HESI Med-Surg Block 3 Questions and Answers

HESI Med-Surg Block 3 Questions and Answers The nurse is caring for a client with a chest tube to water seal drainage that was inserted 10 days ago because of a ruptured bullae and pneumothorax. Which finding should the nurse report to the health care provider before the chest tube is removed? A. Tidaling of water in water seal chamber B. Bilateral muffled breath sounds at bases C. Temperature of 101°F D. Absence of chest tube drainage for 2 days A. Tidaling of water in water seal chamber Rationale: Tidaling (rising and falling of water with respirations) in the water seal chamber should be reported to the health care provider before the chest tube is removed to rule out an unresolved pneumothorax or persistent air leak, which is characteristic of a ruptured bullae caused by abnormally wide changes in negative intrathoracic pressure. Option B may indicate hypoventilation from chest tube discomfort and usually improves when the chest tube is removed. Option C usually indicates an infection, which may not be related to the chest tube. Option D is an expected finding. The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client's plan of care? A. Restore skin integrity. B. Prevent infection. C. Promote healing. D. Improve nutrition. B. Prevent infection. Rationale: The prevention of infection is a priority goal for this client. Gangrene is the result of necrosis (tissue death). If infection develops, there is insufficient circulation to fight the infection and the infection can result in osteomyelitis or sepsis. Because tissue death has already occurred, options A and C are unattainable goals. Option D is important but of less priority than option B. A client diagnosed with chronic kidney disease (CKD) 2 years ago is regularly treated at a community hemodialysis facility. Before the scheduled dialysis treatment, which electrolyte imbalance should the nurse anticipate? A. Hypophosphatemia B. Hypocalcemia C. Hyponatremia D. Hypokalemia B. Hypocalcemia Rationale: Hypocalcemia develops in CKD because of chronic hyperphosphatemia, not option A. Increased phosphate levels cause the peripheral deposition of calcium and resistance to vitamin D absorption needed for calcium absorption. Prior to dialysis, the nurse would expect to find the client hypernatremic and hyperkalemic, not with option C or D. The nurse is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.) A. Encourage alcohol and smoking cessation. B. Suggest supplementing diet with vitamin E. C. Promote regular weight-bearing exercises. D. Implement a home safety plan to prevent falls. E. Propose a regular sleep pattern of 8 hours nightly. Answer: A,C,D Rationale: Options A, C, and D are factors that decrease the risk for developing osteoporosis. Vitamin D and calcium are important supplements to aid in the decrease of bone loss. Regular sleep patterns are important to overall health but are not identified with a decreasing risk for osteoporosis. The nurse is preparing a 45-year-old client for discharge from a cancer center following ileostomy surgery for colon cancer. Which discharge goal should the nurse include in this client's discharge plan? A. Reduce the daily intake of animal fat to 10% of the diet within 6 weeks. B. Exhibit regular, soft-formed stool within 1 month. C. Demonstrate the irrigation procedure correctly within 1 week. D. Attend an ostomy support group within 2 weeks. D. Attend an ostomy support group within 2 weeks. Rationale: Attending a support group will be beneficial to the client and should be encouraged because adaptation to the ostomy can be difficult. This goal is attainable and is measurable. Option A is not specifically related to ileostomy care. The client with an ileostomy will not be able to accomplish option B. Option C is not necessary. The nurse is concerned about infection for a client after an esophagogastrostomy for esophageal cancer. Which actions should the nurse include in the client's plan of care? (Select all that apply.) A. Frequent oral care every 2 hours while awake. B. Use incentive spirometer every 2 hours. C. Empty contents from NG tube every 8 hours. D. Ambulate within 1 hour of return from the PACU. E. Limit visitors until postoperative day 2. Correct Answer: A,B,C Rationale: One hour post op is too soon to ambulate for this client. Visitors help support the patient and are encouraged to visit. Oral care is necessary as the client will be NPO. To decrease the risk of infection post operatively, implement routine pulmonary exercises. The client will have an NG tube in place, likely to intermittent suction, to decompress the stomach post surgery. A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. What action should the nurse immediately? A. Place the client in a 45-degree Trendelenburg position to promote cerebral blood flow. B. Turn the client prone to place pressure on the abdominal wound to help staunch the bleeding. C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. D. Put the client on the right side to apply pressure to the liver and spleen to stop hemorrhaging. C. Maintain the client in a supine position to reduce diaphragmatic pressure and visualize the wound. Rationale: Placing the client in a supine position reduces diaphragmatic pressure, thereby enhancing oxygenation, and allows for visualization of the abdominal wound. Option A compromises diaphragmatic expansion and inhibits pressoreceptor activity. Option B places the client at risk of evisceration of the abdominal wound and increased bleeding. Option D will not stop internal bleeding in the liver and spleen caused by the gunshot wound. The nurse is caring for a client who is one day post-acute myocardial infarction. The client is receiving oxygen at 2 L/min via nasal cannula and has a peripheral saline lock. The nurse notes that the client is having eight premature ventricular contractions (PVCs) per minute. Which action should the nurse take first? A. Obtain an IV pump for antiarrhythmic infusion. B. Increase the client's oxygen flow rate. C. Prepare for immediate countershock. D. Gather equipment for endotracheal intubation. B. Increase the client's oxygen flow rate. Rationale: Increasing the oxygen flow rate provides more oxygen to the client's myocardium and may decrease myocardial irritability as manifested by the frequent PVCs. Option A can be delegated and is a lower priority action than option B. Defibrillation may eventually be necessary, but option C is not the immediate treatment for frequent PVCs. Option D may become necessary if the client stops breathing but is not indicated at this time. The nurse is providing care for a client diagnosed with trigeminal neuralgia (tic