med_surge_V_2

HESI MEDSURGE VERSION 2 EXAM   HESI MEDSURGE VERSION 2 EXAM A client arrives in the ED with slurred speech and right-sided weakness Onset of symptoms The community mental health nurse is planning to visit 4 clients with schizophrenia..see first The father who took his children from school because aliens were after them The nurse is assessing several clients at a homeless shelter. Which client should the nurse refer for involuntary admission to a psych facility A young adult who has lost his appetite because the communists are asking him to kill all conservative Catholics An adult male who has not eaten for 3 days and says he is Jesus Christ and that God loves all people A middle-aged woman who sits for long periods of time and mumbles to herself about wanting to die A 7-year-old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history, which finding should the nurse expect to obtain A recent strep throat infection Beginning with the vena cava, what is the normal sequence of blood circulation through the heart (arrange from entry of the heart on top to exit of the heart on the bottom) Right atrium, tricuspid valve, right ventricle, pulmonary semilunar valve, left atrium, mitral valve, left ventricle, aortic semilunar valve The nurse is assessing the emotional status of a client with Parkinson’s disease. Which client finding is most helpful in planning goals to meet the client’s emotional needs Cries frequently during the interview What nursing intervention is particularly indicated for the second stage of labor Assisting the client to push effectively so that expulsion of the fetus can be achieved A newborn is apneic for 20 seconds. What action should the nurse implement Stimulate by gently rubbing infant’s trunk The nurse is completing a neurological assessment. Which observation indicates an abnormal pupil response When shining the light into the right eye, the left pupil does not constrict The nurse manager is concerned about the number of falls that have occurred on the unit in the last month. Which action is most likely to decrease the number of falls Obtain the evidence based practice guidelines for falls prevention The healthcare provider prescribes diltiazem (Cardizem ) for a child with hypertension who weighs 66 pounds. Based on the recommended dose of 3.5 mg/kg/day, how many mg should the child receive per day One year after being diagnosed with Pneumocystic carinii pneumonia, a client is admitted with respiratory failure. Respirations are shallow with periods of apnea. After the HCP delivers a grim prognosis to the client’s family, which intervention should the nurse implement first Clarify client’s end of life wishes When preparing to start change-of-shift report, the charge nurse observes an unlicensed assistive personnel (UAP) walking in the hallway with a urine specimen that is not covered. After telling the UAP to cover the specimen, what intervention should the charge nurse implement Review infection control guidelines with the UAP at the next opportunity In monitoring a client’s respiratory status, which symptom is characteristic of early acute (adult) respiratory distress syndrome (ARDS) Increased respiratory rate A client’s serum potassium test level is 6 mEq/L. The laboratory indicates, “Specimen is hemolyzed.” What action should the nurse take Draw a new blood specimen Which action should the nurse implement to reduce a clients risk for nosocomial infection Replace continuous tube feeding bag and tubing at least daily During the admission interview, the nurse leader learns that a newly admitted adult client has a six month history if recurring somatic pain. Which problem is most important for the nurse to further explore with the client Feelings of depression An older male adult resident of an extended care facility receives a prescription for diphenhydramine (Benadryl) 25 mg PO to treat generalized pruritis. Two hours after administration of the drug, he continues to experience itching, is confused, and has an unsteady gait. Which actions should the nurse implement first Place the client on fall precautions A female resident of a long-term care facility is being admitted to the medical department. The client has a fractured humerous and methicillin-resistant staphylococcus aureus (MRSA). Which room should the charge nurse assign this client A semi-private room with another client who also has MRSA The healthcare provider is working with a client who was recently diagnosed with asthma. Which statement by the client indicates to the nurse that further teaching is needed “I should always use my beclomethasone inhaler first, then follow it with my albuterol inhaler.” The nurse is preparing to conduct discharge teaching for a client who had an anaphylactic reaction following administration of ampicillin (Omnipen-N). What instruction is essential for the nurse to provide this client prior to discharge Instruct the client to