam (Ativan) 24- What is the primary purpose for initiating nursing intervention that promote good nutrition, rest, and exercise, and stress reduction for clients diagnosed with an HIV infection? a- Prevent spread of infection to others b- Improve function of the immune system c- Increase ability to carry out activities of daily living • Promote a feeling of general well-being 25- When assessing a client with acute asthma, the nurse is most likely to obtain which finding? • Pursed lip breathing and clubbing of fingers • Fever and a high- pitched inspiratory stridor • A short expiratory phase and hemoptysis • Cough and musical breath sound on expiration 26- During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client’s point of maximal impulse (PMI) (Click the chosen location. To change, click on a new location) 27- Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? a- Intravenous administration of thyroid hormones b- Oral administration of hypnotic agents c- Intravenous bolus of hydrocortisone d- Subcutaneous administration of vitamin k 28- A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care? • Encourage the use of corrective lenses during the day • Practice visual exercises that focus on a still object • Alternate an eye patch from eye every 2 hours • Teach techniques for scanning the environment. 29- The nurse applies a blood pressure cuff around a client’s left thigh. To measure the client’s blood pressure, where should the diaphragm of the stethoscope be placed? (Mark the location on one of the images.) “On left thigh with arrow pointing to inner thigh” 30- Which intervention should the nurse include in the plan of care for a patient with tetanus? Open window shades to provide natural light • Encourage coughing and deep breathing • Minimize the amount of stimuli in the room • Reposition from side to side every hour 31- The nurse is caring for a newborn who arrives in the nursery following a precipitous birth on the way to the hospital. A drug screen of the mother reveals the presence of cocaine metabolites. The infant has a heart rate of 175 beats/ minute, cries continuously, is irritable, and is hyperreactive to stimuli. Which intervention is most important for the nurse to include in this infant’s plan of care? • Initiate infant sepsis protocol • Implements seizure precautions • Refer to protective child services • Formula feed every 3 hours 32- A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client’s teaching plan? (Select all that apply.) a- Take an additional dose for signs of hyperglycemia b- Recognize signs and symptoms of hypoglycemia. c- Report persist polyuria to the healthcare provider. d- Use sliding scale insulin for finger stick glucose elevation. e- Take Glucophage with the morning and evening meal. 33- 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? a- Observe aspiration site. b- Assess body temperature c- Monitor skin elasticity d- Measure urinary output 34- A client collapses while showering and is found discovered by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next? • Follow the prompts of the AED • Apply the AED pads to the client’s chest • Wipe the client’s chest dry • Move the client from the bathroom 35- A female client with cancer tells the home care nurse that she has a good appetite but experiences nausea whenever she smells food cooking. What action should the nurse implement? • Encourage family members to cook meals outdoors and bring the cooked food inside • Advise the client to replace cooked foods with a variety of different nutritional supplements • Assess the client’s mucus membranes and report the findings to the healthcare provider • Instruct the clients to take an antiemetic before every meal to prevent excessive vomiting. 36- A 13 years-old girl, diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? • Ate an extra peanut butter sandwiches before gym class • Incorrectly drew up and administered too much insulin • Was not hungry, so she skipped eating lunch • Has had a cold and ear infection for the past two days 37- At 1130, the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer. After reviewing the client’s electronic health record, which priority nursing action should the nurse implement? Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record. • Administer insulin per sliding scale • Assess appearance of foot wound • Obtain antibiotic peak and trough levels • Initiate hourly urine output measurements 38- Following morning care, a client with C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which intervention should the nurse implement first? a- Relieve any kinks or obstruction in the client’s Foley tubing b- Asses the client’s blood pressures every 15 minutes c- Administer a prescribed PRN dose of hydralazine (Apresoline) e-Teach the client to recognize symptoms of dyreflexia 39- After a motor vehicle collision a client admitted to the medical unit with acute adrenal insufficiency (Addisonian crisis). Which prescription should the nurse implement? • Determine serum glucose levels • Withhold potassium additives to IV fluids • Give IV corticosteroid replacement • Prepare to initiate IV vasopressors 40- Which instruction is most important for the nurse to provide a client who receives a new prescription for risedronate sodium to treat osteoporosis a- Remain upright after taking the medication b- Increase intake of foods rich in calcium c- Begin a weight-bearing exercise plan • Schedule a bone density test