douloureux). Which symptoms will the nurse be looking for in the focused assessment related to this condition? (Select all that apply.) A. Facial muscle spasms B. Sudden facial pain C. Unilateral facial weakness D. Difficulty in chewing E. Tinnitus F. Hearing difficulties Correct Answer: A,B Rationale:Trigeminal neuralgia is characterized by paroxysms of pain, similar to an electric shock, in the area innervated by one or more branches of the trigeminal nerve (cranial V). The remaining symptoms are not related to trigeminal neuralgia. The nurse witnesses a baseball player receive a blunt trauma to the back of the head with a softball. What assessment data should the nurse collect immediately? (Select all that apply.) A. Reactivity of deep tendon reflexes B. Heart rate and respiratory rate C. Memory of recent events D. Ability to open the eyes spontaneously E. Dizziness F. Ringing in the ears Correct Answer: B,C,D,E,F Rationale:The level of consciousness (LOC) should be established immediately when a head injury has occurred. Deep tendon reflexes are not an indicator of LOC or concussion. Spontaneous eye opening is a simple measure of alertness that indicates that arousal mechanisms are intact. The remaining assessments are included in the concussion protocol. What is the correct location for placement of the hands for manual chest compressions during cardiopulmonary resuscitation (CPR) on the adult client? A. Just above the xiphoid process, on the upper third of the sternum B. Below the xiphoid process, midway between the sternum and the umbilicus C. Just above the xiphoid process, on the lower third of the sternum D. Below the xiphoid process, midway between the sternum and the first rib C. Just above the xiphoid process, on the lower third of the sternum Rationale: The correct placement of the hands for chest compressions in CPR is just above the notch where the ribs meet the sternum on the lower part of the sternum. Option A is too high. Option B would not compress the heart. Option D would likely cause damage to both structures, possibly causing a puncture of the heart, and would not render effective compressions. An emaciated homeless client presents to the emergency department complaining of a productive cough, with blood-tinged sputum and night sweats. Which action is most important for the emergency department triage nurse to take for this client? A. Initiate airborne infection precautions. B. Place a surgical mask on the client. C. Don an isolation gown and latex gloves. D. Start protective (reverse) isolation precautions. A. Initiate airborne infection precautions. Rationale: This client is exhibiting classic symptoms of tuberculosis (TB), and the client is from a high-risk population for TB. Therefore, airborne infection precautions, which are indicated for TB, should be used with this client. Option B is used with droplet precautions. There is no evidence that option C or D would be warranted at this time. Which instruction is best for the nurse to provide to a client with emphysema and chronic fatigue? A. "Pace your activities and schedule rest periods." B. "Increase the amount of oxygen you use at night." C. "Obtain medical evaluation for antibiotic therapy." D. "Reduce your intake of fluids containing caffeine." A. "Pace your activities and schedule rest periods." Rationale: Manifestations of emphysema include an increase in AP diameter (referred to as a barrel chest), nail bed clubbing, and fatigue. The nurse can provide instructions to promote energy management, such as pacing activities and scheduling rest periods. Option B may result in a decreased drive to breathe. The client is not exhibiting any symptoms of infection, so option C is not necessary. Option D is less beneficial than option A. A tornado warning alarm has been activated at the local hospital. Which action should the charge nurse working on a surgical unit take first? A. Instruct the nursing staff to close all window blinds and curtains in clients' rooms. B. Move clients and visitors into the hallways and close all doors to clients' rooms. C. Visually confirm the location of the tornado by checking the windows on the unit. D. Assist all visitors with evacuation down the stairs in a calm and orderly manner. B. Move clients and visitors into the hallways and close all doors to clients' rooms. Rationale: In the event of a tornado, all persons should be moved into the hallways, away from windows, to prevent flying debris from causing injury. Although option A may help decrease the amount of flying debris, it is not safe to leave clients in rooms with closed blinds; option B is a higher priority at this time. Hospital staff should stay away from windows to avoid injury and should focus on client evacuation into hallways rather than option C. Option D is not the first action that should be taken. Which instruction should the nurse teach a female client about the prevention of toxic shock syndrome? A. "Get immunization against human papillomavirus (HPV)." B. "Change your tampon frequently." C. "Empty your bladder after intercourse." D. "Obtain a yearly flu vaccination." B. "Change your tampon frequently." Rationale:Certain strains of Staphylococcus aureus produce a toxin that can enter the bloodstream through the vaginal mucosa. Changing the tampon frequently reduces the exposure to these toxins, which are the primary cause of toxic shock syndrome. Option A helps prevent cervical cancer, not toxic shock syndrome. Option C can lessen the incidence of urinary tract infection. Option D can help prevent some individuals from contracting the flu and pneumonia, but no relationship to toxic shock syndrome has been proven. A 62-year-old client who lives alone tripped on a scatter rug resulting in a fractured hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur? C. Osteoporosis resulting from declining hormone levels Rationale: The most common cause of a fractured hip in older women is osteoporosis, resulting from reduced calcium in the bones as a result of hormonal changes in the perimenopausal years. Option A may or may not have contributed to the accident, but eye changes were not involved in promoting the hip fracture. Option B is not a common condition of older people but is associated with CKD. Although option D may result in transient ischemic attacks (TIAs) or stroke, it will not result in fragility of the bones, as does osteoporosis. A client is diagnosed with an acute small bowel obstruction and suddenly spikes a temperature of 102°F/38.9°C. What other assessments should the nurse include in the client's focused assessment? (Select all that apply.) A. Nausea and vomiting B. Loss of appetite C. Abdominal cramping D. Guarding with abdominal