HESI Practice Exam 131 Questions with Verified Answers,100% CORRECT

HESI Practice Exam 131 Questions with Verified Answers Which assessment is most important for the nurse to perform on a client who is hospitalized for Guillain-Barre syndrome that is rapidly progressing? Respiratory effort. Unsteady gait. Intensity of pain. Ability to eat. - CORRECT ANSWER Respiratory effort. Guillain-Barre syndrome causes paralysis or weakness that typically starts at the feet and progresses upwards. As the condition progresses, the nurse must ensure that the client is able to breathe effectively. A male client comes into the clinic with a history of penile discharge with painful, burning urination. Which action should the nurse implement? Collect a culture of the penile discharge. Palpate the inguinal lymph nodes gently. Observe for scrotal swelling and redness. Express the discharge to determine color. - CORRECT ANSWER Collect a culture of the penile discharge. Penile discharge with painful urination is commonly associated with gonorrhea. The nurse should collect a culture of the penile discharge to determine the cause of these symptoms. The cause must be determined or confirmed through culture to identify the organism and ensure effective treatment. A client with history of atrial fibrillation is admitted to the telemetry unit with sudden onset of shortness of breath. The nurse observes a new irregular heart rhythm and should perform which assessment at this time? Check for a pulse deficit. Palpate the apical impulse. Inspect jugular vein pulse. Examine for a carotid bruit. - CORRECT ANSWER Check for a pulse deficit. A client with a past history of atrial fibrillation may return to that rhythm. Any signs of atrial fibrillation, such as sudden onset shortness of breath, requires further investigation. The nurse should assess this client for a pulse deficit because this condition occurs with atrial fibrillation. Which client should be further assessed for an ectopic pregnancy? A 24-year-old with shoulder and lower abdominal quadrant pain. A 33-year-old with intermittent lower abdominal cramping. A 20-year-old with fever and right lower abdominal colic. A 40-year-old with jaundice and right lower abdominal pain. - CORRECT ANSWER A 24-year-old with shoulder and lower abdominal quadrant pain. A 24-year-old with sudden onset of lower abdominal quadrant pain should be assessed for an ectopic pregnancy. The pain can also be referred to the shoulder and may be associated with vaginal bleeding. Which dietary assessment finding is most important for the nurse to address when caring for a client with diabetic nephropathy? Drinks a six pack of beer every day. Enjoys a hamburger once a month. Eats fortified breakfast cereal daily. Consumes beans and rice every day. - CORRECT ANSWER Drinks a six pack of beer every day. Drinking six beers every day is the dietary assessment finding most important for the nurse to address when caring for a client with diabetic nephropathy. The usual can of beer is 12 ounces (355 mL). Clients with diabetes are recommended to drink no more than 12 ounces of beer per day because beer contains carbohydrates that can create unhealthy fluctuations in blood glucose and promote poor glucose control. Nephropathy is exacerbated by poor blood glucose control. Which assessment finding is of greatest concern to the nurse who is caring for a client with stomatitis? Cough brought on by swallowing. Sore throat caused by speaking. Painful and dry oral cavity. Unintended weight loss. - CORRECT ANSWER Cough brought on by swallowing. A cough brought on by swallowing is a sign of dysphagia, which is a finding of particular concern in a client with stomatitis. Dysphagia can cause numerous problems, including airway obstruction, and should be reported to the healthcare provider immediately. The nurse is teaching a client diagnosed with peripheral arterial disease. Which genitourinary system complication should the nurse include in the teaching? Altered sexual response. Sterility. Urinary incontinence. Decreased pelvic muscle tone. - CORRECT ANSWER Altered sexual response. Peripheral arterial disease (PAD) is a cardiovascular condition characterized by narrowing of the arteries and reduced blood flow to the extremities. PAD is known to alter the blood flow to the male's penis and is associated with erectile dysfunction in men. A 40-year-old female client has a history of smoking. Which finding should the nurse identify as a risk factor for myocardial infarction? Oral contraceptives. Senile osteopenia. Levothyroxine therapy. Pernicious anemia. - CORRECT ANSWER Oral contraceptives. Women older than 35 years old who smoke and take oral contraceptives have an increased risk of myocardial infarction or stroke. A client has been told that there is cataract formation over both eyes. Which finding should the nurse expect when assessing the client? Decreased color perception. Presence of floaters. Loss of central vision. Reduced peripheral vision. - CORRECT ANSWER Decreased color perception. Decreased color perception occurs with cataract formation. Cataract formation is also associated with blurred vision and a global loss of vision so gradual that the client may not be aware of it. Which assessment finding should most concern the nurse who is monitoring a client two hours after a thoracentesis? New onset of coughing. Low resting heart rate. Distended neck veins. Decreased shallow respirations. - CORRECT ANSWER New onset of coughing. A pneumothorax (partial or complete lung collapse) is the potential complication of a thoracentesis. Manifestations of a pneumothorax include new onset of a nagging cough, tachycardia, and an increased shallow respiration rate. While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? Monitor infusing IV fluids and any replacement blood products. Prepare for esophagogastroduodenoscopy (EGD). Maintain the client on strict bedrest. Insert a nasogastric tube (NGT) for intermittent suction. - CORRECT ANSWER Monitor infusing IV fluids and any replacement blood products. Maintaining hemodynamic stability in a client with esophageal varicescan precipitatea life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products. The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? Urine output of 40 mL/hour. Apical pulse 100 and blood pressure 76/42. Urine specific gravity 1.001. Tented skin on dorsal surface of hands. - CORRECT ANSWER Urine output of 40 mL/hour. A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, 40 mL/hour, the client's kidneys are perfusing adequately and indicates the client's status is stablizing. After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? Position client on left side with pillow placed under the costal margin. Assist the client with voiding immediately after the procedure. Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. Ambulate client 3 times in first hour with pillow held at abdomen. - CORRECT ANSWER Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. Vital signs should be checked every 10 to 20 minutes to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right side with a pillow or sandbag under the costal margin and supporting the biopsy site. The client should be maintained on bedrest for several hours to decrease the risk of bleeding from the biopsy site. The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm 3 and a platelet countof 160,000/mm 3. Which intervention is the primary focus in the client's plan of care for the RN to implement? Assist with frequent ambulation. Encourage visitors to visit. Maintain strict protective precautions. Avoid peripheral injections. - CORRECT ANSWER Maintain strict protective precautions. The client should be under strict protective transmission precautions because the WBC values are low and normal WBC levels are 4,000-10,000/mm3, so the client is an increased high risk for infection. The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for the two hour postprandial result? 140 mg/dl. 160 mg/dl. 180 mg/dl. 200 mg/dl. - CORRECT ANSWER 140 mg/dl. The two hour postprandial level should be less 140 mg/dl for a young adult client. The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? Lower back pain. Headache of 7 on scale 1 to 10. Blood pressure of 140/98. Dyspnea. - CORRECT ANSWER Dyspnea A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately. The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatment? The development of resistant strains of TB are decreased with a combination of drugs. Compliance to the medication regimen is challenging but should be maintained. Side effects are minimized with the use of a single medication but is less effective. The treatment time is decreased from 6 months to 3 months with this standard regimen. - CORRECT ANSWER The development of resistant strains of TB are decreased with a combination of drugs. Combination therapy is necessary to decrease the development of resistant strains of TB and ensure treatment efficacy. The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema how to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing? Decreases respiratory rate. Increases O 2 saturation throughout the body. Conserves energy while ambulating. Promotes CO 2 elimination. - CORRECT ANSWER Promotes CO 2 elimination. Pursed lip breathing helps eliminate CO2 by increasing positive pressure within the alveoli increasing the surface area of the alveoli making it easier for the O2 and CO2 gas exchange to occur . The registered nurse (RN) is caring for a client with acute pancreatitis and reviews the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis? Triglycerides. Amylase. Creatinine. Uric acid. - CORRECT ANSWER Amylase An elevated amylase level is associated with acute pancreatitis. A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the registered nurse (RN) identify in the client's history? Chronic bronchitis. Gastroesophageal reflux disease (GERD). Heart failure (HF). Chronic pancreatitis. - CORRECT ANSWER Heart failure (HF) Paroxysmal nocturnal dyspnea is classic sign of heart failure and is secondary to fluid overload associated with heart failure which causes pulmonary edema. A client is recently diagnosed with systemic lupus erythematosus (SLE) and the registered nurse (RN) is assessing for common complications. Which symptom should the RN instruct the client to report immediately? Fever related to infection. Weight loss and anorexia. Depressed mood. Break in tissue integrity. - CORRECT ANSWER Fever related to infection Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections should be reported immediately. A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which explanation by the nurse accurately describes the client's fracture? Straight fracture line that is also a simple, closed fracture. Nondisplaced fracture line that wraps around the bone. A complete fracture that also punctures the skin. A fracture that bends or splinters part of the bone. - CORRECT ANSWER A fracture that bends or splinters part of the bone An incomplete fracture occurs when part of the bone is splintered (broken) and it has not gone completely through the thickness of the bone. The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding would indicate to the nurse that the client is at risk for diabetes insipidus (DI)? High fever. Low blood pressure. Muscle rigidity. Polydipsia. - CORRECT ANSWER Polydipsia A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia). DI can occur when there has been damage or injury to the pituitary gland or hypothalamus as a result of head trauma, tumor or an illness such as meningitis. This damage interrupts the ADH production, storage and release causing the excessive urination and thirst. The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after the removal of the chest tube? Prepare the client for chest x-ray at the bedside. Review arterial blood gases after removal. Elevate the head of bed to 45 degrees. Assist with disassembling the drainage system. - CORRECT ANSWER Prepare the client for chest x-ray at the bedside. A chest x-ray should be performed immediately after the removal of a chest tube to ensure lung expansion has been maintained after its removal. A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? Creatine Kinase (CK-MB). Serum troponin. Myoglobin. Ischemia modified albumin. - CORRECT ANSWER Serum troponin. Troponin is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB. A female client is recently diagnosed with Sarcoidosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching the client, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? African American women. Caucasian women. Asian women. Hispanic women. - CORRECT ANSWER African American women. Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs and has shown familial tendency due to multiple genes that together increase the susceptibility of developing the disease. In research studies it occurs more commonly in African American women (10-80 out of 100,000); compare to Caucasian women of the United States (8 out of 100,000). The registered nurse (RN) is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the RN report to the healthcare provider? Dry mucous membranes and lips. Rebound abdominal tenderness over right lower quadrant. Dizziness when client ambulates from a sitting position. Poor skin turgor over client's wrist. - CORRECT ANSWER Rebound abdominal tenderness over right lower quadrant. Right lower quadrant (RLQ) rebound abdominal tenderness may be related to acute appendicitis and should be reported to the healthcare provider. The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? (Select all that apply). Hematemesis. Gastric pain on an empty stomach. Colic-like pain with fatty food ingestion. Intolerance of spicy foods. Diarrhea and stearrhea. - CORRECT ANSWER Hematemesis. Gastric pain on an empty stomach. Intolerance of spicy foods. Manifestations of PUD include hematemesis, gastric pain, and spicy food intolerance. The registered nurse (RN) recognizes which client group is at the greatest risk for developing a urinary tract infection (UTI)? (Rank from highest risk to lowest risk.) 1Older males. 