every year. 41- The unlicensed assistive personnel (UAP) reports that a client’s blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. What action should the nurse implement? • Advise the UAP to document the last blood pressure obtained on the client graphic sheet • Estimate the blood pressure by assessing the pulse volume of the client’s radial pulses • Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed • Document why the blood pressure cannot be accurately measured at the present time 42- The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately? • Change the dressing using a compression bandage • Test fluid on the dressing for glucose • Document the findings in the electronic medical record • Mark drainage area with a pen and continue monitor 43- Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client’s constipation, which suggestions should the nurse provide? (Select all that apply) a- Decrease laxative use to every other day, and use oil retention enemas as needed. b- Include oatmeal with stewed pruned for breakfast as often as possible. c- Increase fluid intake by keeping water glass next to recliner. d- Recommend seeking help with regular shopping and meal preparation. e- Report constipation to healthcare provider related to cardiac medication side effects. 44- A male client with diabetes mellitus takes NPH/ regular 70/30 insulin before meals and azithromycin PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, the client tells the nurse that he took his insulin but forgot to take his daily dose of the azithromycin an hour before breakfast as instructed. What action should the nurse implement? • Provide a PRN dose of an antacid to take with the azithromycin right after breakfast • Offer to obtain a new breakfast tray in an hour so the client can take the azithromycin • Instruct the client to eat his breakfast and take the azithromycin two hours after eating • Tell the client to skip that day’s dose and resume taking the azithromycin the next day 45- After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? • Ask the client about gastrointestinal pain • Measure the client’s fluid intake and output • Monitor the client’s serum electrolyte levels • Auscultate for bowel sounds in all quadrants 46- Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? a- Ensure that the knot can be quickly released. b- Tie the knot with a double turn or square knot. c- Move the ties so the restraints are secured to the side rails. d- Ensure that the restraints are snug against the client's wrist. 47- An older male client arrives at the clinic complaining that his bladder always feels full. He complains of a weak urine flow frequent dribbling after voiding and increasing nocturia with difficulty initiating his urine stream action should the nurse implement? • Palpate the client’s suprapubic area for distention • Advise the client to maintain a voiding diary for one week • Instruct in effective techniques to cleanse the glans penis • Obtain urine specimen for culture and sensitivity 48- A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first? • Review the current treatment plan with the client • Inform the healthcare provider about the client’s behaviors • Determine if the client has PRN medication for anxiety • Explore the client’s reasons for wanting to be discharged. 49- The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement? • Wake all the clients and instruct them go to dining area for medication administration • Explain to the clients that it will be necessary to cooperate until another RN arrives • Ask the PN to administer medications as clients are awakened so both nurses are available • Allow the clients to sleep until a third staff person can assist with unit activities 50- A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement? • Instruct the mother to give the child sugar water only • Maintain intravenous fluid therapy per prescription • Provide Pedialyte feedings via the nasogastric tube • Offer the infant Pedialyte feedings every 2 hours. 51- A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? • Stroke secondary to hemorrhage • Acute kidney injury due to glomerular damage • Heart block due to myocardial damage • Blindness secondary to cataracts 52- . The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned? a- Empty the urinary drainage bag b- Feed the client a snack c- Offer the client oral fluids • Assess the breath sounds 53- A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the las 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescriptions has the highest priority? • Ringers Lactate IV 125ml/8 hours • Obtain specimens for cultures • Assign private room • Vital signs q4 hours 54- An older female client living in a low income apartment complex tells the home health nurse that she is concerned about her 81 – year old neighbor, a widow whose son recently assumed her financial affairs. Lately, her neighbor has become reclusive, but is occasionally seen walking outside wearing only robe and slippers. What response should the nurse offer? • Explain that it is not unusual for older adults to suffer from dementia which often causes such behaviors • Tell the client to talk to a healthcare provider before reporting suspicion of neglect to the authorities • Provide the number for Adult Protective Services so the client can report any suspicion of elder abuse • Encourage the client to avoid becoming involved the neighbor’s problems, for one’s own protection 