palpation E. Low urine output F. Cool, clammy skin Correct Answer: A,B,C,D Rationale: The client is showing signs of peritonitis with the sudden spike in temperature. Low urine output and cool clammy skin are not seen with peritonitis. Peritonitis is a medical emergency and the health care provider must be notified immediately. A home health nurse is assessing a 70-year-old male client who is convalescing at home following a hip replacement. The nurse is concerned that the client may develop pressure ulcers. Which physical characteristic of aging puts the client at risk? A. 16% increase in overall body fat B. Reduced melanin production C. Thinning of the skin, with loss of elasticity D. Calcium loss in the bones C. Thinning of the skin, with loss of elasticity Rationale: Thin nonelastic skin is an important factor in pressure formation. The proportion of body fat to lean mass increases with age and might help decrease ulcer tendency. Option B causes gray hair. Option D can contribute to broken bones, but it is probably not a factor in pressure ulcer formation. Which data would the nurse expect to find when reviewing laboratory values of an 80-year-old who is in good health overall? A. Complete blood count reveals increased white blood cell (WBC) and decreased red blood cell (RBC) counts. B. Chemistries reveal an increased serum bilirubin level with slightly increased liver enzyme levels. C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. D. Serum electrolytes reveal a decreased sodium level and increased potassium level. C. Urinalysis reveals slight protein in the urine and bacteriuria, with pyuria. Rationale: In older adults, the protein found in urine slightly rises, probably as a result of kidney changes or subclinical urinary tract infections, and clients frequently experience asymptomatic bacteriuria and pyuria as a result of incomplete bladder emptying. Laboratory findings in options A, B, and D are not considered to be normal findings in an older adult. A client with alcohol-related liver disease is admitted to the unit. Which prescription should the nurse call the health care provider about for reverification for this client? A. Vitamin K1, 5 mg IM daily B. High-calorie, low-sodium diet C. Fluid restriction to 1500 mL/day D. Nembutal sodium at bedtime for rest D. Nembutal sodium at bedtime for rest Rationale: Sedatives such as pentobarbital are contraindicated for clients with liver damage and can have dangerous consequences. Option A is often prescribed because the normal clotting mechanism is damaged. Option B is needed to help restore energy to the debilitated client. Sodium is often restricted because of edema. Fluids are restricted to decrease ascites, which often accompanies cirrhosis, particularly in the later stages of the disease. A practical nurse (PN) tells the charge nurse in a long-term facility that she does not want to be assigned to one particular resident. She reports that the male client keeps insisting that she is his daughter and begs her to stay in his room. What is the best managerial decision? A. Notify the family that the resident will have to be discharged if his behavior does not improve. B. Notify administration of the PN's insubordination and need for counseling about her statements. C. Ask the PN what she has done to encourage the resident to believe that she is his daughter. D. Reassign the PN until the resident can be assessed more completely for reality orientation. D. Reassign the PN until the resident can be assessed more completely for reality orientation. Rationale: Temporary reassignment is the best option until the resident can be examined and his medications reviewed. He may have worsening cerebral dysfunction from an infection or electrolyte imbalance. Option A is not the best option because the family cannot control the resident's actions. The administration may need to know about the situation, but not as a case of insubordination. Implying that the PN is somehow creating the situation is inappropriate until a further evaluation has been conducted. A client is being discharged following radioactive seed implantation for prostate cancer. What is the most important information that the nurse should provide to this client's family? A. Follow exposure precautions. B. Encourage regular meals. C. Collect all urine. D. Avoid touching the client. A. Follow exposure precautions. Rationale: Clients being treated for prostate cancer with radioactive seed implants should be instructed regarding the amount of time and distance needed to prevent excessive exposure that would pose a hazard to others. Option B is a good suggestion to promote adequate nutrition but is not as important as option A. Option C is unnecessary. Contact with the client is permitted but should be brief to limit radiation exposure. A client with type 2 diabetes takes metformin daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A. NPO except for metformin and regular snacks B. NPO except for oral antidiabetic agent C. Novolin N insulin subcutaneously twice daily D. Regular insulin subcutaneously per sliding scale D. Regular insulin subcutaneously per sliding scale Rationale: Regular insulin dosing based on the client's blood glucose levels (sliding scale) is the best method to achieve control of the client's blood glucose while the client is NPO and coping with the major stress of surgery. Option A increases the risk of vomiting and aspiration. Options B and C provide less precise control of the blood glucose level. The nurse is providing care to a client with a central venous catheter. The health care provider orders multiple labs. Using the discard method, what steps will the nurse use to draw the blood samples? (Select all that apply.) A. Prepare the catheter hub with an antiseptic solution according to facility protocol. B. Attach a syringe to the hub containing 2 mL of normal saline and flush the line. C. Attach the vacutainer sleeve or 20 mL syringe to the catheter hub. D. Withdraw waste blood and discard it in an appropriate container. E. Draw the amount of blood needed for the laboratory samples. F. Flush the line with no more than 2 mL of normal saline to flush the line. Correct Answer: A,C,D,E Rationale: The amount of normal saline flush solution is incorrect. Two milliliters is too small an amount. The minimum amount is 5 mL, or according to the policies of the institution. The remaining steps are correct. The nurse is completing an admission interview for a client with Parkinson disease. Which question will provide additional information about manifestations that the client is likely to experience? A. "Have you ever experienced any paralysis of your arms or legs?" B. "Do you have frequent