Exit HESI Practice Questions

Exit HESI Practice Questions A client presents at the ED complaining of a raspy voice, cold intolerance, and fatigue. Lab tests indicate an elevated TSH and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement? A) Assess for presence of non-pitting edema. B) Administer the prescribed dose of levothyroxine. C) Offer additional blankets and a warm drink. D) Note client's most recent hemoglobin levels. - ANS B) Administer the prescribed dose of levothyroxine. Rationale: In the negative feedback mechanism of hypothyroidism, a low level of thyroid hormone stimulates TSH production by the hypothalamus and results in an elevated TSH level, but the thyroid gland does not respond with adequate production of T3 and T4 to regulate basal metabolic rate. These serum hormone levels indicate the need to administer supplementary thyroid hormone as soon as possible to avert possible myxedema coma. Non-pitting edema is seen in chronic hypothyroidism and assessment of the presence and location of the edema (A) is not a top priority. Providing warmth (C) is beneficial but of less priority than (B). Anemia is common in hypothyroidism, but (D) is of lower priority than initiating treatment to prevent myxedema coma. The nurse suspects that a client might be hemorrhaging internally. Which findings of an orthostatic tilt test are a most likely indication of a major bleed ( 1000 ml)? A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20. B) A decrease in the systolic BP of 10 mm Hg with a corresponding decrease in the HR of 20. C) A decrease in the systolic BP of 20 mm Hg with a corresponding decrease in the HR of 10. D) A decrease in the systolic BP of 20 mm Hg with a corresponding increase in the HR of 10. - ANS Ans: A) A decrease in the systolic BP of 10 mm Hg with a corresponding increase in the HR of 20. Rationale: The loss of circulatory volume results in a 10 mm Hg drop in the systolic pressure, while the HR increases by 20 % above normal as a compensatory response to the low pressure. When conducting diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat? SATA. A) Canned fruit cocktail B) Creamy peanut butter C) Vegetable juice D) Vanilla frozen yogurt E) Clear beef broth - ANS Ans: C, D, E A full liquid diet includes all liquids that are not clear such as vegetable juice and frozen yogurt, as well as clear liquids. Pieces of fruit as found in fruit cocktail and peanut butter are not considered liquids. A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why he is prescribed all these medications? SATA. A) One of the medications is used to anesthetize the corneal surface. B) The iris must be paralyzed during the surgery to prevent it from reacting to light. C) Medication is used to induce sleep during the procedure. D) Pupillary dilation is necessary to access the eye chamber for lens removal. E) These meds assist in obstructing the client's vision during the surgery. - ANS Ans: A, B, D Cataract surgery is accessed through the cornea using eyelid retractors while the client is awake. It is necessary to anesthetize the corneal surface (A), paralyze the ciliary body (B), and provide pupil dilation (D)(mydriasis) to facilitate access to the lens which ties behind the iris (posterior chamber of the anterior cavity). A sedative may be administered to reduce anxiety but it is not used to induce sleep. (C) Cloudy vision may be a side effect of these agents, but the client will still be able to see during the surgery (E). When assessing an IV site that is sued for fluid replacement and medication administration, the client complains of the tenderness when the arm is touched above the site. Which additional assessment warrants immediate intervention by the nurse? A) Sluggish blood return B) Client uses the arm cautiously C) Spot of dried blood at the insertion site D) Red streak tracking the vein - ANS Ans: D A red streak (D) indicates vein irritation and necessitates discontinuing the IV at the present site. A, B, and C are indications for relocating the IV site or other immediate intervention. A client with a liver abscess develops septic shock. A sepsis resuscitation bundle protocol is initiated and the client receives a bolus of IV fluids. Which parameter should the nurse monitor to assess effectiveness of the fluid bolus? A) Blood cultures. B) Oxygen saturation. C) White blood count. D) Mean arterial pressure (MAP). - ANS D) Mean arterial pressure (MAP) The cornerstone of initial sepsis resuscitation is fluid volume administration to restore and then maintain MAP of at least 65 mmHg. When attempting to establish risk reduction strategies in a community, the nurse notes that regional studies indicate a high number of persons with growth stunting and irreversible mental deficiencies (cretinism) caused by hypothyroidism. The nurse should seek funding to implement which screening measure? A)T4 levels in newborns. B) TSH levels in women over 45. C) T3 levels in school-aged children D) Iodine levels in all persons over 60. - ANS A) T4 levels in newborns. Screening for low T4 levels in newborns with follow-up treatment can reduce the risk for irreversible growth stunting and mental deficiencies caused by congenital hypothyroidism. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administered to a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? A) Loss of appetite B) Serum K+ 4.0 mEq/L or mmol/L (SI) C) Loose, runny stools. D) Tented skin turgor. - ANS D) Tented skin turgor. Indicates dehydration, a serious complication following prolonged diarrhea that requires further intervention by the nurse. A male client with ulcerative colitis received an Rx for a corticosteroid last month but because of the S/E, he stopped taking the medications 6 days ago. Which finding warrants immediate intervention by the nurse? A) Fluid retention B) Hypotension and fever C) Anxiety and restlessness D) Increased blood glucose - ANS B) Hypotension and fever Sudden withdrawal from a corticosteroid can cause sudden decreased adrenal function resulting in low serum sodium, high serum potassium, and low blood pressure which can lead to shock and possible death. Hypotension and fever (B) are the first signs of precipitous withdrawal. Fluid retention (A), anxiety and restlessness (C), and glucose intolerance (D) are common S/E of taking corticosteroids. The nurse who working in the ED is obtaining evidence for a rape kit from a woman who reports that she was raped. Which intervention is most important for the nurse to implement? A) Do not allow client to shower until all evidence is obtained. B) Report incident to the university's security department. C) Listen attentively to the client's description of the event. D) Determine the client's personal reaction to the reported rape. - ANS A) Do not allow client to shower until all evidence is obtained. It is most important to gather evidence and a shower distorts such evidence. The client should not be allowed to shower until all the evidence is collected. The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's HR drops to 60 bpm. Which action could the nurse take? A) Continue the insertion since this is a typical response. B) Insert the feeding tube into the infant's nasal passage. C) Pause and monitor for a continued drop of the HR D) Postpone the feeding until the infant's vital signs are stable. - ANS C) Pause and monitor for a continued drop of HR. Insertion of an orogastric tube for gavage feedings often triggers vagus stimulation which can result in bradycardia. Pausing during insertion and monitoring (C) the infant's HR and color may be