55- A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care? • Observe for bleeding side effects related to heparin therapy. • Assess blood pressure and heart rate at least q4 hours • Measure calf girths to evaluate edema in the affected leg • Encourage mobilization to prevent pulmonary embolism 56- A nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurse’s request, what action is best for the charge nurse to take? • Ask to meet with the impaired nurse’s therapist before allowing the nurse back on the unit • Meet with staff to assess their feelings about the impaired nurse’s return to the unit • Since treatment is completed, assign the nurse to routine RN responsibilities • Allow the impaired nurse to return to work and monitor medication administration 57- A preschool teacher notifies the school nurse that child A has bitten child B on the arm. Child B’s skin is broken, but is not bleeding. What action should the school nurse take first? • Apply antibiotic cream to Child B’s arm immediately • Determine if Child A has a history of Hepatic C or HIV • Determine the date of Child B’s latest tetanus booster • Wash Child B’s arm thoroughly with soap and water 58- At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond? • Ask the woman if she also performs monthly breast self-exams. < • Advise the woman that mammograms are only needed every two years at her age. • Encourage the woman to explore her fears about breast cancer. • Comment the woman for adhering to the recommended cancer detection guidelines. 59- (ESTA PREGUNTA TIENE DOS FORMAS DIFERENTES DE PREGUNTAR AQUI LES DEJO LAS DOS OPCIONES LA RESPUESTA ES LA MISMA) The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN? The charge nurse is making assignments for one practical nurse (PN) and three registered nurses (RN) who are caring for neurologically compromised clients. which client with which change in status is best to assign to the PN? • Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7 • Subdural hematoma whose blood pressure changed from 150/80 mmHg to 170/60 mmHg • Myxedema coma whose blood pressure changed from 80/50 mmHg to 70/40 mmHg • Viral meningitis whose temperature changed from 101° F ( 38.3 C) to 102° F (38.9C). 60- Prior to surgery, written consent must be obtained. What is the nurse’s legal responsibility with regard to obtaining written consent? • Validate the clients understanding of the surgical procedure to be conducted • Explain the surgical procedure to the client ask the client to sign the consent form • Ask the client or a family member to sign the surgical consent form • Determine that the surgical consent form has been signed and is included in the client’s record 61- The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch the toes. Which finding indicates an a student should be referred for scoliosis evaluation? • Inability to touch toes • Asymmetry of the shoulders when standing upright • Audible crepitus when bending • An exaggerated upper thoracic convex curvature 62- The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take? a- Document that an accurate oxygen saturation reading cannot be obtained b- Elevate to client's hands for five minutes prior to obtaining a reading from the finger c- Increase the oxygen based on the clients breathing patterns and lung sounds d- Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading 63- The nurse provides sliding scale insulin administration instruction to an adult who was recently diagnose with diabetes mellitus. The client demonstrates and understanding on the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.) Obtain blood glucose level Verify the insulin prescription Draw insulin into insulin syringe Cleanse the selected site 64- What is the primary focus of postoperative nursing care for the client with colon trauma? • Monitoring for elevated coagulation studies • Observation for and prevention of fistulas • Monitoring for signs of hyponatremia • Observation for and prevention of infection 65- While assessing a client four hours post-thoracentesis, the nurse is unable to auscultate breath sounds on the right side of the chest. What action should the nurse take first? • Instruct the client to perform cough and deep breathing exercises • Assess the client’s vital signs and respiratory effort • Administer oxygen per nasal canula per PNR protocol • Document assessment findings in client’s medical record 66- During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? • Obtain at the same time every day • Report weight gain of 2 pounds (0.9kg) in 24 hours • Keep a daily weight record • Limit intake of dietary salt 67- A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory values requires intervention by the nurse? a- Total calcium 9 mg/dl (2.25 mmol/L SI) b- Creatinine 4 mg/dl (354 micromol/L SI) c- Phosphate 4 mg/dl (1.293 mmol/L SI) d-Fasting glucose 95 mg/dl (5.3 mmol/L SI) 68- A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? • Children usually resume their toileting behaviors when they leave the hospital • A retraining program will need to be initiated when the child returns home • Diapering will be provided since hospitalization is stressful to preschoolers • A potty chair should be brought from home so he can maintain his toileting skills 69- The nurse is caring for a group of a clients on a surgical unit. Which client should the nurse assess first? • A client who is two days post knee surgery and who describes pain at “4” on