blackout spells?" C. "Have you ever been frozen in one spot, unable to move?" D. "Do you have headaches, especially ones with throbbing pain?" C. "Have you ever been frozen in one spot, unable to move?" Rationale: Clients with Parkinson disease frequently experience difficulty in initiating, maintaining, and performing motor activities. They may even experience being rooted to the spot and unable to move. Parkinson disease does not typically cause option A, B, or D. The nurse is administering a nystatin suspension for stomatitis. Which instruction will the nurse provide to the client when administering this medication? A. "Hold the medication in your mouth for a few minutes before swallowing it." B. "Do not drink or eat milk products for 1 hour prior to taking this medication." C. "Dilute the medication with juice to reduce the unpleasant taste and odor." D. "Take the medication before meals to promote increased absorption." A. "Hold the medication in your mouth for a few minutes before swallowing it." Rationale: Nystatin suspension is prescribed for fungal infections of the mouth. The client should swish the medication in the mouth for 2 minutes and then swallow. Option B does not affect administration of this medication. The medication should not be diluted because this will reduce its effectiveness. Option D is not necessary. The post-operative client states to the nurse, "I hate the feeling of those compression stockings as they inflate and deflate all the time. It keeps me awake." What is the nurse's best response? A. "They are for your own good." B. "Your health care provider ordered them. You have no choice but to wear them." C. "They are to help prevent blood clots. Do don't want that to happen, do you?" D. "Tell me what you know about the intermittent compression stockings." D. "Tell me what you know about the intermittent compression stockings." Rationale: The purpose of the intermittent compression stockings is to decrease the risk of blood clots forming in the legs. By assessing the client's knowledge about the devise, the nurse can determine if the client is aware of the potential for blood clots and the sequela that clots have. By answering "They are for your own good," the nurse dismisses the client's concerns. Having no choice about treatment does not acknowledge client autonomy. The "Do you want that to happen to you" is a statement using coercion by fear. An older client comes to the outpatient clinic complaining of left calf pain. The nurse notices a reddened area on the calf of the right leg that is warm to the touch, and the nurse suspects that the client may have thrombophlebitis. Which additional assessment is most important for the nurse to perform? A. Measure the client's calf circumference. B. Auscultate the client's breath sounds. C. Observe for ecchymosis and petechiae. D. Obtain the client's blood pressure. B. Auscultate the client's breath sounds. Rationale: All these techniques provide useful assessment data. The most important is to auscultate the client's breath sounds because the client may have a pulmonary embolus secondary to the thrombophlebitis. Option A may provide data that support the nurse's suspicion of thrombophlebitis. Option C is the least helpful assessment because bruising is not a typical finding associated with thrombophlebitis. Option D is always useful in evaluating the client's response to a problem but is of less immediate priority than breath sound auscultation. The nurse assesses a postoperative client whose skin is cool, pale, and moist. The client is very restless and has scant urine output. Oxygen is being administered at 2 L/min, and a saline lock is in place. Which action should the nurse take first? A. Measure the urine specific gravity. B. Obtain IV fluids for infusion per protocol. C. Prepare for insertion of a central venous catheter. D. Auscultate the client's breath sounds. B. Obtain IV fluids for infusion per protocol. Rationale: The client is at risk for hypovolemic shock because of the postoperative status and is exhibiting early signs of shock. A priority intervention is the initiation of IV fluids to restore tissue perfusion. Options A, C, and D are all important interventions but are of lower priority than option B. During assessment of a client in the intensive care unit, the nurse notes that the client's breath sounds are clear on auscultation, but jugular vein distention and muffled heart sounds are present. Which action should the nurse take first? A. Prepare the client for a pericardial tap. B. Administer intravenous furosemide. C. Assist the client to cough and breathe deeply. D. Instruct the client to restrict oral fluid intake. A. Prepare the client for a pericardial tap. Rationale: The client is exhibiting symptoms of cardiac tamponade, a collection of fluid in the pericardial sac that results in a reduction in cardiac output, which is a potentially fatal complication of pericarditis. Treatment for tamponade is a pericardial tap. Lasix IV is not indicated for treatment of pericarditis. Because the client's breath sounds are clear, option C is not a priority. Fluids are frequently increased in the initial treatment of tamponade to compensate for the decrease in cardiac output, but this is not the same priority as option A. The nurse receives the client's next scheduled bag of TPN labeled with the additive NPH insulin. Which action should the nurse implement? A. Hang the solution at the current rate. B. Refrigerate the solution until needed. C. Prepare the solution with new tubing. D. Return the solution to the pharmacy. D. Return the solution to the pharmacy. Rationale: Only regular insulin is administered by the IV route, so the TPN solution containing NPH insulin should be returned to the pharmacy. Options A, B, and C are not indicated because the solution should not be administered. While at a home game, the mother of a 6-year-old is heard screaming, "My child is having an asthma attack! Can anyone help?" The nurse arrives and finds the child gasping for breath with circumoral cyanosis. What are the nurse's next actions? (Select all that apply.) A. Yell, "Call 911." B. Ask the mother if she has the child's bronchodilator. C. Start cardiopulmonary respirations. D. Ask the mother if the child is allergic to bee stings. E. Stay with the child and mother until the ambulance arrives. F. Sit the child straight up in Fowler's position. Correct Answer: A,B,E,F Rationale:CPR is not needed at this time as the child is still moving air. An allergy to bee stings is related to anaphylactic shock, which is not the situation here. The remaining actions are correct for asthma. The clinic nurse is teaching a client with osteoarthritis to the knees