wear a medic-alert bracelet so penicillin will not be given again What is the goal when planning nursing care for a client with edema and leg discoloration secondary to chronic venous insufficiency client’s skin integrity will remain intact A client with a psychotic disorder is receiving haloperidol (Haldol) 3 mg IM q30 minutes x 3 hours for agitation control. The medication is available in 5mg/ml. How many ml will the client receive over the next 3 hours The nurse plans to administer 1 teaspoon of a liquid to a toddler. What is the most accurate way to administer the medication measure the medication in an oral syringe When assessing a client who had a supratentorial craniotomy, what action should the nurse implement when determining the client’s Glasgow coma scale (GCS) rating instruct the client to raise an arm A client with a 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 In assessing a client 48 hours following a fracture, the nurse observes ecchymosis at the fracture site, and recognizes that hematoma formation at the bone fragment site has occurred. What action should the nurse implement document the extent of the bruising in the medical record A client who is admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test lumbar puncture The school nurse is planning to begin an obesity screening program in a school system. It is best to begin the screening program with which group kindergarten During a home visit, the nurse determines that a male client is experiencing symptoms that should be controlled by his prescribed medication. The client states that he forgot when he was supposed to take his medications. What is the priority nursing problem when the nurse develops the plan of care for this client ineffective health maintenance related to lack of knowledge Immediately after an elective cardioversion for a rapid supraventricular tachycardia (SVT), a male client who was premedicated with hydromorphone (Dilaudid) and midazolam (Versed) is difficult to arouse. His vital signs are: oxygen saturation 94% while receiving oxygen at 2L/minute per nasal cannula, heart rate 78 beats/minute, respirations 6 breaths/minute, and blood pressure 102/70. Which intervention should the nurse implement give IV naloxone (Narcan) When completing a mental health assessment, the nurse wishes to obtain information about a client’s insight and judgment. Which interview technique is most useful in assessing these mental abilities have the client describe what should be done if a child was observed alone in a locked car on a hot day An adult Muslim client with ulcerative colitis was admitted to the post-surgical unit earlier today following a bowel resection with temporary colostomy. Which intervention is most important for the nurse to implement assign a care provider of the same gender The parents of a 6-year-old recently diagnosed with Duchene 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 lessons with supervision The nurse initiates a one-to-one relationship with a 35-year-old depressed female client who was recently admitted to the psychiatric facility. Which nursing action is most effective in promoting the development of a therapeutic relationship ensure that scheduled appointments begin according to the schedule An 18-year-old female client is admitted to the unit after ingesting an overdose of Phenobarbital (Luminal). She is unresponsive and ABG results are: pH 7.18, PaCO2 60 mmHg, and HCO3 26 mEq/L. Which interpretation of the client’s ABG results by the nurse is accurate Respiratory acidosis, uncompensated A male client with multiple myeloma is admitted with pneumonia and pancytopenia. The nurse reviews the complete blood cell count findings and identifies a platelet count of 20,000 cells/mm3. Which intervention should the nurse include in the client’s plan of care Avoid intramuscular injections A client’s left femoral artery is difficult to palpate. To compare pulses bilaterally, where should the nurse palpate As a means of relieving a client’s pain associated with osteoarthritis, the nurse plans to provide local rest. To implement this intervention, which action should the nurse take Immobilize the affected joint with a splint The healthcare provider prescribes isosorbibide (Isordil) 40 mg every 8 hours for a male client with acute angina pectoris. Which finding should the nurse report to the healthcare provider prior to administering Isordil Currently, takes sildenafil (Viagra) A client is admitted with syncopal episodes related to a third degree heart block. After the placement of a transcutaneous pacemaker, the nurse observes several episodes of the pacemaker’s failure to sense. What action should the nurse take Increase the sensitivity A 60-year-old male client with cancer of the liver has been in a hepatic coma for the past 24 hours. On admission, the client signed a release of information to his family. His oldest son arrives from out of town