2School-age female. 3Older females. 4Adolescent males. - CORRECT ANSWER 1. Older females. 2. School-age female. 3. Older males. 4. Adolescent males. Hypoestrogenism and alkalotic urine are other age-related factors put older women at the highest risk for UTIs. School age girls (6 to 12 years) are at risk for UTIs due to a higher prevalence to taking baths instead of showers, but these risks can be controlled in this population as well as hypoestrogenism and alkalotic urine. Older men are at risk due to possible obstruction of the bladder due to benign prostatic hypertrophy (BPH). Adolescent males (12 to 19 years) are the lowest at risk for a UTI. A female client admitted with abdominal pain is diagnosed with cholelithiasis. The client asks the registered nurse (RN) what she should expect as a common treatment. What recommended plan of care should the nurse provide the client? Rest with liquid diet only. Drugs such as ursodiol. Cholecystectomy via laparoscopy. LaVeen vena caval shunt. - CORRECT ANSWER Cholecystectomy via laparoscopy. The nurse should explain to the client that gall bladder surgical removal is most often recommended via laparoscopic excision. Which action should the nurse implement on the scheduled day of surgery for a client with type 1 diabetes mellitus (DM)? Obtain a prescription for an adjusted dose of insulin. Administer an oral anti-diabetic agent. Give an insulin dose using parameters of a sliding scale. Withhold insulin while the client is NPO. - CORRECT ANSWER Obtain a prescription for an adjusted dose of insulin. Stressors, such as surgery, increase serum glucose levels. A client with type 1 DM who is NPO for scheduled surgery should receive a prescribed adjusted dose of insulin. A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? Heart palpitations. Anorexia. Hypersomnia. Stress incontinence. - CORRECT ANSWER Heart palpitations Characteristic features of premenstrual syndrome include heart palpitations, sleeplessness, increased appetite and food cravings, and oliguria or enuresis. Which preexisting diagnosis places a client at greatest risk of developing superior vena cava syndrome? Carotid stenosis. Steatosis hepatitis. Metastatic cancer. Clavicular fracture. - CORRECT ANSWER Metastatic cancer. Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava. When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority? Acute pain related to movement of the stone. Impaired urinary elimination related to obstructed flow of urine. Risk for infection related to urinary stasis. Deficient knowledge related to need for prevention of recurrence of calculi. - CORRECT ANSWER Acute pain related to movement of the stone. The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's movement". The nurse should explain to a client with lung cancer that pleurodesis is performed to achieve which expected outcome? Prevent the formation of effusion fluid. Remove fluid from the intrapleural space. Debulk tumor to maintain patency of air passages. Relieve empyema after pneumonectomy. - CORRECT ANSWER Prevent the formation of effusion fluid. Instillation of a sclerosing agent to create pleurodesis is aimed at preventing the formation of a pleural effusion by causing the pleural spaces sealed together, thereby preventing the accumulation of pleural fluid. The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A description of inflammation, infection, and tumors. Continuous visualization of intracranial neoplasms. Imaging of tumors without exposure to radiation. An image that describes metastatic sites of cancer. - CORRECT ANSWER An image that describes metastatic sites of cancer PET scans provide information regarding certain diseases of the heart (determination of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors and their metastasis. A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? Suprapublic pain and distention. Bounding pulse at 100 beats/minute. Fingerstick glucose of 300 mg/dl. Small vesicular perineal lesions. - CORRECT ANSWER Fingerstick glucose of 300 mg/dl. Elevated fingerstick glucose levels needs to be reported tot he healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also elevated glucose levels, spills into the urine and provide a medium for bacterial growth. Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)? Use an end-tital CO2 detector. Ascultate for bilateral breath sounds. Obtain pulse oximeter reading. Check symmetrical chest movement. - CORRECT ANSWER Use an end-tital CO2 detector. The end-tidal carbon dioxide detector indicates the prescence of CO2tidal by a color change or a number indicated on the detector, which is supporting evidence that the ETT is in the trachea, not the esophagus. A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse? Serum amylase of 132 units/L. Serum sodium of 134 mEq/L. Chest x-ray indicating a mediastinal shift. Abdominal x-ray air throughout intestines. - CORRECT ANSWER Chest x-ray indicating a mediastinal shift. Immediate action is required for findings of a mediastinal shift, which can precipitate life-threatening cardiovascular collapse as the great cardiac vessels become kinked and compressed due to the tension pneumothorax. The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? Large amounts of expelled flatus with mucus. Tympanic abdomen and hyperactive bowel sounds. Increased abdominal pain with rebound tenderness. Complaint of feeling weak with watery diarrheal stools. - CORRECT ANSWER Increased abdominal pain with rebound tenderness. Positive rebound tenderness following a colonoscopy may be an indication of a perforation and the development of peritonitis and requires follow-up immediately. A client with acute appendicitis is experiencing anxiety and loss of sleep about missing final examination week at college. Which outcome is most important for the nurse to include in the plan of care? Sleep 6 to 8 hours. Achieve a sense of control. Utilize problem solving skills. Increase focus of attention. - CORRECT ANSWER Achieve a sense of control. The experience of psychological discomfort may be as real as physical pain for the client and should be seen as a priority in care. Because the client is experiencing anxiety, achieving a sense of control is the overall outcome of this client's nursing care plan. A client with type II diabetes arrives at the