bilaterally about self-care. Which teaching points will the nurse include in the client's plan of care? (Select all that apply.) A. Apply heat packs to your knees as needed for pain. B. Support your knees while you are in bed with a pillow or a rolled towel. C. Take 1000 mg of acetaminophen every 4 hours, as needed for pain. D. Walk no less than 3 miles every day. E. Get 7 to 8 hours of sleep every night. F. Eat a balanced diet, including fish with Omega-3 fatty acids. Correct Answer: A,B,E,F Rationale: The maximum daily dose of acetaminophen is 4 g, the instruction includes up to 6 g/per day. The best type of exercise does not place additional stress on the knee joints, such as biking or swimming. Apply heat to increase circulation and ice packs to decrease swelling. Support to the knees can take the strain off of the joint. Getting rest will help with coping with the pain of the disease. Eating a balanced diet may help with weight loss; additional weight places strain on the joint. An older client is admitted with a diagnosis of bacterial pneumonia. Which symptom should the nurse report to the health care provider after assessing the client? A. Leukocytosis and febrile B. Polycythemia and crackles C. Pharyngitis and sputum production D. Confusion and tachycardia D. Confusion and tachycardia Rationale: The onset of pneumonia in the older client may be signaled by general deterioration, confusion, increased heart rate, and/or increased respiratory rate. Options A, B, and C are often absent in the older client with bacterial pneumonia. When assigning clients on a medical-surgical floor to an RN and a PN, it is best for the charge nurse to assign which client to the PN? A. A young adult with bacterial meningitis with recent seizures B. An older adult client with pneumonia and viral meningitis C. A female client in isolation with meningococcal meningitis D. A male client 1 day postoperative after drainage of a brain abscess B. An older adult client with pneumonia and viral meningitis Rationale: The most stable client is option B. Options A, C, and D are all at high risk for increased intracranial pressure and require the expertise of the RN for assessment and management of care. The clinic nurse is providing post-operative teaching for a client scheduled for a myringoplasty. Which client statements indicate to the nurse that the teaching has been effective? (Select all that apply.) A. "I can wash my hair in the shower when I get home." B. "I will avoid forceful and deep coughing until my post-op checkup." C. "I must lay flat on my non-operative side for the first 12 hours after surgery." D. "My hearing may be less or muffled until the packing comes out." E. "I need to only take the first two doses of antibiotics and save the rest for another time." Correct Answer: B,C,D Rationale: The client must keep the ear bandage clean and dry until the packing is removed. Showering and hair washing is discouraged. As with all prescriptions for antibiotics, the client must take the full course of treatment. The remaining client statements do indicate effective teaching. The nurse is providing care to a client admitted to the emergency room with a blood glucose level of 40 mg/dL and is semiconscious. What are the nurse's next actions? (Select all that apply.) A. Place 4 sugar cubes under the tongue. B. Place 1 tablespoon of honey in the client's cheek. C. Start an IV of Normal Saline. D. Obtain a 50% dextrose solution. E. Administer glucagon as per the standing order. F. Turn the client to the side. Correct Answer: C,D,E,F Rationale: Oral carbohydrates, such as sugar and honey, should never be given to the semiconscious or unconscious clients with low blood sugar levels, for concern for aspiration. Glucagon can be administered immediately, followed by starting an IV. Await the orders for the 50% dextrose solution. Place the client in a side lying position as there is a risk for vomiting and aspiration with these clients. Which foods will the nurse recommend for the client with tuberculosis being discharged to home? (Select all that apply.) A. Bean soup B. Spinach C. Apples D. Bananas E. Dark chocolate F. Shellfish Correct Answer: A,B,E,F Rationale: Apples and bananas are good sources of fiber but are low in protein and iron. The remaining foods are high in iron along with organ meats, all legumes, red meat, pumpkin seeds, quinoa, turkey, broccoli, and tofu. A 55-year-old male client has been admitted to the hospital with a medical diagnosis of chronic obstructive pulmonary disease (COPD). Which risk factor is the most significant in the development of this client's COPD? A. The client's father was diagnosed with COPD in his 50s. B. A close family member contracted tuberculosis last year. C. The client smokes one to two packs of cigarettes per day. D. The client has been 40 pounds overweight for 15 years. C. The client smokes one to two packs of cigarettes per day. Rationale: Smoking, considered to be a modifiable risk factor, is the most significant risk factor for the development of COPD. The exact mechanism of genetic and hereditary implications for the development of COPD is still under investigation, although exposure to similar predisposing factors (e.g., smoking or inhaling secondhand smoke) may increase the likelihood of COPD incidence among family members. Options B and D do not exceed the risks associated with cigarette smoking in the development of COPD. The nurse hears the presence of secretions in the lungs and determines the client, post thoracotomy, needs to be suctioned. What steps will the nurse include in the suctioning procedure? (Select all that apply.) A. Perform hand hygiene. B. Position in no less than a semi-Fowler's position. C. Lubricate the suction catheter with a petroleum-based product. D. Insert the catheter with the suction on. E. Listen for breath sounds. F. Hyperoxygenate the client. Correct Answer: A,B,E,F Rationale: The suction catheter does need to be lubricated, but with a water-based product, not a petroleum-based product. The suction catheter needs to be inserted with the suction off, not on. Suction should be applied intermittently while withdrawing the catheter. The remainder are steps in the suction process. A client is ready for discharge following the creation of an ileostomy. Which instruction should the nurse include in discharge teaching? A. Replace the stoma appliance every day. B. Use warm tap water to irrigate the ileostomy. C. Change the bag when the seal is broken. D. Measure and record the ileostomy output. C. Change the bag when the seal is broken. Rationale: A seal must be maintained to prevent leakage of irritating liquid stool onto the skin. Option A is excessive and can cause