and asks the nurse how his father is doing. Which response is best for the nurse to provide “Your father has given no response for 24 hours. His condition is extremely critical at this time” The nurse is preparing a client for a scheduled cesarean section. In what order should the nurse perform these actions (place the first action on top and the last action on the bottom) Verifying the consent form is signed Inserting an indwelling catheter Prepping the site with iodophor (Betadine) Performing a time-out procedure A client receives a prescription for bacitracin 20,000 units every 12 hours IM. The medication is available in a vial that contains 50,000 units and includes reconstitution instructions: “Use 4.8 ml diluent to yield a total volume of 5 ml.” how many ml should the nurse administer The nurse identifies which recent event as placing a client at high risk for cardiogenic shock Myocardial infarction in the right ventricle The unit manager of an acute care unit evaluates the time management skills of the nursing staff and determines that one staff nurse is consistently behind in meeting the needs of assigned clients. What action should the unit manager take Schedule a private meeting with the staff nurse as soon as possible The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours Which assessment finding has the highest priority when planning nursing care for a client with peptic ulcer disease (PUD) Dark tarry liquid stools The nurse is obtaining a blood sample via venipuncture from a preschool-aged child. Which intervention should the nurse implement Apply a large colored band-aid to the puncture site A 3-year-old boy is brought to the emergency department after the mother found the child in the back yard holding a piece of a toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement Auscultate all pulmonary lung fields and attempt a Heimlich maneuver The nurse plans to obtain a urine specimen for culture from a client’s indwelling catheter. The nurse enters the room with the syringe and notes there is 100ml of urine in the drainage bag, but no urine is in the tubing. What action should the nurse take Clamp the tubing until urine is observed in the tubing The scrub nurse places the fenestrated drapes to expose the operative area for a client who is having a hepatic tumor removed. The scrub nurse should assist with applying the sterile impermeable adhesive drape or surgical skin barrier to which area Right subcostal An elderly client is experiencing disturbed sleep patterns. Which intervention should the nurse implement to help the client attain maximal sleep function Assess daytime somnolence Review medication side effect profiles A 58-year-old male client with chronic kidney disease (CKD) is receiving aluminum hydroxide (Amphojel). He tells the nurse that since he does not have indigestion there is no need for him to take the antacid with his meals. Which response is best for the nurse to provide “Your serum phosphate levels are up, and aluminum antacids prevent absorption of phosphates in foods” A client slips and falls while getting out of bed and the charge nurse instructs the nurse who is caring for the client to complete an incident report. What is the main purpose in having the nurse complete the incident report To provide computer documentation of the incident as a basis for further investigation The registered nurse (RN) is observing a newly hired practical nurse (PN) give a newborn a vitamin K (AquaMEPHYTON) injection. The PN uses a filter needle to draw 0.25 mg of AquaMEPHYTON into the syringe, cleanses the thigh with alcohol in a circular motion, and prepares to inject the needle at a 90 degree angle in the left vastus lateralis. What action should the RN take Direct the PN to change the filter needle to a ½ inch needle At bedtime, an unlicensed assistive personnel (UAP) is positioning a client with obstructive sleep apnea syndrome (OSAS). The UAP elevates the head of the bed and encourages the client to turn on side. In supervising the UAP, what action should the nurse take Confirm that the UAP has placed the call bell within reach of the client Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. What action should the nurse take Report the complaint of eye pain to the surgeon An elderly male client tells the nurse that he often wakes up during the night. What action should the nurse implement first Ask the client to describe what happens when he awakens During assessment of a 2-month-old infant, the nurse notices a bluish-black discoloration over the lumbosacral area. Which action should the nurse take Document the findings in the record Dinoprostone (Prostin E-2) is prescribed for primigravada who had a missed spontaneous abortion. An increase in which finding should the nurse expect Contractions of the uterus Which client should the charge nurse on the oncology unit assign to an RN, rather than a practical nurse (PN) An elderly