clinic with a blood glucose of 50 mg/dL. The nurse provides the client with 6 ounces of orange juice. In 15 minutes the client's capillary glucose is 74 mg/dL. What action should the nurse take? Obtain a specimen for serum glucose level. Administer insulin per sliding scale. Provide cheese and bread to eat. Collect a glycosylated hemoglobin specimen. - CORRECT ANSWER Provide cheese and bread to eat Once blood glucose is greater than 70 mg/dL, the client should eat a regularly scheduled meal or a snack that contains protein and carbohydrates to help prevent hypoglycemia from recurring. The unlicensed assistive personnel (UAP) reports that an 87-year-old client who is sitting in a chair at the bedside has an oral temperature of 97.2°F (36.4°C). Which intervention should the nurse implement? Document the temperature reading on the vital sign graphic sheet. Report the temperature to the healthcare provider immediately. Instruct the UAP to take the client's temperature again in 30 minutes. Advise the UAP to assist the client in returning to bed. - CORRECT ANSWER Document the temperature reading on the vital sign graphic sheet. A subnormal oral temperature of 97.2°F (36.4°C) is a common finding in elderly clients, so the nurse should document the findings and continue with the plan of care. The nurse is assessing a client who is bedfast and refuses to turn or move from a supine position. How should the nurse assess the client for possible dependent edema? Compress the flank and upper buttocks. Measure the client's abdominal girth. Gently palpate the lower abdomen. Apply light pressure over the shins. - CORRECT ANSWER Compress the flank and upper buttocks. Dependent edema collects in dependent areas, such as the flank and upper buttocks of the client who is persistently flat in bed. By compressing these areas, the nurse can determine if any pitting edema is present. An 85-year-old male client comes to the clinic for his annual physical exam and renewal of antihypertensive medication prescriptions. The client's radial pulse rate is 104 beats/minute. Which additional assessment should the nurse complete? Palpate the pedal pulse volume. Count the brachial pulse rate. Measure the blood pressure. Assess for a carotid bruit. - CORRECT ANSWER Measure the blood pressure. Elderly clients who take antihypertensive medications often experience side effects, such as hypotension, which causes tachycardia, a compensatory mechanism to maintain adequate cardiac output, so the client's blood pressure should be measured. The nurse is completing the health assessment of a 79-year-old client who denies any significant health problems. Which finding requires the most immediate follow-up assessment? Kyphosis with a reduction in height. Dilated superficial veins on both legs. External hemorrhoids with itching. Yellowish discoloration of the sclerae. - CORRECT ANSWER Yellowish discoloration of the sclerae. In a geriatric client, a yellowish discoloration (jaundice) of the sclerae is not a normal finding and may indicate liver damage and requires further assessment. The nurse is assessing a client with a chest tube that is attached to suction and a closed drainage system. Which finding is most important for the nurse to further assess? Upper chest subcutaneous emphysema. Tidaling (fluctuation) of fluid in the water-seal chamber. Constant air bubbling in the suction-control chamber. Pain rated "8" (0-10) at the insertion site. - CORRECT ANSWER Upper chest subcutaneous emphysema. Subcutaneous emphysema is a complication and indicates air is leaking beneath the skin surrounding the chest tube. A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? Side effects are less likely if therapy is started early. Collateral circulation increases as the tumor grows. Sensitivity of cancer cells to CT is based on cell cycle rate. The cell count of the tumor reduces by half with each dose. - CORRECT ANSWER The cell count of the tumor reduces by half with each dose. Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with each dose. A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A scalp laceration oozing blood. Serosanguineous nasal drainage. Headache rated "10" on a 0-10 scale. Dizziness, nausea and transient confusion. - CORRECT ANSWER Serosanguineous nasal drainage. Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis. The nurse is teaching a client about precautions for a new prescription for lovastatin. Which symptom should the nurse instruct the client to report to the healthcare provider immediately? Terrible nightmares. Increased nocturia. Severe muscle pain. Visual disturbances. - CORRECT ANSWER Severe muscle pain. A potential, serious side effect of statin therapy that is used to lower both LDL-C and triglyceride levels is rhabdomyolysis, which is manifested by severe muscle pain and aching. The nurse is caring for a client who is two days postoperative. Which observation should alert the nurse to call the Rapid Response Team (RRT)? Fresh bleeding noted on abdominal surgical wound dressing. Pulse change from 85 to160 beats/minute lasting more than 10 minutes. Temperature of 103.1 F (39.5 C) and white blood cell (WBC) count of 16,000 mm3. Weakness, diaphoresis, reports of feeling faint. BP 100/56 mmHg. - CORRECT ANSWER Pulse change from 85 to160 beats/minute lasting more than 10 minutes. The RRT should be called to intervene for a postoperative client with an acute life-threatening change, such as a pulse change resulting in tachycardia for a prolonged time period. A client is admitted after blunt abdominal injury. Which assessment finding requires immediate action by the nurse? Radiating abdominal pain with left lower quadrant palpation. Grimacing after palpation of the right hypochondriac region. Rebound tenderness with abdominal palpation. Bluish periumbilical skin discoloration. - CORRECT ANSWER Bluish periumbilical skin discoloration. Immediate action is indicated for intraperitoneal hemorrhage which causes periumbilical discoloration and indicates the presence of a splenic rupture, a life-threatening complication of blunt abdominal injury. Based on an analysis of the client's rhythm, atrial fibrillation, the nurse should prepare the client for which treatment protocol? Diuretic therapy. Pacemaker implantation. Anticoagulation therapy. Cardiac catheterization. - CORRECT ANSWER Anticoagulation therapy. The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria. The nurse is preparing a client for orthopedic surgery on the left leg and completing a safety checklist before transport to the operating room. Which items should the nurse remove from the client? (Select all that apply.) Nail polish. Hearing aid. Wedding band. Left leg brace. Contact lenses. Partial dentures. - CORRECT ANSWER Nail polish. Hearing aid. Contact lenses. Partial dentures. The removal