all that is necessary for the HR to return to normal. A client who has a tracheal stoma is c/o of mouth pain. While performing oral care, nurse determines that the client has mouth ulcers and that oral mucosa is irritated. The client also has halitosis. Which intervention should the nurse implement? A) Encourage frequent use of mouthwash. B) Apply viscous gel to ulcers during mouth care. C) Provide flavored oral swabs to use Q2H D) Rinse out mouth with a liquid germicide daily. - ANS B) Apply viscous gel to ulcers during mouth care. Mouth ulcers and irritation of the lining of the mucous membranes are very painful. An oral viscous gel such as a lidocaine anesthetic can be used to temporarily relieve the pain. (B) Routine mouth care is necessary but should not be done too frequently because it may cause further irritation of the mucous membranes. An adult male is admitted in a rehab center after 3 weeks in an acute care hospital. The client suffered a R sided brain injury that occurred as the result of a fall from a ladder. Which intervention should the nurse include in this client's plan of care? A) Maintain elastic stockings continuously. B) Apply a hand splint for finger extension. C) Monitor BP every 4 hours. D) Give antithrombolytic injections daily. - ANS B) Apply a hand splint for finger extension. The nurse is explaining the need to reduce salt intake for a client with primary HTN. What explanation should the nurse provide? A) high salt can damage the lining of the blood vessels. B) Too much salt can cause the kidneys to retain fluid. C) Excessive salt can cause blood vessels to constrict. D) Salt can cause inflammation inside the blood vessels. - ANS B) Too much salt can cause the kidneys to retain fluid. Excessive salt intake can contribute to primary HTN by causing renal salt retention which influences water retention that expands blood volume and pressure. A client with cirrhosis of the liver is admitted with complications related to end-stage liver disease. Which interventions should the nurse implement? SATA. A) Monitor abdominal girth. B) Increase oral fluid intake to 1,500 mL daily. C) Report serum albumin and globulin levels. D) Provide a diet low in phosphorus. E) Note signs of swelling and edema. - ANS Ans: A, C, E Ad adult male is admitted to the ED after falling from a ladder. While waiting to have a CT scan, he requests for stronger pain medication. Which intervention should the nurse implement? A) Request that the CT scan be done immediately. B) Review client's history for use of illicit drugs. C) Assess client's pupils for their reaction to light. D) Explain the reason for using only non-narcotics. - ANS D) Explain the reason for using only non-narcotics. The patient needs to understand that any pain medication that can mask declining neurological symptoms such as narcotics should be avoided. A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? SATA. A) Topical corticosteroid B) Topical acobicide C) Topical alcohol rub D) Transdermal analgesic E) Oral antihistamine - ANS Ans: A, E Which patient requires most immediate attention by the nurse? A) Gunshot wound three hours ago with dark drainage of 2 cm noted on dressing. B) Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-Pratt drain. C) Collapsed lung after a fall 8 hours ago with 100 ml in the chest tube collection container. D) Abdominal perineal resection 2 days ago with no drainage on dressing who has fever and chills. - ANS D) Abdominal perineal resection 2 days ago with no drainage on dressing who has fever and chills. Risk for peritonitis and needs to be immediately assessed for other signs and symptoms for sepsis. In assessing an infant 10 hours after birth, the nurse notes that the infant is slightly cyanotic and has a large amount of mucus. Which interventions should the nurse implement first? A) Begin O2 at 2 L/min B) Insert a nasogastric tube. C) Suction the infant as needed. D) Assess the heart rate. - ANS C) Suction the infant as needed. To clear the airway, nurse should first suction the mucous. A 12 year-old boy who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hr. His urine specific gravity is 1.035. What action should the nurse implement? A) Evaluate postural blood pressure measurements. B) Obtain a specimen for urinalysis. C) Encourage popsicles and fluids of choice. D) Assess bowel sounds in all quadrants. - ANS C) Encourage popsicles and fluids of choice. Specific gravity of urine is a measurement of hydration status (NR 1.010 to 1.025) which is indicative of fluid volume deficit); when Sp Gr increases as urine become more concentrated. The nurse should continue the prescribed IV fluids and increase PO intake. The nurse is caring for a one-week-old infant who has a ventriculoperitoneal (VP) shunt that was placed 2 days after birth. Which findings are an indication of a postoperative complication? SATA. A) Poor feeding and vomiting. B) Leakage of CSF from the incisional site. C) Hyperactive bowel sounds. D) Abdominal distention. E) White blood count of 10,000/mm3. - ANS Ans: A, B, D are signs of postoperative complications. A couple who is trying to have a baby asks the nurse when they are most likely to conceive a child. The woman has a regular 36 day cycle and the first day of her LMP was on January 15. Which information should the nurse provide? A) Have intercourse every other morning because this is when sperm count is higher. B) Plan to have intercourse on February 7, as this is when ovulation should occur. C) Have intercourse every 3 days to ensure that ovulation and intercourse coincide. D) The woman should ovulate mid-cycle, so plan to have intercourse on February 3. - ANS B) Plan to have intercourse on February 7, as this is when ovulation should occur. Ovulation usually occurs 14 days before the first day of the menstrual cycle. The client's next menstrual period should begin on February 21 so ovulation should occur on February 7. A newborn infant is receiving positive pressure ventilation after delivery. Based on which assessment finding should the nurse initiate chest compressions? A) Apgar score of 7 B) Heart rate of 54 C) Central cyanosis D) Limp muscle tone - ANS Ans: B) Heart rate of 54 Chest compressions should be initiated when a newborn's heart rate is less than 60 bpm (B) despite the use of positive pressure ventilation. The Apgar score is obtained at 1 minutes and 5 minutes but a score of 7 is not the criterion used to determine neonatal response to ventilation. Which fetal heart pattern requires immediate nursing intervention? A) An FHR deceleration that mirrors the contraction. B) An increase in the FHR to 100 that quickly returns to baseline. C) An FHR deceleration that occurs at the same time of contraction. D) A decrease in the FHR that occurs after the peak of a contraction. - ANS D) A decrease in the FHR that occurs after the peak of contraction. A decreased FHR after the peak of contraction is an ominous sign and indicates fetal distress (hypoxia). A and C are describing the same contraction pattern and both are normal signs of fetal descent. B is a description of FHR acceleration which is normal. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? SATA. A) hot chocolate B) apple juice C) chicken broth D) orange juice E) black coffee - ANS Ans: B, C Apple juice and chicken broth are included in a clear liquid diet and are consumed by Mormons. Black coffee (E) is included in a clear liquid diet, but caffeinated beverages are not consumed by Mormons. A nine-day old infant with congenital adrenal hyperplasia (CAH) develops dehydration and is admitted to the hospital for aldosterone replacement therapy. The HCP prescribes fludrocortisone acetate (Florinef) 0.05 mg PO daily. Which finding indicates the newborn is experiencing a therapeutic response? A) Resting blood pressure of 62/41 mmHg B) Plasma glucose 45 mg/dl C) Serum sodium 142 mEq/L D) Capillary refill is greater than 3 seconds. - ANS C) Serum sodium 142 mEq/L Infants with CAH produce inadequate cortisol and aldosterone that leads to dehydration and salt-losing crises which require urgent medical intervention. Aldosterone replacement therapy is prescribed to promote increased reabsorption of sodium and water int eh distal renal tubules, which should result in a normalization of serum sodium (134-146). A client with a cervical spinal cord injury has Crutchfield tongs and skeletal traction applied as a method. Which intervention is most important for the nurse? A) Provide daily care of tong insertion site using saline and antibiotic ointment. B) Modify the client's diet to prevent constipation. C) Encourage active ROM Q2-4 hours. D) Instruct the client to report any symptoms of upper extremity paresthesia. - ANS A) Provide daily care of tong insertion site using saline and antibiotic ointment. Crutchfield tongs, a skeletal traction device for cervical immobilization requires daily care of the surgically inserted tongs to minimize the risk of infection of the insertion sites and cranial bone. Daily cleansing with normal saline solution and antibiotic ointment applications minimize the bacterial colonization and helps to prevent infections. Following breakfast, the nurse is preparing to administer 0900 medications to clients on a medical floor. Which medications should the nurse hold until a later time? A) Loop diuretic furosemide (Lasix) for a client with a serum potassium level of 4.2 B) The mucosal barrier, sucralfate (Carafate) for a client diagnosed with PUD. C) The antiplatelet agent aspirin for a client discharged within the hour. D) The antifungal nystatin suspension for a client who has just brushed his teeth. - ANS B) The mucosal barrier, sucralfate (Carafate) for a client diagnosed with PUD. Carafate coasts the mucosal lining prior to eating a meal, so this med should be held until prior to the next meal. Since the potassium level is (A) within normal limits, there is no reason to hold the lasix. The nurse can safely administer (C). In (D), the client should rinse the mouth prior to administering nystatin swish and swallow but the medication does not need to be held. Which interventions should the nurse implement for a client with a superficial (first degree) burn? A) Spray an anesthetic agent over the burn every 3-4 hours. B) Position the burn victim in front of a cool fan to decrease discomfort. C) Apply ice packs for 30 minutes to lower surface temperature. D) Place wet cloths on the burned areas for short periods of time. - ANS D) Place wet cloths on the burned areas for short periods of time. Placing wet cloths on the burned areas for short periods of time (D) provides comfort and helps to relieve the pain of a first degree burn, which involves only the epidermal layer of the skin. (A and B) are not likely to provide pain relief. (C) Applying ice for 30 minutes is too long and can result in additional skin damage. The nurse is teaching a mother of a newborn with a cleft lip on how to bottle feed her baby using a Haberman feeder that has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated lip to the back of the oral cavity. What instructions should the nurse provide the mother about feedings? A) Squeeze the nipple base to introduce milk into the mouth. B) Position the baby in the left lateral position after feeding. C) Alternate milk with water during the feeding. D) Hold the newborn in an upright position. - ANS D) Hold the newborn in an upright position. The mother should be instructed to hold the infant during feedings in a sitting or upright position to prevent aspiration. Impaired sucking is compensated by the use of special feeding appliances and nipples, such as Haberman feeder that prevents aspiration by adjusting the flow of milk according to the effort of the neonate. Squeezing the nipple base may introduce a value that is greater than the neonate can coordinate swallowing (A). The preferred position of an infant after feeding is on the right side (B) to facilitate stomach emptying. Suckling difficulty impedes the neonate's intake of adquate nutrient needed for weight gain, and water should be provided after the feeding (D) to cleanse the oral cavity and not fill up the neonate's stomach. A male client with terminal cancer is brought to the ED manifesting a Cheyenne Stokes respiratory pattern. The wife tells the nurse that her husband has an advanced directive that indicates "Do not resuscitate (DNR) status," but the documents are at home. When the client becomes apneic and pulseless, what action should the nurse take? A) Ask the wife if her husband's wishes ever changed. B) Call the HCP for a DNR prescription. C) Begin CPR. D) Determine if the family wants hospice care. - ANS C) Begin CPR. If a client's signed documents such as a living will or advanced directive is unavailable, (C) should be implemented. Which findings should the nurse include that are often the earliest indications of fat embolism syndrome (FES)? A) Confusion, restlessness B) Tachycardia, fever C) Pulmonary crackles D) Petechial rash - ANS A) Confusion, restlessness In FES, fat globules transported to the lungs cause a hemorrhagic interstitial pneumonitis, acute respiratory distress syndrome, poor oxygen exchange, and hypoxemia resulting in poor cerebral perfusion. Memory loss, restlessness, confusion (A) should prompt further investigation. B, C, and D are also signs of FES but occur later than A. A client is admitted with acute pancreatitis who admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs every 2 hours. Which finding should the nurse report immediately to the HCP? A) Confusion and tremors. B) Yellowing and itching of skin. C) Abdominal pain and vomiting. D) Anorexia and abdominal distension. - ANS A) Confusion and tremors. Daily alcohol is the likely etiology for the client's pancreatitis. Abrupt cessation of alcohol intake can result in delirium tremors (DT) causing confusion and tremors (A) which can precipitate cardiovascular complications and should be reported immediately to avoid life-threatening complications. Chronic alcoholism can cause multiple comorbidities such as B and D that are expected findings in those with liver dysfunction, but do not require immediate action. C is an expected finding of pancreatitis that requires nursing action, but the priority is reporting signs of DTs. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? A) Withhold food and fluid intake. B) Initiate IV fluid replacement. C) Administer antiemetics as needed. D) Evaluate intake and output ratio. - ANS A) Withhold food and fluid intake. The pathophysiologic processes in acute pancreatitis result from oral fluid and food ingestion that causes secretion of pancreatic enzymes which destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas. The main focus of nursing care is reducing pain caused by pancreatic destruction through interventions that decrease GI activity, such as keeping the client NPO (A). A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse that the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide? A) The hernia is a normal variation that resolves without treatment. B) Restrictive clothing will be adequate to help the hernia go away. C) An abdominal binder can be worn daily to reduce the protrusion. D) The quarter should be secured with an elastic bandage wrap. - ANS A) The hernia is a normal variation that resolves without treatment. Am umbilical hernia is a normal variation in infants that occurs due to an incomplete fusion of the abdominal musculature through the umbilical ring that usually resolves spontaneously (A) as the child learns to walk. B, C, and D are ineffective and unnecessary. An adult male is admitted to the ICU because he experienced a sudden onset of sharp chest pain and SOB earlier today. Following an emergent pulmonary angiogram, the client is diagnosed with a pulmonary embolism. What intervention is most important for the nurse to include in this client's plan of care? A) Observe for confusion and restlessness B) Monitor for signs of increased bleeding. C) Instruct in the use of an incentive spirometry. D) Administer IV opioids for severe pain. - ANS A) Observe for confusion and restlessness In PE pulmonary parenchyma is destroyed and reduces the lungs; ability to adequately oxygenate the client. Signs of confusion and restlessness (A) are critical indications of hypoxia which is this client's highest priority problems. B, C, and D should also be implemented as needed, but do not have the priority of identifying the client's oxygenation (A). A client with metabolic syndrome plans to begin an exercise program. What instruction is most important for the nurse to provide this client? A) Monitor blood pressure and heart rate as exercise activity is increased. B) Wear long sleeves and a hat when exercising outdoors in direct sunlight. C) Weight-bearing exercises are most effective in improving bone strength. D) Use hand-held weights to strengthen muscles and build muscle mass. - ANS A) Monitor blood pressure and heart rate as exercise activity is increased. Metabolic syndrome is characterized by hypertension and hypercholesteremia, which places the client at risk for CV pathology. CV status should be monitored as activity increases (A) to prevent excessive workload on the heart. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the IV line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? A) Replace the IV site with a smaller gauge. B) Redress the abdominal incision. C) Leave the lights on at night. D) Apply soft bilateral wrist restraints. - ANS B) Redress the abdominal incision. The abdominal incision should be redressed using aseptic technique (B). The IV site (A) should be assessed to ensure that it has not been dislodged and a dressing reapplied, if needed. An older client with atrial fibrillation receives a new prescription for Dabigatran to reduce the risk of blood clot formation. What information should the nurse include in this client's medication teaching plan? SATA. A) Medication injections are self-administered daily. B) Plan to monitor and record the pulse rate daily. C) Contact the HCP if bruising occurs. D) Report bleeding in the urine or stool right away. E) Inform the dentist of medication usage before the procedure. - ANS Ans: C, D, E Dabigatran is an oral anticoagulant used to decrease clot formation in atrial fibrillation, thus reducing the risk for stroke. The home health nurse is visiting an older client who was discharged form the hospital 3 days ago following hip pinning surgery. Which meal choices should the nurse suggest for this client's diet? SATA. A) Low fat milk B) Oat bran C) White rice D) Grilled salmon E) Baked chicken - ANS Ans: A, B, D, E Dairy products such as low fat milk provide calcium, Vitamin D, and protein. Salmon and tuna fish are high in omega 3. Oat bran provides Vitamin D which promotes absorption of dietary calcium. Decreased mobility following hip surgery combined with slower peristalsis leads to constipation, so including oat bran foods provides increased dietary fiber. Baked chicken provides protein which is important for healing. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bay bridge. What action in the treatment plan should the nurse implement? A. Tell the client to drive over the bridge until fear is manageable B. Teach the client to listen to music or audiobooks while driving C. Encourage the client to have spouse drive in stressful places D. Recommend that the client avoid driving over the bridge - ANS B. Teach client to listen to music or audio books while driving Desensitization is a component in the treatment plan for client's with panic attacks which is best approached with anxiety-reducing strategies such as listening to audio books during situations that precipitate symptoms. A young adult female presents at the ED with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the HCP? A) Pain scale rating is a 9 out of 10. B) LMP was 7 weeks ago. C) Reports white, curdy vaginal discharge. D) History of IBS. - ANS B) LMP was 7 weeks ago. Acute lower abdominal pain in a young adult female can be indicative of ectopic pregnancy which can be life threatening. An older female client is admitted to the ICU with severe abdominal pain, abdominal distension, and absent bowel sounds. She has a hx of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are temperature 96 F, 122 bpm, RR 36/min, MAP 64 mmHg, and CVP 7 mm Hg. Serum lab findings include: Hgb 6.5, platelets 60,0000, and WBC 3,000. Based on these findings, this client is at greatest risk for which condition? A) Multiple organ dysfunction syndrome (MODS) B) Disseminated intravascular coagulation (DIC) C) Chronic obstructive pulmonary disease (COPD) D) Acquired immunodeficiency syndrome (AIDS) - ANS A) Multiple organ dysfunction syndrome (MODS) MODS is a progressive dysfunction of two or more major organs that requires medical intervention to maintain homeostasis. This client has several organ systems that require intervention, such as BP, Hgb, WBC, and RR. An adult male with severe depression was admitted to psychiatric unit yesterday evening. Although the client ran a marathon one year ago, his wife states that he no longer runs, but sits and watches television most of the day. Which intervention is most important for the nurse to include in this client's plan of care for today? A) Assist client in identifying his goals for the day. B) Encourage client to participate for one hour on a team sport. C) Schedule client for a group that focuses on self-esteem. D) Help client to develop a list of daily affirmations. - ANS A) Assist client in identifying his goals for the day. Client with severe depression have low energy and benefit from structured activities because concentration is decreased. Having the client participate in his care by identifying his goals for the day (A) is the most important intervention for his first day on the unit. B, C, and D can be implemented over time as his depression decreases. The legs of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personnel (UAP) place a heating pad on the mottled areas, what action should the nurse take? A. Remove the heating pads and pace a soft blanket over the client's legs and feet B. Advise the UAP to observe the client's skin while the heating pads are in place C. Evaluate the client's feet on a pillow and monitor the client's pedal pulses frequently D. Instruct the UAP to reposition the heating pads to the sides of the legs and feet - ANS A. Remove the heating pads and pace a soft blanket over the client's legs and feet Mottling occurs as circulation diminishes and death approaches. Heating pads provide warmth but may damage the client's skin due to diminished sensation, so the heating pad should be replaced with soft blankets to provide comfort and warmth. The heating pad should be removed. The nurse is initiating IV fluid replacement for a child who has dry, sticky, mucous membranes, flushed skin, and a fever of 103.4 F. Laboratory findings indicate that the child has a serum sodium concentration of 156. What physiologic mechanism contributes to this finding? A) The IV fluid replacement contains a hypertonic solution of sodium chloride. B) Urinary and gastrointestinal fluid loss reduce blood viscosity and stimulate thirst. C) Insensible loss of body fluids contributes to the hemoconcentration of serum solutes. D) Hypothalamic resettling of core body temperature causes vasodilation to reduce body heat. - ANS C) Insensible loss of body fluids contributes to the hemoconcentration of serum solutes. Fever causes insensible fluid loss which contributes to fluid volume deficit and results in hemoconcentration of sodium. 