female client with cancer and her children who are trying to decide whether to change to palliative care measures or continue disease control A client taking tamoxifen citrate following a lumpectomy reports several problems to the nurse. It is most important for the nurse to follow-up on which reported problem Calf tenderness During morning rounds, the nurse finds a client who has no spontaneous respirations and does not respond to shaking. The nurse activates the “Code-Blue” system. While waiting for the code team to arrive, what action should the nurse implement Check the pulse for 10 seconds and begin chest compressions The nurse learns that a client in a semi-private room has a postoperative wound that is colonized with a multi-drug resistant organism. What action should the nurse implement Move the client to a private room and implement contact precautions for the client The healthcare provider prescribes digoxin (Lanoxin) 0.5 mg PO daily for a client with heart failure. When the nurse scans the medication label, “digoxin 0.25 mg/tablet,” using an electronic scanner, a “pop-up” window in the electronic medical record indicates, “Error in dose.” What action should the nurse take Enter the value, 2 tablets, administered The nurse in the outpatient department is caring for a client who had a right femoral cardiac catheterization two hours ago. What assessment finding requires immediate intervention The client wants assistance walking to the bathroom Before placing a client’s dentures in the sink for cleansing, what action should the nurse take Place a washcloth on the bottom of the sink The nurse assesses the perineum of a client who is complaining of perineal pain 6 hours after a normal delivery and finds small perineal (vulvar) hematomas. Based on this assessment finding, which treatment should the nurse implement Apply ice packs in the perineum A nurse is caring for an elderly client who recently attempted suicide with an overdose of sedatives. Which conclusions regarding this client’s achievement of normal development is accurate The adult who is unfulfilled at an advanced age fails to achieve ego integrity, and instead experiences despair An infant has a medical diagnosis of tracheoesophageal fistula (TEF). What nursing intervention is indicated for this infant prior to surgical repair Maintain suction equipment available at all times A male client with chronic renal failure (CRF) is admitted to the intensive care unit after missing his last three appointments at the dialysis center. His arterial blood gas (ABG) results are: pH 7.32; PaCO2 32 mmHg; HCO3 18 mEq/L. Which assessment finding should the nurse expect this client to exhibit Tachypnea A community health nurse is concerned about the incidence of asthma among preschool aged children in a metropolitan area. Which intervention reflects a primary prevention strategy the nurse might initiate to combat this chronic illness Inform the city council of the need to strengthen the city’s air pollution ordinances The nurse caring for a client with dysphagia is attempting to insert a nasogastric tube (NGT), but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus Flex the client’s head with chin to the chest and insert What is the primary purpose for initiating nursing interventions that promote good nutrition, rest and exercise, and stress reduction for clients diagnosed with an HIV infection Improve function of the immune system A client receives a prescription for an intramuscular pain medication. The nurse uses the Z-track method to administer the injection. Which rationale supports the nurse’s use of this method Seals needle track to avoid medication leakage through the tissue A female client is seen in the Emergency Department with a broken arm. She is visibly anxious and tells the nurse “I am afraid my husband is going to kill me. The beatings are getting worse, and everyone says I should leave him, but I am afraid of what he will do to me and the children if I do leave.” What question is most important for the nurse to ask this client “Have you thought about what to do when you in an unsafe situation?” The charge nurse is establishing priorities of client needs at the beginning of the morning shift. Which client situation has the highest priority for immediate care An elderly client who is trying to climb over the side rails Two months after treatment with radioactive iodine (I131) (RAI) for hyperthyroidism, a male client reports the onset of extreme fatigue, depression, and hair loss. What action should the nurse take Explain to the client that thyroid replacement hormones may be needed A client with dementia who is cared for at home by her husband becomes increasingly confused in the evening. Her husband reports to the home health care nurse that his wife often believes that she is waiting for the oil to be changed in her car and insists on leaving. Which recommendation should the nurse provide