of nail polish provides a more accurate pulse oximetry readings and evaluation of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent damage, loss or misplacement, or injury during surgery. Ideally, give the client's significant other the contact lenses if they are not the disposable ones, hearing aids and partial dentures once placed in an appropriate labeled container to hold for safe keeping. If no significant other is not able to hold onto the items, then secured them in an appropriate and safe place. The nurse obtains a client's history that includes right mastectomy and radiation therapy for breast cancer 10 years ago. Which current health problem should the nurse consider is a consequence of the radiation therapy? Asthma. Myocardial infarction. Chronic esophagitis with gastroesophageal reflux. Pathologic fracture of two ribs on the right chest. - CORRECT ANSWER Pathologic fracture of two ribs on the right chest. The ribs lie in the radiation pathway and lose density over time, becoming thin and brittle, so the occurrence of two right-sided ribs with pathological fractures resulting without evidence of trauma is related to radiation damage. The nurse is preparing a teaching plan for a client with newly diagnosed glacoma and a history of allergic rhinitis. Which information is most important for the nurse to provide the client about using over-the-counter (OTC) medications for allergies? Notify your healthcare provider if there is an increase in heart rate. Increase fluid intake while taking an antihistamine or decongestant. Avoid allergy medications that contain pseudoephedrine or phenylephrine. Ophthalmic lubricating drops may be used for eye dryness due to allergy medications. - CORRECT ANSWER Avoid allergy medications that contain pseudoephedrine or phenylephrine. OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications. A client who is receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. Which assessment finding is most important for the nurse to identify? Increased anxiety since the transfusion began. Drowsiness after receiving diphenhydramine (Benadryl). Reports of feeling cold. Flushed skin and headache. - CORRECT ANSWER Flushed skin and headache. The most common type of reaction is a febrile, nonhemolytic blood transfusion reaction related to leukocyte incompatibility, which causes chills, fever, headache, and flushing. The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? Administer medications for pain relief, shortness of breath, and nausea. Clarify family members' feelings about the meaning of client behaviors and symptoms. Develop a plan of care after assessing the needs of the client and family. Teach family members to recognize restlessness and grimacing as signs of client discomfort. - CORRECT ANSWER Administer medications for pain relief, shortness of breath, and nausea. Hospice care provides symptom management and pain control during the dying process and enhances the quality of life for a client who is terminally ill. Administering medication and monitoring for therapeutic and adverse effects are within the scope of practice for the PN. Which client should the nurse assess first? A 27-year-old complaining of severe back pain. A 63-year-old complaining of foot and ankle pain. A 49-year-old with pancreatitis complaining of unrelenting abdominal pain. A 55-year-old newly admitted client complaining of jaw pain and indigestion. - CORRECT ANSWER A 55-year-old newly admitted client complaining of jaw pain and indigestion. The 55-year-old client should be assessed first to rule out cardiac involvement because jaw pain and indigestion are common descriptors of myocardial injury. A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. Which nursing activity should the nurse implement instead of delegating to a practical nurse (PN)? Determine the client's level of discomfort using a pain rating scale. Ask the client about her past experience with chronic pain. Observe the client's facial expressions for pain and discomfort. Evaluate the client's ability to adjust the voltage to control pain. - CORRECT ANSWER Evaluate the client's ability to adjust the voltage to control pain. The oncology nurse has the knowledge and experience with the use of a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain relief, so the nurse should evaluate the client's skill in effectively controlling the pain by adjusting the voltage. A Korean-American client, who speaks very little English, is being discharged following surgery. Which nurse should the nurse manager assign to provide the discharge instructions for the client? A graduate registered nurse (RN) with three weeks of experience. The registered nurse (RN) case-manager for the unit with 1 year's experience. A "floating" registered nurse (RN) with five years of nursing experience. An Korean-American practical nurse (PN) with six years of nursing experience. - CORRECT ANSWER The registered nurse (RN) case-manager for the unit with 1 year's experience. The RN case-manager is the best qualified nurse to assess and provide discharge educational needs, obtain resources for the client, enhance coordination of care, and prevent fragmentation of care. A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. What action should the nurse implement? Notify the healthcare provider. Decrease the IV solution flow rate. Document the finding as the only action. Administer potassium replacement as prescribed. - CORRECT ANSWER Document the finding as the only action. Coronary artery bypass surgery graft (CABG) places a client at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy, so the serum potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. Documentation of the normal finding is indicated at this time. A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next? Inform the healthcare provider. Obtain a 12-lead electrocardiogram. Give a sublingual nitroglycerin tablet. Administer prescribed analgesic. - CORRECT ANSWER Give a sublingual nitroglycerin tablet. After a percutaneous transluminal coronary angioplasty (PTCA), a client who experiences acute chest pain may be experiencing cardiac ischemia related to restenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin to dilate the coronary arteries and increase myocardial oxygenation. A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. What action should the nurse implement? Notify the healthcare provider. Increase the IV flow rate. Place the client in the supine position. Prepare the client for an emergency echocardiography. - CORRECT ANSWER Notify the healthcare provider. Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a client with a myocardial infarction indicate impending cardiogenic shock related to heart failure, a common complication of MI. The healthcare provider should be notified immediately for emergency interventions of this life-threatening complication. A 24-year-old female client diagnosed with a human papillomavirus infection (HPV) is angry at her ex-boyfriend and says she is not going to tell him that he is infected. What response is best for the nurse to provide? "You do not have to tell him because this is not a reportable disease." "Because there is no cure for this disease, telling him is of no benefit to him or to you." "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." "You should tell him, so he can feel as guilty and miserable as you do now, knowing that you have this disease." - CORRECT ANSWER "Even though you are angry, he should be told, so he can take precautions to prevent the spread of infection." Anger is a common emotional reaction when confronted with the diagnosis of a STI, and often lay blame and project this anger at the sexual partner. Although HPV is not a reportable disease in many states, all contacts should be informed of the infection, treatment, transmission, and precautions to minimize infecting others. During the initial outbreak of genital herpes simplex in a female client, what should be the nurse's primary focus in planning care? Promotion of comfort. Prevention of pregnancy. Instruction in condom use. Information about transmission. - CORRECT ANSWER Promotion of comfort. The initial outbreak of genital herpes simplex in a woman causes severe discomfort. Promotion of comfort is the first priority. The nurse is caring for a client with multiple trauma after a motor vehicle collision. The nurse learns that the client has secondary syphilis. Which precaution should the nurse implement? A mask should be worn by anyone entering the client's room. Hand washing is required before and after contact with the client. Gloves should be worn during direct contact with the client's skin. No precautions in addition to standard precautions are necessary. - CORRECT ANSWER Gloves should be worn during direct contact with the client's skin. The secondary stage of syphilis is a systemic blood-borne disease that presents with skin lesions and rashes that may drain the highly contagious spirochete, so gloves should be worn during direct contact with the client's skin. The client should be placed on contact precautions. What is the primary nursing problem for a client with asymptomatic primary syphilis? Acute pain. Risk for injury. Sexual dysfunction. Deficient knowledge. - CORRECT ANSWER Deficient knowledge. An asymptomatic client with primary syphilis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing diagnosis is deficient knowledge of the disease pathophysiology. Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan that increases the risk for cervical cancer? Neisseria gonorrhoea. Chlamydia trachomatis. Herpes simplex virus. Human papillomavirus. - CORRECT ANSWER Human papillomavirus. According to the CDC (2017), it is estimated at least 80% of all women who are sexually active will contract the Human papillomavirus (HPV) in their lifetime. Certain types of HPV have been suspected to cause cervical cancer and HPV strain 16 and 18 have been identified to cause 70% of cervical cancers. A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first? Notify the client's healthcare provider. Document the finding in the client record. Prepare a warm enema solution for rectal instillation. Obtain a large bore needle for aspiration of the corpora cavernosa. - CORRECT ANSWER Notify the client's healthcare provider. Priapism, a urologic emergency, is common during sickle cell crisis due to sickle cells clogging the microcirculation in the penis, causing a reduction of blood flow and oxygenation to the penis, so the healthcare provider should be first notified immediately. The prescribed therapy may consist of noninvasive measures such as applying ice to the penis, instilling a warm solution enema to increase outflow in the corpora cavernosa and giving pain medications. If noninvasive measures do not work, then needle aspiration of the corpora cavernosa is implemented by the healthcare provider. The nurse is providing discharge instructions to a client who has undergone a left orchiectomy for testicular cancer. Which statement indicates that the client understands his post-operative care and prognosis? "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." "I should wear an athletic supporter and cup to prevent testicular cancer in my remaining testicle." "I should always use a condom because I am at increased risk for acquiring a sexually transmitted disease." "I should make sure my sons know how to perform TSE because they are at increased risk for this type of cancer." - CORRECT ANSWER "I should continue to perform testicular self-examination (TSE) monthly on my remaining testicle." Although testicular cancer protocols, such as surgery, radiation, or chemotherapy, focus on the primary site of testicular cancer, these treatments do not reduce the risk of testicular cancer in the remaining testicle, so early recognition is the best prevention. The client's understanding is reflected in the statement to perform monthly TSE for changes in size, shape, or consistency of the testis that may indicate early cancer. The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? Wear a condom when having sexual intercourse. Avoid consuming alcohol and caffeinated beverages. Empty the bladder completely with each voiding. Have intercourse or masturbate at least twice a week. - CORRECT ANSWER Have intercourse or masturbate at least twice a week. The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated seminal fluids. An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. Which is the priority nursing diagnosis for this client? Risk for injury. Impaired comfort. Disturbed body image. Ineffective health maintenance. - CORRECT ANSWER Impaired comfort. In menopausal women, the vaginal mucous membrane responds to low estrogen levels causing the vaginal walls to become thinner, drier, and susceptible to infection, which leads to atrophic vaginitis. Perineal cutaneous candidiasis contributes to other manifestations of vaginal infections, such as vaginal irritation, burning, pruritus, increased leukorrhea, bleeding, and dyspareunia, which supports the primary nursing diagnosis, "impaired comfort." Which findings are within expected parameters of a normal urinalysis for an older adult? (Select all that apply.) pH 6. Nitrate small. Protein small. Sugar negative. Bilirubin negative. Specific gravity 1.015. - CORRECT ANSWER pH 6 Bilirubin Negative Sugar Negative Specific gravity 1.015 A pH of 6.0 is within the normal pH range for urine. Glucosuria and bilirubinuria are abnormal and should be negative upon urinalysis. Normal changes associated with aging include decreased creatinine clearance and decreased concentrating and diluting abilities which influence the normal range of urine specific gravity, 1.001 to 1.035. Although common health problems associated with aging include renal insufficiency, urinary incontinence, urinary tract infection, and enlarged prostate, these are indicative of pathology which should be treated. Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? Full thickness burns rather than partial thickness. Supinates extremity but unable to fully pronate the extremity. Slow capillary refill in the digits with absent distal pulse points. Inability to distinguish sharp versus dull sensations in the extremity. - CORRECT ANSWER Slow capillary refill in the digits with absent distal pulse points. A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy. Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? Pulse oximetry reading of 80%. Expiratory stridor and nasal flaring. Cherry red color to the mucous membranes. Presence of carbonaceous particles in sputum. - CORRECT ANSWER Cherry red color to the mucous membranes. The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules and the subsequent vasodilation induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning. The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? Follow contact isolation procedures. Wash hands after caring for the client. Wear gloves when providing personal care. Restrict pregnant staff or visitors into the room. - CORRECT ANSWER Wash hands after caring for the client. The organism Candida albicans, that causes this infection, is part of the normal flora on the skin of most adults. Good handwashing is all that is needed to prevent nosocomial spread. The nurse is preparing discharge instructions for a client who is going home with a surgical wound on the coccyx that is healing by secondary intention. What is the priority nursing diagnosis that should guide the discharge instruction plan? Acute pain. Risk for infection. Disturbed body image. Risk for deficient fluid volume. - CORRECT ANSWER Risk for infection. A wound healing by secondary intention is an open wound that is at risk for infection and the location of the wound near the anal area increases the risk for infection even more so. A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? Body mass index. Skin elasticity and turgor. Thought processes and speech. Exposure to cold environmental temperatures. - CORRECT ANSWER Exposure to cold environmental temperatures. TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Prolonged exposure to cold environmental temperatures stimulates the hypothalamus to secrete thyrotropin-releasing hormone, which increases anterior pituitary serum release of TSH. The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. Which position should the nurse ask the client to demonstrate to assess for asterixis? Extend the left arm laterally with the left palm upward. Extend the arm, dorsiflex the wrist, and extend the fingers. Extend the arms and hold this position for 30 seconds. Extend arms with both legs adducted to shoulder width. - CORRECT ANSWER Extend the arm, dorsiflex the wrist, and extend the fingers. Asterixis (flapping tremor, liver flap) is a hand-flapping tremor that is often seen frequently in hepatic encephalopathy. The tremor is induced by extending the arm and dorsiflexing the wrist, causing rapid, nonrhythmic extension and flexion of the wrist while attempting to hold position. During the assessment of a client who is 24 hours post-hemicolectomy with a temporary colostomy, the nurse determines that the client's stoma is dry and dark red in color. What action should the nurse implement? Notify the surgeon. Document the assesment. Secure a colostomy pouch over the stoma. Place petrolatum gauze dressing over the stoma. - CORRECT ANSWER Notify the surgeon. The stoma should appear reddish pink and moist, which indicates circulatory perfusion to the surgical diversion of the intestine. If the stoma becomes dry, firm, flaccid, or is dark red or purple, the stoma is ischemic, and the surgeon should be notified immediately. The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? Assessment of the client's vital signs. Document the finding as the only action. Determine the time the client last voided. Insert a rectal tube for the passage of flatus. - CORRECT ANSWER Determine the time the client last voided. Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided should be determined next. A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect? Rub a liberal amount of cream into the skin thoroughly. Cover the skin with a gauze dressing after applying the cream. Leave the cream on the skin for 1 to 2 hours before the procedure. Use the smallest amount of cream necessary to numb the skin surface. - CORRECT ANSWER Leave the cream on the skin for 1 to 2 hours before the procedure. Topical anesthetic creams, such as EMLA, should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter. A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first? Cleanse perineum with warm soapy water 3 times per day. Instill the first dose of nystatin vaginally per applicator. Perform glucose measurement using a capillary blood sample. Obtain a blood specimen for sexually transmitted diseases (STDs). - CORRECT ANSWER Instill the first dose of nystatin vaginally per applicator. Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a "cottage-cheese" appearance and vaginal nystatin should be implemented first to initiate treatment to provide relief of symptoms. The nurse is providing instructions about log rolling to a client who returns to the postoperative unit after a lumbar laminectomy. Which explanation should the nurse give the client about this technique? Helps to minimize pain and anxiety. Maintains correct spinal alignment to protect the surgical area. Prevents dizziness while stabilizing the spine. Allows the nurse to move the client freely without assistance. - CORRECT ANSWER Maintains correct spinal alignment to protect the surgical area. Log rolling technique maintains the spine in a straight superior-inferior plane and aligns the spine without movement while protecting the surgical area. This is particularly important when the procedure involves bone grafts that may take several weeks for the bone to fuse. A nurse is preparing a teaching plan for a client who is postmenopausal. Which measure is most important for the nurse to include to prevent osteoporosis? Take a multivitamin daily. Use only low fat milk products. Perform weight resistance exercises. Bicycle for at least 3 miles every day. - CORRECT ANSWER Perform weight resistance exercises. Weight bearing on the skeletal system stimulates bone formation, so recommending weight resistance exercises is most important in the prevention of osteoporosis in postmenopausal clients. A client with rheumatoid arthritis is prescribed