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 action would be best 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. - ANS C) Measure the area of swelling and crackling. A crackling sensation or crepitus indicates subcutaneous emphysema, or air leaking into the skin. This area should be measured and the finding documented. A client with acute renal failure is admitted for uncontrolled type 1 DM and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this client's plan of care? A) Monitor the client's cardiac activity via telemetry. B) Maintain venous access with an infusion of normal saline. C) Assess glucose via fingerstick Q4-6 hours. D) Evaluate hourly urine output for return of normal renal funciton. - ANS A) Monitor the client's cardiac activity via telemetry. As insulin lowers the blood glucose of a client with DKA, potassium returns to the cell but may not impact hyperkalemia related to acute renal failure. The priority is to monitor the client for cardiac dysthymia related to abnormal serum potassium level. A male client presents to the clinic with large draining ulcers on his lower legs that are characteristic of Kapok's sarcoma lesions. He is accompanied by two family members. What actions should the nurse take? A. Ask the family members to wear gloves when touching the client B. Send family to the waiting area while the client's history is taken C. Obtain a blood sample to determine of the client is HIV positive D. Complete a head to toe assessment to identify other signs of HIV - ANS B. Send family to the waiting area while the client's history is taken To protect the client's privacy, the family members should be asked to wait outside while the client's history is taken. Gloves should be worn when touching the client's body fluids (A). if he is HIV positive and these lesions are actually Kaposi's sarcoma lesions. HIV testing (C) cannot legally be done without the client's consent. (D) can be implemented after the family has left the client. The nurse is preparing to send a client to the cardiac cath lab for elective cardioversion. Which interventions should the nurse implement before the client leaves the medical unit? A) Document that the client has remained NPO. B) Secure cardioversion pads on the client's chest. C) Notify the rapid response team of the transfer. D) Confirm monitor reading in synchronous mode. - ANS A) Document that the client has remained NPO. A client undergoing elective cardioversion should be NPO prior to the procedure, and the nurse should confirm the client's NPO status and document in the EHR. To reduce risk of an episode of diverticulitis, the nurse should encourage which snack choice for a client with diverticulosis? A) Tuna with low fiber crackers B) Fruit flavored Greek yogurt C) Low fat cheese cubes D) Fresh vegetable slices - ANS D) Fresh vegetable slices Nutritional management of diverticulosis focuses on increased fiber and fluid intake to reduce risk for constipation and related inflammation of the diverticula. Fresh fruits and vegetables provide fiber. The nurse learns during shift report that a client is experiencing frequent ectopic beats on the cardiac telemetry monitor. Which assessment finding should the nurse expect the client to exhibit? A) Loose electrode pads. B) S3 or S4 sounds. C) Irregular heart rhythm. D) Bounding pulse volume. - ANS C) Irregular heart rhythm. Ectopic beats originate outside the normal conduction pathway of the heart to usurp the pacemaker's impulse which causes an irregular cardiac rhythm. Ectopic beats are not the result of loose or incorrect electrode pad placements. A client exposed to TB is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose? A) Conversion of the client's PPD test from negative to positive. B) Length of time of the exposure to TB C) Current diagnosis of Hep B D) History of IV drug use. - ANS C) Current diagnosis of Hep B Prophylactic treatment of TB with isoniazid is contraindicated for persons with liver disease because it may cause liver damage. The nurse should hold the prescribed dose and contact the HCP. A 62 year old male client who has been diagnosed with emphysema asks the nurse to tell him about the symptoms of his disease. Which statement should be included in the nurse's description of emphysema to this client? A) Breathing through pursed lips causes lung expansion and decreased physical exertion. B) Tolerance for oxygen deprivation results in an increased ability to carry out daily activities. C) A barrel chest results because of using a hyperventilating breathing pattern. D) Oxygen requirements decrease because of the over-expansion of alveoli. - ANS C) A barrel chest results because of using a hyperventilating breathing pattern. Emphysema clients avoid hypoxia by breathing faster (hyperventilating) which eventually causes a barrel chest. Emphysema clients do breathe through pursed lips which helps to expand the resistant alveoli but does not decrease physical exertion. Emphysema clients have the same oxygen requirements as any other person, but work harder to meet these requirements (B and D). They also become increasingly debilitated and require frequent rest periods to carry out daily activities. A client who is admitted to the ICU with a R chest tube attached to a THORA SEAL chest drainage unit becomes increasingly anxious and c/o of difficulty breathing. The nurse determines that the patient is tachypneic with absent breath sounds in the client's R lung fields. Which additional finding indicates that the client has developed a tension pneumothorax? A) Continued bubbling in the water seal chamber. B) Decreased bright red bloody drainage. C) Tachypnea with difficulty breathing. D) Tracheal deviation toward the left lung. - ANS D) Tracheal deviation toward the left lung. Tracheal deviation toward the unaffected left lung with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax. Bubbling in the water seal chamber indicates that there is a loose connection in the chest drainage system. A decrease in the amount of drainage occurs with an obstruction or a displaced chest tube. Tachypnea with difficulty breathing are early signs of respiratory distress which can result from a variety of causes, including a pneumothorax. A client at 30 weeks gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 0.25 mg is given SQ. Based on which finding should the nurse withhold the next dose of this drug? A) Maternal blood pressure of 90/60 B) FHR of 170 bpm for 15 minutes C) Maternal pulse rate of 162 bpm D) Serum potassium of 2.8 - ANS C) Maternal pulse rate of 162 bpm The nurse should check the maternal pulse prior to administering the beta sympathomimetic drug terbutaline and notify the HCP before