to this husband Try to interest his wife in a different activity A female client receives a prescription for alendronate sodium (Fosamax) to treat her newly diagnosed osteoporosis. What instruction should the nurse include in the client’s teaching plan Take on an empty stomach with a full glass of water After receiving a prescribed dose of quinapril (Accupril), losartan (Cozaar), and clonidine (Catapres), a female client tells the nurse that she usually takes Accupril at 0800, Cozaar at 1600, and Clonidine at 2200 at home. The nurse informs the charge nurse that an error was made during the morning medication administration. What action should the charge nurse implement first Evaluate the client’s blood pressure Which symptom is characteristic of ureteral colic in the client diagnosed with renal calculi Acute, excruciating, wave-like pain radiating to the genitalia A home health nurse is visiting a client with a history of heart failure (HF). When interviewing the client, which question provides the most useful information for the nurse “How many pillows do you sleep on at night?” An older male client diagnosed with end-stage chronic obstructive pulmonary disease (COPD) is on strict bed rest, and asks the nurse, “Why can’t I get out of bed?” what response for the nurse to provide Bed rest decreases your body’s need for oxygen At 1000 the healthcare provider prescribes an increased in the dosage of a client’s loop diuretic from 40 mg to 80 mg a day. The nurse has already administered today’s 40 mg dose of the loop diuretic at 0600. Which action should the nurse implement Clarify the start date of the new dose with the healthcare provider Which client situation requires the most immediate intervention by the nurse A bedfast client experiences an episode of urinary incontinence A terminally ill client on a palliative care unit has an advanced directive stipulating comfort measures only. The client has not taken oral fluids in the last 36 hours and is not receiving intravenous fluids. The client’s blood pressure is 64/38 and urinary output is 50 ml for the last 12 hours. What is the priority nursing intervention Determine the client’s level of discomfort A client in the third trimester of pregnancy reports that she feels some “lumpy places” in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take Explain that this normal secretion can be assessed at the next visit A frail, elderly female with rheumatoid arthritis (RA) complains to the nurse that the weight of the sheets on her legs hurts all the time. Which action should the nurse implement Use a bed cradle to keep linens off her legs 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 The nurse on a busy surgical unit is assigning client care to a registered nurse (RN) and a practical nurse (PN). Which client is best to assign to the PN A preoperative client who has developed urinary retention and needs a urinary catheter inserted The nurse manager of a pediatric unit needs to assign a room for a 6-month-old diagnosed with respiratory syncytial virus (RSV). Which room assignment is best for the nurse manager to make Double room with a 4-month-old who has RSV To assess for the presence of diaphragmatic breathing, what action should the nurse take Observe the movement of the abdomen The nurse and a social worker are talking when a male client with psychosis angrily shouts at the nurse, “Stop talking about me.” The nurse should document the client is exhibiting which symptom Ideas of reference Before administering a parenteral nutrition solution through a central vein, the nurse should confirm information from which sources Client’s identification band Healthcare provider’s prescription Solution label Medication administration record A male client with chronic asthma tells the nurse that he is having more episodes of bronchoconstiction and increased mucous production. Which action should the nurse implement Determine if rescue inhaler is being used first during an acute episode The nurse plans to administer 5,000 units of heparin, an anticoagulant. Which procedure should the nurse implement when administering this drug Assess all needle insertion sites daily for hematoma and signs of inflammation A new mother tells the nurse that she does not want her newborn to receive any immunizations. It is the hospital’s policy to routinely administer immunizations to all newborns. What intervention should the nurse implement Document that the mother has refused immunization permission for her newborn A client is correctly receiving an infusion labeled Heparin Sodium 25,000 units in 5% Dextrose Injection 500 ml at 14 ml/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many ml/hour At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client’s medical record. Based on data contained in the record, what action should the nurse take before assisting the client with ambulation (click on each chart tab for additional