skin irritation and breakdown. Ileostomies produce liquid fecal drainage, so option B is not necessary. Option D is not needed. The nurse is providing care to a client after a percutaneous transluminal coronary angioplasty (PTCA). What actions will the nurse include in the client's plan of care? (Select all that apply.) A. Frequent vital signs. B. Determine if the client is allergic to aspirin. C. Assist out of bed 2 hours after return from the procedure. D. Offer fluids of choice. E. Assess distal pulses on the side of the procedure. F. Monitor infusion of IV nitroglycerine. Correct Answer: A,B,D,F Rationale: The client's incisional leg needs to stay straight for 6 to 8 hours to decrease the risk of hemorrhage from the incision site. Pulses must be assessed bilaterally for a point of comparison. The remaining actions are included in the care plan for the client after a PTCA. A client with congestive heart failure and atrial fibrillation develops ventricular ectopy with a pattern of 8 ectopic beats/min. Which action should the nurse take based on this observation? A. Assess for bilateral jugular vein distention. B. Increase oxygen flow via nasal cannula. C. Administer PRN furosemide. D. Auscultate for a pleural friction rub. B. Increase oxygen flow via nasal cannula. Rationale: This client should have the oxygen flow immediately increased to promote oxygenation of the myocardium. Ventricular ectopy, characterized by multiple PVCs, is often caused by myocardial ischemia exacerbated by hypokalemia. The nurse would expect the client in congestive heart failure to have some degree of option A, which does not exacerbate the ectopy. Option C could create a more severe hypokalemia, which could increase the ectopy. The client is not exhibiting signs of option D. The nurse on a medical-surgical unit is receiving a client from the postanesthesia care unit (PACU) with a Penrose drain. Before choosing a room for this client, which information is most important for the nurse to obtain? A. If suctioning will be needed for drainage of the wound B. If the family would prefer a private or semiprivate room C. If the client also has a Hemovac in place D. If the client's wound is infected D. If the client's wound is infected Rationale: The fact that the client has a Penrose drain should alert the nurse to the possibility that the surgical wound is infected. Penrose drains provide a sinus tract or opening and are often used to provide drainage of an abscess. To avoid contamination of another postoperative client, it is most important to place any client with an infected wound in a private room. A Penrose drain does not require option A. Although option B is helpful information, it does not have the priority of option D. A Hemovac is used to drain fluid from a dead space and is not a determinant for the room assignment. The nurse is counseling a healthy 30-year-old female client regarding osteoporosis prevention. Which activity would be most beneficial in achieving the client's goal of osteoporosis prevention? A. Cross-country skiing B. Scuba diving C. Horseback riding D. Kayaking A. Cross-country skiing Rationale: Weight-bearing exercise is an important measure to reduce the risk of osteoporosis. Of the activities listed, cross-country skiing includes the most weight-bearing, whereas options B, C, and D involve less. The nurse observes ventricular fibrillation on telemetry and, on entering the client's bathroom, finds the client unconscious on the floor. Which action should the nurse take first? A. Administer an antidysrhythmic medication. B. Start cardiopulmonary resuscitation. C. Prepare for mechanical ventilation. D. Assess the client's pulse oximetry. B. Start cardiopulmonary resuscitation. Rationale: Ventricular fibrillation is a life-threatening dysrhythmia, and CPR should be started immediately until the crash cart arrives. Options A and C are appropriate, but CPR is the priority action until a defibrillator is available, which is the most effective treatment for ventricular fibrillation. The client is dying, and option D does not address the seriousness of this situation. Which content about self-care should the nurse include in the teaching plan of a female client who has genital herpes? (Select all that apply.) A. Encourage annual physical and Pap smear. B. Take antiviral medication as prescribed. C. Use condoms to avoid transmission to others. D. Warm sitz baths may relieve itching. E. Use Nystatin suppositories to control itching. F. Use a douche with weak vinegar solution to decrease itching. Correct Answer: A,B,C,D Rationale: The nurse should include (A, B, C, and D) in the teaching plan of a female client with genital herpes. (E) is specific for Candida infections, and option (F) is used to treat Trichomonas. Client census is often used to determine staffing needs. Which method of obtaining census determination for a particular unit provides the best formula for determining long-range staffing patterns? A. Midnight census B. Oncoming shift census C. Average daily census D. Hourly census C. Average daily census Rationale: An average daily census is determined by trend data and takes into account seasonal and daily fluctuations, so it is the best method for determining staffing needs. Options A and B provide data at a certain point in time, and that data could change quickly. It is unrealistic to expect to obtain an hourly census, and such data would only provide information about a certain point in time. A postoperative client receives a Schedule II opioid analgesic for pain. Which assessment finding requires the most immediate intervention by the nurse? A. Hypoactive bowel sounds with abdominal distention B. Client reports continued pain of 8 on a 10-point scale C. Respiratory rate of 12 breaths/min, with O2 saturation of 85% D. Client reports nausea after receiving the medication C. Respiratory rate of 12 breaths/min, with O2 saturation of 85% Rationale: Administration of a Schedule II opioid analgesic can result in respiratory depression, which requires immediate intervention by the nurse to prevent respiratory arrest. Options A, B, and D require action by the nurse but are of less priority than option C. The client is return demonstrating wrapping of the left limb amputated above the knee. The nurse evaluates the client is starting the wrapping method correctly when the client places the end of the bandage at which point? A. Around the waist B. At the inner aspect of the left stump C. At the outer aspect of the left stump D. At the left groin area A. Around the waist Rationale: The waist is the anchor point for the bandage for an above the knee amputation. A client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last 