a 1 to 10 scale • A client who is one day post bowel resection with no bowel sounds • A client who is 8 hours post appendectomy with urinary output of 480 ml • A client who was admitted with severe abdominal pain and suddenly has no pain 70- A client who is mechanically ventilated is receiving continuous enteral feedings through a nasogastric feeding tube. To prevent aspiration, which intervention is most important for the nurse to implement? • Verify the feeding tube position with a daily chest x-ray • Maintain head of bed elevated while enteral feeding is infusing • Check feeding tube placement with air bolus prior to use • Aspirate stomach contents every 4 hours to assess residuals 71- 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? • Monitor for urinary incontinence • Apply sequential compression stockings • Provide a wide variety of meal choices • Observe for signs of depressions 72- A client with diabetes mellitus tells the nurse that she uses cranberry juice to help prevent urinary tract infection. What instruction should the nurse provide? • Be sure to drink sugar-free cranberry juice • Drinking cranberry juice does not prevent infection • Cranberries may increase the effect of insulin • Excess cranberry juice can be constipating 73- After receiving report on an inpatient acute care unit, which client should the nurse assess first? • The client with bowel obstruction due to a volvulus who is experiencing abdominal rigidity • The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds • The client with an obstruction of the large intestine who is experiencing abdominal distention • The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid 74- An adolescent male client is admitted to the hospital. Based on Erikson’s theory of psychosocial development, which nursing intervention best assists this adolescent’s adjustment to his hospital stay? • Invite him to participate in the evening group activity • Schedule frequent private phone calls to his parents • Provide access to a variety of video games in his room • Encourage him to learn his way around the hospital 75- A client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take? • Explain the importance of regular dressing change • Administer an anti-anxiety medication • Proceed with the scheduled dressing change • Encourage the client to express any anxieties 76- A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement? • Administer infusion via an infusion pump • Obtain current serum potassium level • Continuously monitor blood pressure • Teach guided imagery to decreased pain 77- When caring for a client with diabetes insipidus (DI), it is most important for the nurse to include frequent assessment for which conditions in the client’s plan of care? • Dry mucous membranes, hypotension • Decreased appetite, headache • Nausea and vomiting, muscle weakness • Elevated blood pressure, petechiae 78- The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the healthcare provider? a- Decreased white blood cell count b- Pruritus and muscle aches c- Elevated liver function tests • Vomiting and diarrhea 79- A child with heart failure (HF) is taking digitalis. Which signs indicates to the nurse that the child may be experiencing digitalis toxicity? • Tachycarcia • Dyspnea • Vomiting • Muscle cramps 80- A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric phase? a- RUQ abdominal pain b- Clay – colored stool c- Icteric sclera d- Pruritis 81- An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care? • Provide additional light in the room to promote sensory stimulation • Teach the client to turn his head from side to side for visual scanning • Place a clock and calendar in the room to improve orientation • Use hand and arm gestures to improve communication and comprehension 82- The nurse is caring for a client with a tracheostomy. Which action should the nurse perform when suctioning the tracheostomy tube? • Increase wall suction with removal of the suction catheter • Place sterile saline 10 ml in the tracheostomy tube, then suction as continuous suction is applied • Suction the client’s oropharynx before tracheal suctioning • Insert the suction catheter into the trachea, and apply intermittent suction with removal catheter 83- The urinary drainage of a client with a continuous bladder irrigation is becoming increasingly red. Which intervention should the nurse implement? • Increase the irrigation rate • Lower the head of the bed • Milk the catheter tubing • Evaluate for fluid overload 84- The nurse is preparing to administer a suspension ampicillin labeled, 250mg/5ml, to a 12-year old child with impetigo. The prescription is for 500 mg QID. How many ml should the child receive per day? (Enter numeric value only) 40 85- A client with a severe prostatic infection that caused a blocked urethra is 3 days post-surgical urinary diversion. The healthcare provider directs the nurse to remove the suprapubic catheter to allow the client to void normally. Which intervention should the nurse implement first? • Cleanse the site around the catheter • Use a 20 ml syringe to deflate balloon • Clamp catheter until a client voids naturally • Empty urine from urinary drainage bag 86- The nurse receives report on four clients who are complaining of increased pain. Which client requires immediate by the nurse ? • Burning pain due to a Morton’s neuroma • Sharp pain related to a crushed femur • Paresthesia of fingers due to carpal tunnel syndrome • Stinging