information, be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record) Remove sequential compression devices A client with dyspnea is being admitted to the medical unit. To best prepare for the client’s arrival, the nurse should ensure that the client’s bed is in which position An adult make who returned from a vacation in Mexico three weeks ago calls the clinic complaining of abdominal pain, weight loss, and diarrhea. What action should the nurse take Instruct the client to bring in a stool sample A newly graduated and licensed registered nurse (RN) is in the second day of orientation to the hospital unit. The education director tells the charge nurse that the new graduate should be assigned to care for one client. Which client is best for the nurse to assign to this new graduate A client who is 4-days post myocardial infarction A female who was admitted for alcohol detoxification is nauseated and describes feeling like roaches are crawling all over her. She is tremulous, and her blood pressure is 146/92; her pulse rate is 94 beats/minute; and her temperature is 100.8oF. Which PRN medication should the nurse administer first Lorazepam (Ativan) A male client with bipolar disorder has difficulty concentrating and plans to attend group for the first time. He tells the nurse that he will try to stay for the music relaxation group. After 20 minutes in the group, he becomes restless and begins to leave. What should the nurse do Allow the client to leave the group A male client with Addison’s disease tells the nurse that he is taking hydrocortisone in a divided daily dose. He reports increasing fatigue and weakness. What action should the nurse take Interview the client about any sources of increased stress in his life The charge nurse in the Labor and Delivery Unit makes assignments for a nurse and unlicensed assistive personnel (UAP). A client in labor is admitted with contractions occurring every 3 to 5 minutes. Which task should be assigned to the UAP Collect a urine specimen With the client’s eyes closed, the nurse places a common object in the client’s hand and asks the client to describe the object. The client accurately names the object. How should the nurse document the assessment finding Positive for stereognosis After a 92-year-old client fractured a hip trying to get out of bed, a nurse is accused of failing to notify the healthcare provider that the client was disoriented. In determining whether the nurse is guilty, a jury would consider which standard What a reasonable and prudent nurse would have done in the same situation A 15-year-old client with a spinal cord injury develops spastic leg tremors, sweating, and a headache. Which action should the nurse implement Palpate the bladder for distention The DASH (Dietary Approaches to Stop Hypertension) diet is prescribed for a client with uncontrolled hypertension. Which dietary choices should the nurse instruct the client to eat Shredded wheat An adult female client is admitted to the psychiatric unit because of a complex hand washing ritual she performs daily that takes two hours or longer to complete. She worries about staying clean and refuses to sit on any of the chairs in the day area. This client’s hand washing is an example of which clinical behavior Compulsion The nurse should instruct the parents of an 11-year-old with Type I diabetes mellitus to carefully watch their child for the symptoms of diabetic ketoacidosis. In which situation is the child most at risk for becoming ketoacidotic During the course of an acute illness A man who has a known problem with alcohol is accused of stealing from his employer. When he returns home that evening, he accuses his son of stealing from school, and physically abuses the child for what the father describes as the child’s dishonest behavior. Which two defense mechanisms are being used by the father Projection and displacement A client with an electrical burn is admitted to the Emergency Department on a backboard with a cervical collar. Which intervention should the nurse implement Place the client on cardiac telemetry A male client with chronic alcohol use is admitted with signs of early cirrhosis. Which nursing action should the nurse delegate to the unlicensed assistive personnel (UAP) Gather oral hygiene products for client’s use Which instruction regarding immediate postoperative care should the nurse plan to include in the preoperative teaching for a client scheduled for an incisional rotator cuff repair It will be necessary to wear a sling to keep the joint still A client who is experiencing panic attacks receives a prescription for the benzodiazepine alprazolam (Xanax). Which instruction should the nurse provide this client Instruct the client of safety issues since this medication causes drowsiness The nurse is assessing an infant on admission to the newborn nursery and finds that both brachial pulses are bounding, but bilateral femoral pulses