2 hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube 5 cm. D. Administer an intravenous antiemetic as prescribed. B. Reposition the client on her side. Rationale: The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention, repositioning the client, should be attempted first, followed by options A and C, unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require option D. A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A. Pedal pulses will be weak or absent in the left foot. B. The client will state that the left foot is usually warm. C. Flexion and extension of the left foot will be limited. D. Capillary refill of the client's left toes will be brisk. A. Pedal pulses will be weak or absent in the left foot. Rationale: Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses. The client with diabetes experiences vascular scarring as a result of atherosclerotic changes in the peripheral vessels. This results in compromised perfusion to the dependent extremities, which further delays wound healing in the affected foot. Although flexion and extension may be limited, depending on the degree of damage, this is not always the case. Options B and D are signs of adequate perfusion of the foot, which would not be expected in this client. Which nursing action is necessary for the client with a flail chest? A. Withhold prescribed analgesic medications. B. Percuss the fractured rib area with light taps. C. Avoid implementing pulmonary suctioning. D. Encourage coughing and deep breathing. D. Encourage coughing and deep breathing. Rationale: Treatment of flail chest is focused on preventing atelectasis and related complications of compromised ventilation by encouraging coughing and deep breathing. This condition is typically diagnosed in clients with three or more rib fractures, resulting in paradoxic movement of a segment of the chest wall. Option C should not be avoided because suctioning is necessary to maintain pulmonary toilet in clients who require mechanical ventilation. Option A should not be withheld. Option B should not be applied because the fractures are clearly visible on the chest radiograph. For the client undergoing hemodialysis, the nurse suspects the client has an air embolism. What symptoms lead the nurse to this conclusion? (Select all that apply.) A. Dyspnea B. B/P 168/92 mm Hg C. Chest pain D. Anxiety E. O2 saturation of 98% F. Blue nail beds Correct Answer: A,C,D,F Rationale: For the client experiencing an air embolism, the nurse will see hypotension and not hypertension. The O2 saturation will also fall with an air embolism. The remaining are signs of an air embolism. The nurse notes that the client's drainage has decreased from 50 to 5 mL/hr 12 hours after chest tube insertion for hemothorax. What is the best initial action for the nurse to take? A. Document this expected decrease in drainage. B. Clamp the chest tube while assessing for air leaks. C. Milk the tube to remove any excessive blood clot buildup. D. Assess for kinks or dependent loops in the tubing. D. Assess for kinks or dependent loops in the tubing. Rationale: The least invasive nursing action should be performed first to determine why the drainage has diminished. Option A is completed after assessing for any problems causing the decrease in drainage. Option B is no longer considered standard protocol because the increase in pressure may be harmful to the client. Option C is an appropriate nursing action after the tube has been assessed for kinks or dependent loops. When developing a discharge teaching plan for a client after the insertion of a permanent pacemaker, the nurse writes a goal of "The client will verbalize symptoms of pacemaker failure." Which behavior indicates that the goal has been met? A. The client demonstrates the procedures to change the rate of the pacemaker using a magnet. B. The client carries a card in his wallet stating the type and serial number of the pacemaker. C. The client tells the nurse that it is important to report redness and tenderness at the insertion site. D. The client states that changes in the pulse and feelings of dizziness are significant changes. D. The client states that changes in the pulse and feelings of dizziness are significant changes. Rationale: Changes in pulse rate and/or rhythm may indicate pacer failure. Feelings of dizziness may be caused by a decreased heart rate, leading to decreased cardiac output. The rate of a pacemaker is not changed by a client, although the client may be familiar with this procedure as explained by his health care provider. Option B is an important step in preparing the client for discharge but does not demonstrate knowledge of the symptoms of pacer failure. Option C indicates symptoms of possible incisional infection or irritation but does not indicate pacer failure. What is the most important nursing priority for a client who has been admitted for a possible kidney stone? A. Reducing dairy products in the diet B. Straining all urine C. Measuring intake and output D. Increasing fluid intake B. Straining all urine Rationale: Straining all urine is the most important nursing action to take in this case. Encouraging fluid intake is important for any client who may have a kidney stone, but it is even more important to strain all urine. Straining urine will enable the nurse to determine when the kidney stone has been passed and may prevent the need for surgery. Option C is not the highest priority action. Option A is usually not recommended until the stone is obtained and the content of the stone is determined. Even then, dietary restrictions are controversial. The nurse is teaching a group of elders at a senior center. Which is the most significant safety implication for this group that the nurse will include in the teaching plan? A. Change in height B. Hair loss C. Stooped posture D. Age spots C. Stooped posture Rationale: Stooped posture results in the upper torso becoming the center of gravity for older persons. The center of gravity for adults is the hips. However, as a person grows older, a stooped posture is common because of changes caused by osteoporosis and normal bone degeneration. Furthermore, the knees, hips, and elbows flex. This age-related change can put the older adult at risk for falls. Options A, B, and D are age-related changes but are not high safety concerns. The nurse is preparing a teaching plan for a group of healthy adults. Which individual is most likely to maintain optimum health? A. A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs B. An accountant whose blood pressure averages 140/96 mm Hg and who says he does not have time to exercise C. A stock broker whose total serum cholesterol level dropped to 290 