administration of the drug if the pulse is over 140 bpm. (A) is within normal limits because peripheral vasodilation accompanies pregnancy and causes the BP to decrease. (B) is a normal response to the fetus to maternal use of terbutaline, but should be reported if above 180. (D) is not an abnormal finding due to the shift of potassium to intracellular spaces that can occur with this medication. When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? A) Collapsed lung B) History of COPD C) Chronic lung infection D) Normal functioning lungs - ANS A) Collapsed lung Unilateral absence of chest movement (or unequal lung expansion because one lung is not moving at all) may indicate previous surgical removal of that lung, a bronchial obstruction, or a collapsed lung (A) caused by air or fluid in the pleural space. Those with (B) often exhibit pursed lip breathing and have a barrel chest. (C) is not exhibited by unequal lung expansion unless there had been a resulting collapsed lung or obstruction. This is not a normal finding (D). Which conditions are most likely to respond to treatment with antihistamines? SATA. A) allergic rhinitis B) contact dermatitis C) otitis media D) bronchitis E) myocarditis - ANS ANS: A, B An older woman who lives alone in a two-story home is admitted after falling while shopping. X-rays reveal a fractured left hip. With no immediate family in the area, the client is concerned about her pets. Which interventions should the nurse implement? SATA. A) Palpate and mark pedal pulses. B) Alert social worker of client's concerns. C) Assess ability to bear weight when standing. D) Evaluate pain using a standard pain scale. E) Support left leg with two pillows. - ANS ANS: A, B, D A change in the pulse (A) may indicate decreased circulation. The social worker (B) can address the client's concerns regarding her home and pets. Pain (D) should be assessed and treated. Bearing weight (C) and elevation on pillow (E) is contraindicated because the client should be on bed rest with traction applied to the left leg. A client with chronic obstructive lung disease who is receiving O2 at 1.5 liters/minute by NC is currently short of breath. What action should the nurse take? A) Increase oxygen to 3 L/min. B) Have the client breathe into a paper bag. C) Ask the client to take short, rapid breaths D) Instruct the client in pursed lip breathing. - ANS D) Instruct the client in pursed lip breathing. Pursed lip breathing (D) keeps the alveoli open by maintaining positive pressure in the thoracic cavity. Increasing the oxygen level (A) decreases the hypercarbia drive to breathe. A middle-aged woman, diagnosed with Grave's disease asks the nurse about this condition. SATA. A) Grave's disease, an autoimmune condition, affects thyroid stimulating hormone receptors. B) Large protruding eyeballs are a sign of hyperthyroidism function. C) Early treatment includes levothyroxine. D) T3 and T4 hormone levels are increased. E) Weight gain is a common complaint in hyperthyroidism. - ANS ANS: A, B, D Grave's disease is an autoimmune disorder in which thyroid stimulating antibodies activate thyroid stimulating hormones receptors (A) causing an increased production of T3 and T4 (D). Manifestations include exophthalmos (B) and weight loss, not weight gain (E). Treatment includes medications to block synthesis of thyroid hormones, so levothyroxine (C) is contraindicated. An adult woman suffered burns to her face and chest resulting from a grease fire. On admission, airway protection with endotracheal intubation was required and a 2-liter bolus of normal saline was administered. Currently, the normal saline is infusing at 25 ml/hr. The client's HR is 12 bpm, BP 90/59, RR are 12/min over the ventilated 12 breaths for a total of 24 breaths/min, and the CVP is 4 mm H20. Which intervention should the nurse implement? A) Infuse an additional bolus of normal saline. B) Increase the oxygen delivered by the ventilator. C) Bring a tracheostomy tray to the bedside. D) Lower head of the bed to a recumbent position. - ANS A) Infuse an additional bolus of normal saline. Burns require a massive amount of fluid resuscitation. A low CVP (NR 5-12) and low BP indicate the need for additional IV fluids (A). The ventilator respirations may need to be increased, but there is no evidence to support increasing the oxygen (B). (C) is not necessary and (D) is contraindicated. A client who weighs 176 pounds receives a prescription for enoxaparin sodium 80 units SQ daily at 0900. What action should the nurse take before administering this medication? A) Explain to the client the painful effects of administering enoxaparin sodium. B) Clarify the correct dosage with the HCP. C) Determine if the client is receiving heparin or warfarin. D) Use a filter needle to give the SubQ injection. - ANS C) Determine if the client is receiving heparin or warfarin. Before initiating therapy with an anticoagulant such as enoxaparin sodium, current use of another anticoagulant like heparin or warfarin should be determined (C) because concurrent use of two can result in hypocoagulation. If given correctly, SQ enoxaparin should not cause pain (A). Enoxaparin sodium 80 units is within the recommended dosage range, 1 mg/kg (B). Drug is available as a prefilled syringe with an attached needle so (D) is not needed. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? A) IV thyroid hormones B) Oral administration of hypnotic agents C) IV bolus of hydrocortisone D) SQ Vitamin K - ANS A) IV thyroid hormones The high mortality of myxedema coma requires immediate administration of IV thyroid hormones (A). (B) is contraindicated because even small doses can cause profound somnolence lasting longer than expected. (C) is administered to someone with adrenal insufficiency (Addison's crisis). Which environmental factor is most significant when planning care for a client with osteomalacia? A) Cool, moist air. B) Adequate sunlight. C) Quiet, calm surroundings D) Stimulating sounds and activity - ANS B) Adequate sunlight A client with osteomalacia is lacking adequate Vitamin D, so treatment should include short periods of exposure to sunlight (B). A woman who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. She states that she is pain free. Which intervention should the nurse include in the client's plan of care? A) Encourage positive self accolades for dietary adherance. B) Determine if the client is overhydrating to feel satiated. C) Maintain the client on NPO status. D) Administer daily vitamin supplements. - ANS C) Maintain the client on NPO status. Following bariatric surgery, excessive scar tissue formation or strictures can occur where the stomach pouch is connected to the bowel, which is corrected by upper endoscopy and balloon dilation. The client must be kept NPO (C) until the procedure is successful. When a blood transfusion is prescribed for a client with large uterine fibroids, she states that she is afraid of getting AIDS from the blood transfusion. What response is best? A) Ask the client to talk about her fears regarding AIDS B) Have the HCP explain the risks involved. C) Inquire about client's exposure through sexual partners. D) State that rigorous blood product screening negates risks. - ANS D) State that rigorous blood product screening negates risks. A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the HCP? A) Blood alcohol level of 0.09% B) Serum lithium level of 1.6 C) Six hours of sleep in the past 3 days. D) Weight loss of 10 pounds in the past month. - ANS B) Serum lithium level of 1.6 The therapeutic level of serum lithium is 0.8 to 