pain related to Plantar fasciitis 87- A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for nurse to include the in this client’s plan of care? • Restrict daily fluid intake to 1500 ml • Weight client every morning • Maintain accurate intake and output • Administer prescribed diuretic 88- A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the clients begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, ‘’ My favorite nurse is on duty now” Which response is best for the nurse to provide to this client’s dichotomous tendency? • I am glad you like me. Which nurse was acting aloof to you? • Tomorrow I will talk to that nurse about how you were treated last night • What did the night nurse that makes you think she is aloof? • I am happy that you are getting better and will be able to go home 89- The nurse is calculating the one-minute Apgar score for a newborn male infant, and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant? (Enter the numeric value only.) 8 90- The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first? a- An older client who is receiving packed RBCs on the third day postoperatively for colon resection b- An older client with continuous bladder irrigation who is 2 day postoperatively for bladder surgery c- An adult one day postoperatively laparoscopic cholecystectomy requesting pain medication d- An adult who is in Buck’s traction, and scheduled for hip arthroplasty within the next 12 hours. 91- While changing a client’s chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take? a-Apply a pressure dressing around the chest tube insertion site. b-Assess the client for allergies to topical cleaning agents. c-Measure the area of swelling and crackling. d-Administer an oral antihistamine per PRN protocol. 92- When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include? a- Wash hands frequently b- Avoid drinking lake water c- Wear long sleeves and pants • Do not share personal products 93- In preparing a nursing care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority? • Ineffective coping related to uncertainly of disease progression • Imbalanced nutrition: less than body requirements related to impaired swallowing reflex • Ineffective breathing pattern related to ascending paralysis. • Impaired physical mobility related to asymmetrical descending paralysis 94- A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? • Ask the most experienced UAP on the team to partner with the newly hired UAP • Evaluate the newly hired UAP’s level of competency by observing the UAP deliver care • Review the UAP’s skills checklist and experience with the person who hired the UAP • Assign the newly hired UAP to clients who require the least complex level of care 95- What Nursing intervention is particularly indicated for the second stage of labor? • Providing pain medication to increase the client’s tolerance of labor • Assessing the fetal heart rate and pattern for signs of fetal distress • Monitoring effects of oxytocin administration to help achieve cervical dilation • Assisting the client to push effectively so that the expulsion of the fetus can be achieved. 96- An adult male with a 6 cm thoracic aneurysm is being prepared for surgery. The nurse reports to the healthcare provider that the client’s blood pressure is 220/112 mmHg, so an antihypertensive agent is added to the client’s IV infusion. Which finding warrants immediate intervention by the nurse? • Reports a tearing, sharp pain between his shoulder blades • Blood pressure reading of 200/100 mmHg 15 minutes later • Rose colored urine draining from the urinary catheter • Sinus tachycardia with frequent premature ventricular beats (PVC) 97- When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement? a- Ignore the behavior and hang the IV antibiotic b- tell the client to stop the inappropriate behavior c- Leave the room and close the door quietly d-Complete an unusual occurrence report 98- A client is admitted with the diagnosis of Wernicke’s syndrome. What assessment finding should the nurse use in planning the client’s care? • Right lower abdominal pain • Confusion • Depression • Peripheral neuropathy 99- The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem? • Low grade fever • Bruising of the skin • Abdominal cramping • Bloody emesis 100- A client with complaints of shortness of breath and abdominal pain 1 week after bariatric surgery is admitted for follow-up evaluation. Which assessment finding warrants immediate intervention by the nurse? • Rectal temperature of 101F • Complaints of left shoulder pain • Blood pressure of 88/50 mmHg • Sustained sinus tachycardia 101- A client with prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement? • The client’s need for pain medication should be determined • The impeding signs of death should be documented • The nurse manager should be update on the client’s status • The client’s status should be conveyed to the chaplain. 102- An adult male is admitted to the intensive care unit because he experienced a sudden onset of sharp chest pain and shortness of breath earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. Which intervention is most important for the nurse to include in this client’s plan of care? • Monitor signs of increased bleeding • Instruct on the use of incentive spirometry • Observe for confusion and restlessness • Administer intravenous opioids for severe pain 103- A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask? a-Does she knows the person who raped her? b-Has she taken a bath since the raped occurred? c-Is the place where she lived a safe place? d- Did she report the rape to the police Department? 