mg/dL with diet modifications D. A recovering IV heroin user who contracted hepatitis more than 10 years ago A. A teacher whose blood glucose levels average 126 mg/dL daily with oral antidiabetic drugs Rationale: The diabetic teacher has assumed responsibility for self-care, so among those listed, he or she is the most likely to maintain optimum health. Option B has expressed a lack of interest in health promotion. Option C continues to demonstrate a high-risk cholesterol level despite a reported attempt at dietary modifications. Previous IV drug use and a history of hepatitis make this individual a health risk despite the fact that the individual is in recovery. The nurse is assessing a client with acute pancreatitis. Which finding requires the most immediate intervention by the nurse? A. The client's amylase level is three times higher than the normal level. B. The client has a carpal spasm when taking a blood pressure. C. On a 1 to 10 scale, the client tells the nurse that her epigastric pain is at 7. D. The client states that she will continue to drink alcohol after going home. B. The client has a carpal spasm when taking a blood pressure. Rationale: A positive Trousseau sign indicates hypocalcemia and always requires further assessment and intervention, regardless of the cause (40% to 75% of those with acute pancreatitis experience hypocalcemia, which can have serious, systemic effects). A key diagnostic finding of pancreatitis is serum amylase and lipase levels that are two to five times higher than the normal value. Severe boring pain is an expected symptom for this diagnosis, but dealing with the hypocalcemia is a priority over administering an analgesic. Long-term planning and teaching do not have the same immediate importance as a positive Trousseau sign. A client who is receiving an angiotensin-converting enzyme (ACE) inhibitor for hypertension calls the clinic and reports the recent onset of a cough to the nurse. Which action should the nurse take first? A. Advise the client to come to the clinic immediately for further assessment. B. Instruct the client to discontinue use of the drug and to make an appointment at the clinic. C. Suggest that the client learn to accept the cough as a side effect to a necessary prescription. D. Encourage the client to keep taking the drug until seen by the health care provider. D. Encourage the client to keep taking the drug until seen by the health care provider. Rationale: Coughing is a common side effect of ACE inhibitors and is not an indication to discontinue the medication. Immediate evaluation is not needed. Antihypertensive medications should not be stopped abruptly because rebound hypertension may occur. Option C is demeaning because the cough may be very disruptive to the client, and other antihypertensive medications may produce the desired effect without the adverse effect. The nurse is performing a skin assessment on a client who is transferred from a long-term care facility to an in-patient hospital unit. The client is unable to move independently while in bed. The nurse observes reddened areas to the sacrum and on the heals bilaterally. What is the next nursing action? A. Document the size and shape of the reddened areas. B. Massage the reddened areas with a hospital-approved lotion. C. Call the nurse from the transferring facility to determine the client's baseline. D. Culture the wounds. A. Document the size and shape of the reddened areas. Rationale: The nurse must document any pressure wounds upon admission to establish the client's baseline and for insurance purposes. Insurance will not reimburse from hospital-acquired pressure ulcers. Massaging is not recommended as it may dislodge the existing tissue. A call is not a good use of the nurse's time as the pressure ulcers exist upon transfer, and the baseline is determined upon admission. The health care provider will order cultures, if needed. A client is placed on a mechanical ventilator following a cerebral hemorrhage. What are the priority nursing actions for this client? (Select all that apply.) A. Assess lung sounds. B. Look for equal and bilateral expansion of the chest. C. Monitor skin color. D. Evaluate the need for suctioning. E. Tell the family the client is expected to fully recover. F. Make sure the ventilator alarms are set. Correct Answer: A,B,C,D,F Rationale: The outcome of the client is too early to relay to the family. The nurse must not offer false reassurance. The remaining actions are correct for a client on a ventilator. In caring for a client with acute diverticulitis, which assessment data warrants an immediate nursing action? A. The client has a rigid hard abdomen and elevated WBC. B. The client has left lower quadrant pain and an elevated temperature. C. The client is refusing to eat any of the meal and is complaining of nausea. D. The client has not had a bowel movement in 2 days and has a soft abdomen. A. The client has a rigid hard abdomen and elevated WBC. Rationale: A hard rigid abdomen and elevated WBC is indicative of peritonitis, which is a medical emergency and should be reported to the health care provider immediately. Options B and C are expected clinical manifestations of diverticulitis. Option D does not warrant immediate intervention. A central venous catheter has been inserted via a jugular vein, and a radiograph has confirmed placement of the catheter. A prescription has been received for a medication STAT, but IV fluids have not yet been started. Which action should the nurse take prior to administering the prescribed medication? A. Assess for signs of jugular venous distention. B. Obtain the needed intravenous solution. C. Flush the line with heparinized solution. D. Flush the line with normal saline. D. Flush the line with normal saline. Rationale: Medication can be administered via a central line without additional IV fluids. The line should first be flushed with a normal saline solution to ensure patency. Insufficient evidence exists on the effectiveness of flushing catheters with heparin. Option A will not affect the decision to administer the medication and is not a priority. Administration of the medication STAT is of greater priority than option B. The nurse is assessing a 75-year-old client for symptoms of hyperglycemia. Which symptom of hyperglycemia is an older adult most likely to exhibit? A. Polyuria B. Polydipsia C. Weight loss D. Infection D. Infection Rationale: Signs and symptoms of hyperglycemia in older adults may include fatigue, infection, and evidence of neuropathy (e.g., sensory changes). The nurse needs to remember that classic signs and symptoms of hyperglycemia, such as options A, B, and C and polyphagia, may be absent in older adults.