are only slightly palpable. Which assessment should the nurse implement next Obtain blood pressures in all extremities What diet modification is most important for the nurse to recommend to a client with high cholesterol Replace beef with fish or poultry The nurse is managing four clients who are mechanically ventilated. The client with which assessment finding requires the most immediate intervention by the nurse Restrained and restless with a low volume alarm A client with chronic kidney disease is being discharged with continuous ambulatory peritoneal dialysis (CAPD). What is the priority nursing diagnosis the nurse should use when developing a discharge teaching plan for this client Risk for sepsis The nurse is preparing to administer 1.6 ml of medication IM to a 4-month-old infant. Which intervention should the nurse implement Divide the medication into two injections with volumes under 1 ml The nurse is giving medications to an older client who has a percutaneous esophageal gastrostomy (PEG) tube in place. Which medication drug form should the nurse question Enteric-coated aspirin (Ecotrin) Assessment of the fetal heart rate is an important finding when caring for a laboring client. Decelerations in fetal heart rate that are of most concern occur at what time during the contraction cycle After the contraction Sodium nitroprusside (Nipride) at 0.8 mcg/kg/minute is prescribed for a client who weighs 65kg. The available IV solution is labeled Nipride 50 mg in 500 ml D5W. The nurse should program the infusion pump to deliver how many ml/hour The home health nurse visits a client with heart failure (HF). Assessment findings include: temperature 97.6oF, pulse 116 beats/minute, respiratory rate 36 breaths/minute, blood pressure 140/70, pulse oximeter 86% on 2 L/min of oxygen, and crackles are heard throughout the lung fields. Which intervention has the highest priority Call 911 and prepare the client for transport Following a devastating hurricane, a client is admitted for dehydration as the result of vomiting and diarrhea that occurred after ingesting contaminated water. The client expresses feelings of fear and anger about the destruction of homes, the loss of property due to the storm, and the looting that occurred following the storm. According to Maslow’s hierarchy of needs, what priority need should be addressed first Physiological needs About 85 victims of a train derailment are brought to the Emergency Department of a small rural hospital. An older male with extensive crush injuries to his lower extremities and pelvis has a blood pressure of 42/28, a thread pulse of 120 beats/minute, and a respiratory rate of 10 breaths/minute with periods of apnea. Using the disaster triage system, which action should the nurse take Assign a black triage color A father brings his pre-school-aged son to the rural urgent care clinic because the child fell from a horse earlier today. Which finding indicates to the nurse that further assessment is required for possible abuse or neglect Dry, peeling skin, ridged nails, and significantly underweight While caring for a client with a new onset of diabetes mellitus, which intervention is most important for the nurse to include in the client’s plan of care Observe client’s glucose self-monitoring technique A client with Type I diabetes mellitus (DM) is admitted for an emergency cholecystectomy. To prevent diabetic ketoacidosis (DKA), which intervention is most important for the nurse to implement Supplement insulin needs using a sliding scale A client with metastatic cancer who was taking hydromorphone (Dilaudid) PO at home is not 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 The nurse observes a newly-employed unlicensed assistive personnel (UAP) taking an elderly client’s blood pressure. The nurse says, “You need to start over. The blood pressure reading you obtained was falsely high for that client.” What is the most likely explanation for the erroneous reading The size of the cuff used was too small for this adult client’s arm Which activity is best for the nurse to initiate with a depressed client Make cut-out cookies Identify the location of the lobule on the pinnae. (click the chosen location. To change, click on the new location) An adolescent male is transferred from the medical unit to the mental health unit because his condition is stable after taking an assortment of prescription drugs. Based on the admission interview, the nurse determines that the client is still having suicidal ideations. What intervention is most important for the nurse to implement Search the client’s belongings for potential weapons A male client with hepatitis A is admitted with elevated hepatic enzymes and jaundice. Which intervention should the nurse implement Meticulous hand washing after each client contact The nurse observes that a client with COPD is exhibiting fingernail clubbing. What action should the nurse take Document