104- A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain? • Level of consciousness. • Percussion of abdomen • Serum electrolytes • Blood glucose. 105- A male client with schizophrenia tells the nurse that the hospital has installed cameras that watch him and listening devices that record what everyone says. Which nursing problem should the nurse document for this client? • Noncompliance with medication related to thought broadcasting • Situational self esteem disturbance secondary to schizophrenia • Disturbed sensory perception related to auditory hallucinations • Impaired environmental interpretation related to paranoid delusions 106- A nurse is administering diazepam, a benzodiazepine, 10 mg IV push PRN, as prescribed to a client with alcohol withdrawal symptoms. Which actions should the nurse implement when administering the medication? (Select all that apply) • Protect medication from exposure to light • Monitor for changes in level of consciousness • Observe for onset of generalized bruising or bleeding • Perform ongoing assessment of respiratory status • Administer slowly over at least two minutes 107- An older male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions the client is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has a foul odor. These findings suggest that this client is experiencing which condition? • Psychotic episode • Dementia • Delirium • Depression 108- While changing the pressure ulcer dressing of a client who is immobile, the nurse notes that the boundary edges of the wound have increased. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s serum laboratory values? • Potassium • Platelets • Creatinine • Albumin 109- A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all apply) • Encourage oral fluid intake of 3,000 ml/day • Observe for evidence of hypokalemia • Teach the client how to restrict dietary sodium • Monitor PTT, PT, and IRN, lab values • Weight the client daily, in the morning 110- A 17-year –old adolescent is brought to the emergency department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? a- Obtain a chest X-ray per protocol. b- Place a mask on the client’s face. c- Assess the client’s temperature. d-Determine the client’s blood pressure 111- The nurse provides discharge teaching to a client who was recently diagnosed with diabetes mellitus (DM). After receiving the instructions, the client expresses understanding about when, how, and why to take his prescribed medications at home. Which intervention is most important for the nurse to implement a- Review the purpose of medications prescribed for the client to take home with him b- Provide the client with a printed list of medications and a schedule for administration. c- Send a list of medications taken while hospitalized to the client’s healthcare provider d- Offer to consult with the pharmacist about resources for reduced price medications 112- The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning? a- An adolescent who works part time in a pain factory b- A 2- year- old who plays on aging outdoor playground equipment c- A 10 – year – old who has Type 1 diabetes mellitus d-An 8 – year old who lives in a housing project 113- An IV infusing in a client’s left forearm becomes infiltrated. After removing the IV, which sites should the nurse select as possible site to insert another IV catheter? (Select all that apply) • Right hand • Right forearm • Left hand • Right subclavian • Left subclavian 114- An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? • 1000, 1600, 2200, 0400. • Give in equally divided doses during waking hours • Administer with meals and a bedtime snack • 0800, 1200, 1600, 2000 115- A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that her voices are saying, “Kill, Kill” What question should the nurse ask the client next? • When did these voices begin? • Are you planning to obey the voices? • Have you taken any hallucinogens? • Do you believe the voices are real? 116- A client has had several episodes of clear, watery diarrhea that starter yesterday. What action should the nurse implement? • Administer a prescribed PRN antiemetic • Assess the client for the presence of hemorrhoids • Check the client’s hemoglobin level • Review the client’s current list of medications 117- The nurse notes that a depressed female client has been more withdrawn and non- communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? • Encourage the client’s family to visit more often • Schedule a daily conference with the social worker • Encourage the client to participate in group activities • Engage the client in a non-threatening conversation. 