1.5. Slurred speech and ataxia are signs of lithium toxicity, which is supported with the client's serum lithium level of 1.6 (B). Although the client's blood alcohol level indicates that he recently consumed alcohol (legal intoxication level in most states is 0.10% with some states using 0.08%), the serum lithium level is a greater priority. Sleep deprivation (C) and recent weight loss (D) should also be reported, but these findings do not have the priority of (B). The nurse assesses a client who has just returned form a diagnostic study as seen in this picture. The client has a prescription for a nasogastric tube to low intermittent suction and now reports feelings of nausea. What actions should the nurse implement first? A) Auscultate bowel sounds. B) Administer an IV antiemetic. C) Remove tape from cheek. D) Connect the tube to suction. - ANS D) Connect the tube to suction. To relieve the client's nausea, the nurse should first connect the nasogastric tube to the prescribed suction (D). If this does not relieve the nausea, an antiemetic agent (B) should be administered. (A and C) can be completed after initial actions are taken to relieve the client's nausea. When conducting diet teaching for a client who was diagnosed with Crohn's Disease, which foods should the nurse encourage the client to eat? SATA. A) Clams B) Raisins C) Buttermilk D) Orange juice E) Processed cheese - ANS ANS: (A and B). Crohn's disease should be supplemented with additional iron in the diet. Foods that are high in iron are some seafoods, such as clams (A) and dark red fruits (B). The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in the client's plan of care? A) Record urine output every hour. B) Monitor blood pressure frequently. C) Evaluate neurological status. D) Maintain seizure precautions. - ANS B) Monitor blood pressure frequently. Pheochromocytoma is a catecholamine-secreting tumor of the adrenal medulla that can cause the BP to reach a life-threatening systolic level of as high as 300 mmHg, so frequent monitoring of the client's BP is the priority intervention. (A, C, and D) should be implemented to detect renal or cerebral hypertensive sequela, but monitoring the BP is the priority intervention for early recognition, management, and prevention of complication. A client is admitted with the diagnosis of Wernicke's syndrome. What assessment finding should the nuse use in planning the client's care? A) RLQ pain B) Confusion C) Peripheral neuropathy D) Depression - ANS B) Confusion Wernicke's syndrome is related to thiamine deficiency in clients with alcohol dependency and is manifested by confusion, ataxia, and vision changes. A resident of a long term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement? A) Allow client to choose foods from a menu. B) Assign a staff member to feed the client. C) Have meals brought to the client's room. D) Encourage the client to eat finger foods. - ANS D) Encourage the client to eat finger foods. Eye-hand coordination is often affected in those with dementia. Providing a way to eat without using utensils (D) is likely to help the client maintain independence while obtaining adequate nutrition. A postpartal client who is bottle feeding develops breast engorgement. What is the best recommendation for the nurse to provide to the client? A) Avoid stimulation of the breasts and wear a tight bra. B) Express a small amount of breast milk by hand. C) Take a prescribed analgesic and expose breasts to air. D) Place warm packs on both of the breasts. - ANS A) Avoid stimulation of the breasts and wear a tight bra. When implementing a disaster intervention plan, which intervention should the nurse implement first? A) Identify a command center where activities are coordinated. B) Assess community safety needs impacted by the disaster. C) Instruct all essential off-duty personnel to report to the facility. D) Initiate the discharge of stable clients from hospital units. - ANS A) Identify a command center where activities are coordinated. First the command center should be identified (A) so activities can be coordinated. During an assessment by the home health nurse of an older man who lives alone, the client reports constipation. To formulate a plan of care, what additional information should the nurse obtain? SATA. A) Daily food and fluid intake. B) Current prescribed and OTC medications C) Next scheduled visit with the HCP D) Level of physical activity and exercise. E) Methods currently used to treat constipation. - ANS ANS: A, B, D, E An older client is admitted in respiratory distress secondary to HF, CAD, HTN, and Afib. Which nursing problems should the nurse expect to include in this client's plan of care? SATA. A) Fatigue B) Fluid volume excess C) Fluid volume deficit D) Decreased cardiac output E) Altered peripheral tissue perfusion - ANS ANS: A, B, D, E HF is characterized by decreased cardiac output (D), which causes compensatory fluid retention resulting in an excess fluid volume (B). The ineffectiveness of the heart's pumping action in those with HF results in altered peripheral tissue perfusion (E) and fatigue (A). Fluid volume deficit (C) is not consistent with the pathogenesis of HF. A client with otosclerosis is scheduled for a stapedectomy. What information is most important to provide the client about the postoperative care? A) Medications to manage pain are available. B) Avoid turning head until dressings are removed. C) Can go to bathroom independently. D) Hearing may seem muffled initially. - ANS D) Hearing may seem muffled initially. Otosclerosis causes bone conduction deafness due to a calcification of the stapes in the bony labyrinth. Surgical correction requires stapendectomy and a stapes prosthetic implant to restore hearing. In the immediate postoperative period, the client should be prepared for muffled hearing (D) due to interauricular packing, swelling, and external dressings that reduce air conduction. The nurse is palpating the lymph nodes of an 18 month old. Which finding should the nurse call to the attention the HCP? A) Small, firm, mobile nodules in the axilla. B) Enlarged, warm, tender preauricular node. C) Enlarged, nontender, movable occipital node. D) Small, discrete, mobile, nontender, inguinal node. - ANS B) Enlarged, warm, tender preauricular node. A kindergarten child who is very drowsy and has a generalized rash and fever comes to the school nurse's office. After reviewing the child's past medical history, the nurse is alerted to arisk for viral meningitis. Which finding is most important for the nurse to report to the HCP? A) Past history of exacerbated asthma B) Febrile seizures before one year of age. C) A recent exposure to mumps at school D) Known to share silverware with classmates. - ANS C) A recent exposure to mumps at school The most common cause of viral meningitis is a recent exposure to mumps (C) a viral infection. Which action should the community health nurse take to assess a pediatric client with a family tree genogram that is positive for a genetically inherited syndrome? A) Note any repetitious patterns of behavior. B) Observe for a defined group of malformation. C) Obtain blood samples for genetic testing. D) Refer to social services for a review of risk factors. - ANS B) Observe for a defined group of malformation. The family genogram illustrates family relationships and genetic variations among its members that may influence inheritance patterns of a genetic syndrome. If an abnormal gene is expressed, physical abnormalities of some degree of severity will be manifested, so assessment for a defined collection of malformations (B) should be obtained before genetic testing (C) or referrals (D) are pursued. A repetitive pattern of behaviors (A) does not imply abnormal genetic inheritance. A client with a history of bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? A) Decreased urinary output B) Low blood glucose levels C) Profound weight gain D) Ventricular arrhythmias - ANS D) Ventricular arrhythmias Adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretion that is characterized by hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias (D) are life-threatening and require immediate intervention to correct critical potassium level. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? A) Report the finding to the police department. B) Discuss treatment options for abusive partners. C) Determine the frequency and type of client's abuse. D) Explore client's readiness to discuss the situation. - ANS D) Explore client's readiness to discuss the situation. By assessing the client's level of readiness to discuss her situation (D), the nurse can begin to establish trust so that further action can be taken to protect her. The nurse needs the client's permission to report the abuse to the police department (A), which might be obtained after trust is established. Although (B) might be an option during the discussion, it is most important that the client has a safe refuge even if the abusive partner does not commit to seeking help. Once trust is established (C) can be established. During the administration of an IM pain medication, the nurse aspirates blood into the medication syringe barrel. What action should the nurse take? A) Inject the IM medication at a rate of 1 ml/10 second. B) Remove the syringe needle from the tissue and prepare a new sterile dose for administration. C) Select a new IM site and inject the medication. D) Discard the medication in the syringe and request instructions from the HCP. - ANS B) Remove the syringe needle from the tissue and prepare a new sterile dose for administration. Aspirating blood into the syringe barrel when giving an IM injection indicates placement of the needle in a vein. The needle and syringe should be removed immediately, discarded, and a new sterile medication dose prepared (B) for administration in a new site. (A) is contraindicated because injection of the medication will be administered intravenously, not the IM route. (C) is contraindicated because the medication is contaminated and should not be injected into another site. A client has an IV fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement? A) Elevate the client's upper extremity before counting the pulse rate. B) Auscultate directly below the IV site with a Doppler stethoscope. C) Turn off the IV fluids that are infusing while counting the pulse. D) Palpate at the radial pulse site with the pads of 2-3 fingers. - ANS D) Palpate at the radial pulse site with the pads of 2-3 fingers. The rapid pulse site (D) is easily accessible and palpable unless an IV is placed at the client's wrist. (A) may make the pulse more difficult to palpate. (B) places the stethoscope over a vein rather than an artery and is unlikely to provide an accurate pulse rate. The pulse rate can be accurately counted without implementing C. A female client with splenomegaly is discharged home and asks the nurse if she can work in her garden. A) No lifting of heavy objects. B) Drink plenty of fluids and rest. C) Avoid acetametophin products. D) Wear sunscreen and long sleeves outdoors. - ANS A) No lifting of heavy objects. Acute inflammation or infection can cause splenomegaly, which causes the spleen to become filled with erythrocytes, thereby becoming vulnerable to trauma. An increase in intraabdominal pressure related to lifting increases the client's risk for rupture of the spleen and bleeding so (A) should be included in the discharge instructions. The HCP prescribes oxycodone/aspirin 1 tab PO every 4 hours as needed for pain, for a client with polycystic kidney disease. Before administering this medication, which component of the Rx should the nurse question? A) Aspirin content B) Dose C) Risk for addiction D) Route - ANS A) Aspirin content Aspirin containing compounds are contraindicated for clients with polycystic kidney disease because of the risk for bleeding. This is the recommended dose and PO is the correct route of administration. Addiction is not the main concern regarding this prescription. Several experienced RNs are serving on a screening committee to interview prospective candidates for a nurse-manager position on an acute care inpatient unit. The candidate with which characteristics is probably best for this position? A) Middle child in family, associates degree in nursing, class treasurer in high school B) Oldest child in family, bachelor's degree in nursing, played on college volleyball team C) Youngest child in family, diploma in nursing and certification in nursing; member of ANA. D) Only child in family, master's degree in nursing with nurse practitioner certification, ran track in college. - ANS B) Oldest child in family, bachelor's degree in nursing, played on college volleyball team A nurse-manager requires leadership skills. As the oldest child in the family, with a BSN, who has played a team sport (B) she has the highest potential for success as a manager. The middle child with an ADN (A) has held an elected office in high school, but treasurers have less leadership responsibility than presidents. The youngest child's membership in a professional organization is not a leadership position (C). The only child's practitioner certification (D) would probably be more useful in primary car than an acute inpatient unit. At 20 weeks gestation, a client who has gained 20 pounds during this pregnancy tells the nurse that she is feeling fetal movement. Fundal height measurement is 20 cm and the client's only complaint is that her breasts are leaking clear fluid. Which assessment finding warrants further evaluation? A) Presence of fetal movement B) Leakage from breasts C) Gestational weight gain D) Fundal height measurement - ANS C) Gestational weight gain At this point in the pregnancy, the client should have gained 10.3 pounds and a weight gain of 20 pounds should be investigated further. The recommended weight gain is 2-4 pounds in the first trimester (up to 13 weeks gestation) and then 1 pound per week thereafter. The vital signs for a client with HF who is admitted to the ICU include 98.6 F, 125 bpm, 22 breaths/min, and 140/50 BP. The nurse determines that the client's CVP and PAWP are elevated. Which intervention should the nurse implement? A) Encourage a liberal PO fluid intake. B) Titrate IV dopamine at 8 mcg/kg/minute C) Administer furosemide (Lasix) 40 mg IV D) Give an IV bolus of 500 ml normal saline. - ANS C) Administer furosemide (Lasix) 40 mg IV Preload is affected by the circulating blood volume, the amount of blood returning to the heart, and ventricular filling time so decrease the client's preload, Lasix a loop diuretic, should be given (C). Additional fluid intake (A and D) increases the circulating intravascular volume and contributes to an increase in the CVP and PAWP. Dopamine is a vasoconstrictor which decreases the intravascular space, causing the afterload to increase. While auscultating a client's abdomen, the nurse hears a low pitched blowing sound in the upper midline area. What is the likely indication of this finding? A) Normal borborygmus sounds B) A minor variation C) Hyperactive bowel sounds D) Possible renal artery stenosis - ANS D) Possible renal artery stenosis