the assessment finding in the nurses’ notes The nurse is assessing a 4-year-old girl with eczema. Her skin is dry and scaly, and the mother reports that she frequently scratches her skin to the point of causing bleeding. Which guideline is indicated for care of this child Keep her nails trim and short A female client who had a total thyroidectomy several weeks ago is admitted with myxedema coma. Which finding indicates that the client has been noncompliant with her postoperative treatment plan Serum T3 and T4 levels are below normal The nurse is assessing a 9-year-old boy who is experiencing an acute asthma attack. When auscultating this child’s breath sounds, which finding is the nurse most likely to obtain Musical sounds upon expiration Thirty-six hours after a cesarean delivery, a client complains of nausea and bloating. Assessment reveals a distended abdomen and no bowel movement since delivery. What intervention should the nurse implement first Auscultate the abdomen The nurse who is performing blood sugar and cholesterol screenings at a community health fair determines that a female client’s blood sugar is 59 mg/dl at 10:00 a.m. Which nursing intervention is most important for the nurse to implement Ask the client how she is feeling The nurse is responding to telephone messages at a psychiatric day clinic. Which client situation requires immediate intervention by the nurse The wife of a client with post-traumatic stress syndrome reports that her husband is threatening to kill her A mother reports to the nurse that the thick-honey-colored crusts on her child’s legs began as flat red spots. This is highly indicative of what condition Impetigo A young woman is preparing to leave for a 7-day boat trip. She requests a prescription for motion sickness so the healthcare provider prescribes meclizine (Antivert). Which instruction should the nurse include in this client’s teaching Suck on hard candy for a dry mouth while taking this drug A female client who has been taking diclofenac (Zipsor) for the past month is admitted with right upper quadrant tenderness, jaundice, and flu-like symptoms. She is also complaining of fatigue, diarrhea, and pruritis. Which intervention is most important to include in this client’s plan of care? Monitor serum bilirubin levels What intervention should the nurse implement to prevent edema and promote healing of a client’s incision resulting from an above-the-knee amputation Maintain the residual limb in a compression dressing A relative comes into the Emergency Department asking for information about a female adult client who was admitted in stable condition following a motor vehicle collision. What action should the triage nurse take Ask the client if she would like to talk with the relative, and then bring the relative to the bedside The nurse observes and 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 The nurse administers the opioid antagonist naloxone HCI (Narcan) to a young adult client who overdosed on hydromorphone (Dilaudid). Which assessment data indicates that the naloxone is effective Respirations increase from 8/minute to 12/minute The nurse is auscultating a client’s heart sounds. Which description should the nurse use to document this sound (listen to the audio file to select the option that applies) S1, S2, S3 The nurse is caring for six clients on a medical-surgical unit. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP) Record vital signs every four hours Assist with ambulation as prescribed Provide oral care after meals An emergency department nurse is giving discharge instructions to the wife of a young adult male client who sustained a concussion after a fall. The nurse should provide the wife with what instruction as part of the discharge teaching plan Tell the wife to bring her husband back to the emergency department if he has projectile vomiting or an unsteady gait In monitoring a client receiving propylthiouracil (PTU) for hyperthyroidism, an increase in which finding indicates that the medication is producing the desired effect Body weight The nurse is investigating a client injury that occurred when a mechanical lift malfunctioned while moving a client from the bed to an orthopedic-chair. Which question should the nurse ask first Was the equipment used according to policy Which menu selection by a male client indicates to the nurse that he understands the dietary management of Crohn’s disease Grilled chicken sandwich and pasta An unlicensed assistive personnel (UAP) is teamed with a nurse who is caring for four clients. Client A is admitted to the medical unit for heart failure (HF). Client B has just returned from surgery. Client C, with chronic obstructive pulmonary disease (COPD), needs new oxygen tubing. Client D is waiting to be discharged. Which activity should the nurse delegate to the UAP as having the highest priority Take vital signs of the client who has just returned from surgery