118- A postpartum client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client? • Take a prescribed analgesic and exposed breasts to air • Place warm packs on both of the breasts • Avoid stimulation of the breasts and wear tight bra • Express a small amount of breast milk by hand 119- A nurse assesses a client whose hand begins to spasm when the blood pressure cuff is inflated. The client complains of paresthesia in the fingers and toes. Which serum laboratory finding should the nurse expect to find? • Elevated serum calcium • Low serum magnesium • Low serum calcium • Elevated serum potassium 120- The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? • Encourage the parents to allow the child to continue attending swimming lesson with supervision • Suggest that the child be encouraged to participate in a team sport to encourage socialization • Explain that their child is too young to understand the risks associated with swimming • Provide a list of alternative activities that are less likely to cause the child experience fatigue 121- An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement? • Explain the importance of bathing or showering daily • Encourage fluid intake of a least 2,000 ml daily • Keep the legs covered as much as possible • Apply emollient to affect area at least twice daily. 122- In performing the admission assessment for a client experiencing complications of long term Parkinson’s disease, which question by the nurse provides the best information about disease progression? • Have you experienced any stiffness in your neck or shoulder?” • “Do you notice any jerky type movements of your arms?” • “Have you ever been frozen to a spot and unable to move?” < • “Do you have any problems with your hands shaking?” 123- An adult suffered burns to face and chest resulting from a grease fire. On admission, the client was intubated and a 2 liter bolus of normal saline was administered IV. Currently the normal saline is infusing at 250ml/hour. The client’s heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP)is 4 mm H2O. Which intervention should the nurse implement? • Increase the oxygen delivered by the ventilator • Infuse an additional bolus of normal saline • Lower head of the bed to a recumbent position • Bring a tracheotomy tray to the bedside 124- The nurse is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to include in this client’s plan of care? • Interventions to decrease emotional stress • Precaution about avoiding sunlight • Strategies to increase omega-3 fatty acids in the diet • Instruct about applying an antifungal ointment 125- After successful resuscitation, a client is given propranolol and transferred to Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 ml D5 W at one gram/hour. Which assessment findings require immediate intervention by the nurse? • Dark amber urine draining per indwelling catheter with 40 ml per hour • Serum calcium of 9.0 mg/dl (2.2 mmol/L SI) and magnesium of 1.8 md/dl or Eq/L (0.74 mmol/L SI) • Sinus rhythm at 72 beats/minute and peripheral blood pressure of 99/62 • Respiratory rate of 10 breaths per minute and pulse oximetry of 90%. 126- A small, round raised are appears under the client’s skin as the nurse administers an intradermal medication. What actions should the nurse take? • Apply a col pack to the area for twenty minutes • Elevate the area and apply light pressure over the site • Document the site where the medication was given • Notify the healthcare provider of the allergic response 127- A client who has been newly diagnosed with abnormally high production of antidiuretic hormone reports muscle cramps and twitching. The client also reports a headache and lethargy. These concerns are most likely related to which electrolyte imbalance? • Hypermagnesium • Hyponatremia • Hypokalemia • Hypercalcemia 128- The nurse asks the parent to stay during the examination of a male toddler’s genital area. Which intervention should the nurse implement? • Examine the genitalia as the last part of the total exam • Use soothing statements to facilitate cooperation • Allow child to keep underpants on to examine the genitalia • Work slowly and methodically so not to stress the child 129- A woman at 12-week gestation comes to the clinic for her first prenatal visit. After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit? • Complications associated with childbirth • Concerns about parenting • Cultural practices related to childbearing • Knowledge about labor and delivery 130- When preparing to transfer a young adult who has a spinal cord injury (SCI) to a rehabilitation center, which information about the client is most important for the nurse to provide to the receiving agency? • The degree of family support available to the client • The client’s current ability to participate in daily care • The client’s remaining length of insurance coverage • A description of the client’s attitude about the transfer 131- A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client’s EKG showed bradycardia, ST depression, but no ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, “I feel like an elephant just stepped on my chest” The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention should the nurse perform? a-Increase the peripheral IV flow rate to 175 ml/hr to prevent hypotension and shock b-Administer prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. c- Obtain a stat 12 lead EKG and perform a venipuncture to check cardiac enzymes levels. d-Notify the healthcare provider of the client’s increase chest pain a call for the defibrillator crash cart. 132- A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which interventions should the nurse implement? (Select all that apply) • Give the client 4 ounces of orange juice • Obtain blood pressure and pulse rate • Provide the client with ½ cup diet carbonated soda • Administer a PRN dose of regular insulin • Check the client’s current finger stick blood glucose 133- The nurse assesses a client who had bilateral total knee replacements (TKR) four hours ago the nurse notes that the dressing on the client’s right knee is