piroxicam, a nonsteroidal anti-inflammatory drug (NSAID). Which effect is characteristic of NSAIDs used for treating rheumatoid arthritis? Production of replacement cartilage is stimulated. Further destruction of the articular cartilage is prevented. Inflammation is reduced by inhibiting prostaglandin synthesis. Bradykinin is inhibited, thereby reducing acute and chronic pain. - CORRECT ANSWER Inflammation is reduced by inhibiting prostaglandin synthesis. Nonsteroidal anti-inflammatory drugs (NSAIDs), used for treating rheumatoid arthritis, work by inhibiting the synthesis of prostaglandins and providing relief from the associated pain. The nurse completes visual inspection of a client's abdomen. What technique should the nurse perform next in the abdominal examination? Percussion. Auscultation. Deep palpation. Light palpation. - CORRECT ANSWER Auscultation. Auscultation of the client's abdomen is performed next because manual manipulation of the abdomen can stimulate peristalsis and create inaccurate assessment of bowel sounds heard during auscultation. A client with a chronic infection of Hepatitis C virus (HCV) is scheduled for a liver biopsy. Which intervention should the nurse perform after the procedure? Progress activity as soon as possible. Assess for signs of bleeding and hypovolemia. Place the client in the left lateral position. Monitor blood pressure, pulse, and breathing every 4 hours. - CORRECT ANSWER Assess for signs of bleeding and hypovolemia. Assessment for signs of bleeding should be implemented because internal bleeding is the greatest risk following a liver biopsy. Having the client placed at right lateral position, not the left side, applies pressure at the biopsy site. The nurse is assessing a client admitted from the emergency department with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) Vagal stimulation. An increased level of stress. Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells. - CORRECT ANSWER Vagal stimulation. Decreased duodenal inhibition. Hypersecretion of hydrochloric acid. An increased number of parietal cells. Hypersecretion of gastric juices and an increased number of parietal cells that stimulate secretion are most often the causes of ulceration. Vagal stimulation and decreased duodenal inhibition also increase the secretion of caustic fluids. A client with heart failure is prescribed digoxin 0.125 mg PO. The client's apical heart rate is70 beats per minute, blood pressure is 125/75 mmHg, and respirations are 18 breaths per minute. Which action should the nurse implement next? Administer the medication. Inform the healthcare provider. Review the vital sign flowsheet. Reassess the apical heart rate. - CORRECT ANSWER Administer the medication. Obtaining the apical heart rate is a common parameter prior to administering digoxin, which may indicate early digoxin toxicity if the heart rate is less than 60 beats per minute, so the dose should be administered since the client is not demonstrating any signs of toxicity. A client with a recent history of blood in the stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) Obtain consent for the procedure. Initiate preoperative sedation. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure. - CORRECT ANSWER Obtain consent for the procedure. Begin fast the morning of the procedure. Administer an enema before the procedure. Provide a clear-liquid diet 48 hours before the procedure. Preoperative preparation for proctosigmoidoscopy includes obtaining the client's consent for the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure. The nurse is caring for a client who is admitted with a hemorrhagic stroke. Which nursing action should be included in the plan of care? Perform active range of motion three times daily. Monitor for Battle's sign every four hours. Teach measures to avoid the Valsalva maneuver. Maintain the head of bed in a flat position. - CORRECT ANSWER Teach measures to avoid the Valsalva maneuver. The Valsalva maneuver, straining with bowel movements while holding one's breath, increases intracerebral pressure (ICP) which may induce bleeding or rupture of cerebral blood vessels. In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning? Mid-Fowler's with knees supported. Supine with trochanter rolls to the hips. Sim's position alternated with right lateral position q2 hours. Left lateral, supine, brief periods on the right side, and prone. - CORRECT ANSWER Left lateral, supine, brief periods on the right side, and prone. After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side is recommended because it prevents impaired circulation and reduces pain. The prone position helps prevent flexion contractures of the hips and prepares the client for optimal functioning and ambulating. The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client? Prognosis after treatment is excellent. Techniques for esophageal speech are relatively easy to learn with practice. The stoma should never be covered after this type of surgery. There is a radical change in appearance as a result of this surgery. - CORRECT ANSWER There is a radical change in appearance as a result of this surgery. Radical neck dissection is the removal of lymphatic drainage channels and nodes, sternocleidomastoid muscle, spinal accessory nerve, jugular vein, and submandibular area. The overall outcome of this type of surgery causes the neck to be disfigured, so the radical change in appearance, "Alteration in body image" will be a priority in the care of this client. What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? Tell another staff member to bring extinguishing equipment to the bedside. Close the doors to the client's area when attempting to extinguish the fire. Use a bag-valve-mask resuscitator while removing the client from the area. Implement an emergency protocol to remove the client from the ventilator. - CORRECT ANSWER Use a bag-valve-mask resuscitator while removing the client from the area. A client on a ventilator should have respirations maintained with a manual bag-valve-mask resuscitator while being moved away from the oxygen wall outlet and fire source. The nurse is assessing a middle-aged male client for risk factors related to chronic illness. Which finding should the nurse assess further? Thinning hair and dry scalp. Increase in appetite and taste-bud acuity. Increase in muscle tone but decreased muscle strength. Increase in abdominal fat deposits. - CORRECT ANSWER Increase in abdominal fat deposits. An increase in the abdominal girth is a risk factor for the development of metabolic syndrome. According to the American Heart Association, men with a waist size 40 inches or larger and women 35 inches or larger double their risk factor of developing CAD and increase their chances 5Xs of developing DMII. The nurse is caring for a clie