saturated with serosanguineous drainage. What action should the nurse implement? • Determine if the wound drainage device is functioning correctly • Confirm that the continuous passive motion device is intact • Withhold next scheduled dose of low molecular weight heparin • Monitor the clients current white blood cell count (WBC) 134- An older adult with known cognitive impairment residing in a long- term care facility suddenly becomes disoriented and confused. There are no signs of extremity weakness or other neurological changes. Which intervention should the nurse implement? • Obtain 12 lead electrocardiogram • Assess the urine for cloudiness • Perform stroke assessment • Auscultate for bowel sounds 135- A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff’s sign). Which pathophysiological mechanism supports this response? a- Arterial Constriction b- Temporary vasodilation c- Poor temperature control d-Severe dehydration. 136- The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. He tells the nurse that he is worried that she might be getting Alzheimer’s disease. What action should the nurse take? a-Explain that memory loss and confusion are common with vitamin B12 deficiency b- Encourage the husband to bring the client to the clinic for a complete blood count c- Determine if the client is taking iron and folic acid supplements d-Ask if the client is experiencing any change in bowel habits 137- A client is receiving enoxaparin 30 mg SUBQ BID. In assessing for adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor? • White blood cell count • Platelet count • Glucose • Calcium 138- A female client with severe renal impairment is receiving enoxaparin (lovenox) 30 mg SUBQ BID. Which laboratory value due to enoxaparin should the nurse report to the healthcare provider? • creatinine clearance 25 mL/ minute • calcium 9 mg/dl • hemoglobin 12 grams/dl • partial thromboplastin time (PTT) 30 seconds 139- After receiving the morning report at 0700 on a postpartum unit, which client should the nurse assess first? The client who is • Complaining of IV site pain whose IV antibiotic is due at 0800 • 23-hours postpartum and complaining of episiotomy pain. • A third day post- cesarean requesting assistance to the bathroom • Requesting assistance with breastfeeding her one-day old infant 140- Which laboratory results should the nurse closely monitor in a client who has end – stage renal disease (ESRD) a- Serum Potassium, calcium, and phosphorus b- Erythrocytes, hemoglobin, and hematocrit c- Blood pressure, heart rate and temperature d-Leukocytes, neutrophils and thyroxine 141- Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client? • 2+ pitting edema of the feet • Right-side paralysis • Orthopnea • Pallor 142- The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client’s room after taking vital signs. What action should the nurse take? • Remind the UAP to continue rubbing the hands together until they dry • Instruct the UAP to return to the client’s room to perform handwashing • Advise the UAP to wear gloves when obtaining vital signs for all clients • Supervise the UAP in the next client’s room to evaluate hand hygiene 143- Which client problem has the higher priority for the child sickle cell anemia who has a temperature of 101 F (38.3)? • Infection related to low platelet count • Activity intolerance related to anemia • Fluid volume deficit related to temperature elevation • Altered urinary elimination related to renal damage 144- A client with chronic kidney disease receives a prescriptions for darbepoetin alfa 40 mcg subcutaneous every 7 days. The darbepoetin alfa vial is labeled, “60 mcg/ml” How many ml should the nurse administer ? (Enter numeric value only. If rounding is required, round to the nearest tenth) 0.7 145- A client with metastatic cancer who was taking hydromorphone (Dilaudid) PO at home is now receiving the medication IV while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the Dilaudid, what assessment should the nurse complete? • Pain scale • Level of consciousness • Respiratory rate • Blood pressure 146- When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? • Withhold food and fluid intake. • Initiate IV fluid replacement. • Administer antiemetic as needed. • Evaluate intake and output ratio. 147- What instruction should the nurse provide to a client who is preparing to have a cystoscopy ? • Avoid strenuous activity and sports for a least 2 weeks • Report any allergies to shellfish or iodine • Lay prone for 24 hours after the procedure • Report any painful urination, blood urine, or fever 148- While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client’s vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? • Provide supplemental oxygen • Auscultate bilateral lung fields • Administer a nebulizer treatment • Reinforce occlusive CT dressing • Give PRN dose of pain medication 149- Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client’s response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom) RESPONDIDA Talk to the physician as a group in a non-confrontational manner. Document concerns and report them to the charge nurse Submit a written report to the director of nursing. Contact the hospital’s chief of medical services. File a formal complaint with the state medical board. 150- While transferring a client with a chest tube from the bed to a stretcher, the chest becomes disconnected from the water-seal drainage container. The nurse immediately i