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Evolve Comprehensive Exam: HESI (Answered+ Rationale) Updated Spring 2022/2023.

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Evolve Comprehensive Exam (Hesi) A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is at least likely to exacerbate asthma? A male client who has been taking propranolol ( inderal) for 18 months tells the nurse the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the use provide? A client who is taking clonidine ( Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make? The nurse is preparing to admister atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain th reason for the prescribed medication. What response is best for the nurse to provide? An 80 year old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urniary retention in this geriatric client. ? The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter Which action should the nurse implement? following an emergency Cesarean delivery the nurse encourages the new mother to breastfed her newborn . the client asks why she should breastfeed now. Which info should the nurse provide? The nurse identifies a clients needs and formulates th nursing problem of " Imbalancee nutrition: Less than body requirements, related to mental impairment and decreased intkae, as evidence by increasing confusion and weight loss of more than 30 pounds over the last 6 months. " which short-term goal is best for this client? the nursie is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30pm. Which client response should the nurse document that indicates a successful outcome? a client who has active tuberculosis ( TB) is admitted to the medical unit. What action is most important for the nurse to implement? A client is receiving atonal (tenormin) 25 mg PO after a myocardial infraction. The nurse determines the clinents apical pulse is 65 beats per minute. What action should the nurse implement next? A 6 year old child is alert but quiet when brought to the emergency center with periobital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with the basilar skull fracture? The nurse is assessing a client who complains of weight loss, racing heart rate and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retrace, and a staring expression. These findings are consistent with which disorder? The nurse is assessing an older adult client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding? The nurse obtains the pluse rate of 89 beats/min for an infant before administering digoxin (Lanoxin) which action should the nurse take? The nurse is developing a teaching plan for an adolescent with a milwaukee brace. Which instruction should the nurse include? A 9 year old is hospitalized for the neutropenia and is placed in reverse isolation. The child asks the nurse " why do you have to wear a gown and mask when you are in my room?" How should the nurse respond? A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement? The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clincail picture ? . Renal failure causes anemia and hyperphosphatemia, not (D). A 56 year old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for this client? Which info should the nurse provide a client who has undergone cryrosyrgery for stage 1A cerviacl cancer? the nurse is preparing a client for schedules surgical procedure. What client statement should the nurse report to the healthcare provider.? The nurse determines that a clients body weight is 105A% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, " Imbalanced nutrition: More than body requirements ? " The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? During the physical assessment, which finding should the nurse recognize as a normal finding? When documenting assessment data, which statement should the nurse record in the narrative nursing notes? . A female client reports to the nurse that her sleep was interrupted by " thoughts of anger towards my husband" What type of thoughts is the client having? The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message , which nursing action is best for the nurse to take? A primipara with a breech presentation is in the transition phase pf labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client? The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. what is the priority expected outcome for these classes? Clinical portfolios are being introduced into the performance apprasial process for the nurses employed at the hospital. What should the nurse-manager request that each staff nurse include in the portfolio? a work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to besot effective in developing the new care map? the scope of professional nursing practice is determined by rules promulgated by which organization.? An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding? When meeting with the client and the family, which nursing intervention demonstrates the nurses role as collaborator of care? Preoperatively, a client is to receive 75mg of meperidine (demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer? A low potassium diet is prescribed for a client what foods should the nurse try to avodi? A client is admitted with a medical diagnosis of addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations? The nurse plans to suction a male client. Who has just undergone right pneumonectomy for cancer of th lung. Secretions can be seen around the endotracheal tube and the nurse osculates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction? the nurse is caring for critically ill clients. Which should be monitored for the development of neutogenic shock? A client with? Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? The nurse is teaching staff in a long term - facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension? A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat diet,low calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. what intervention should the nurse implement? A child with tetrology of ballot suffers a hyper cyanotic episode. Which immediate action by the nurse can lessen the symptoms of this " TET" spell? A client with metastatic cancer is preparing to make a decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate? After eye drops are instilled, which instruction should the nurse provide to the client? the nurse is preparing to administer IV fluid to a client with strict fluid restriction. IV tubing with which feature is most important for the nurse to select? Lasix 20 mg PO is prescirbed for a client at 0600. the medication is available in a sound tablet of 40 mg. Before breaking the tablet, what action should the nurse take? Which assessment finding should make the nurse suspect that a 21 year old male client is taking anabolic steroids Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsycotioc medication? Prior ro the discharge of a family 4-day old newborn the nurse is collecting the blood specimens to screen for phenylketonuria(PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test? which nursing intervention is an example of a competent preformance criterion for an occupational and environmental health nurse? A client is being admitted to the medical unit form the emergency department after having a chest tube inserted. What equipment should be brought to this client's room? The nurse identifies bright-red drainage about 6 cam in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next?? The nurse is planning care for a client who is having abdominal surgery. To achieve postoperative outcomes, the nurse includes interventions that promote progressive mobilization, such a turn, cough, deep breathe, and early ambulation. Which additional intervention should the nurse include? Prior to a cardiac cauterization, which activity should the nurse have the client practice? The nurse is caring for a client who is one day postoperative after a left total knee arthroplasty (TKA) which intervention should the nurse include in the plan of care? A client with osteomyelitis is scheduled for surgery to treat the infection which has not responded to three months of intravenous antibiotic therapy. The client asks the nurse why surgery is necessary. Which is the best response for the nurse to provide? After one month of short-term corticosteroid therapy, a client with an acute exacerbation of rheumatiod arthritis returns to the clinic for a follow up visit. Which laboratory finding should the nurse review for a therapeutic response? A male client who lives in an area endemic with lyme disease asks the nurse what to do if he thinks he may have been exposed. Which response should the nurse provide? The nurse is planning a teaching program about prenatal care for a diverse ethnic group of clients. Which factor is most influential for the acceptance of the healthcare practices? A female client tells the nurse that her home pregnancy test is positive and her last menstrual period (LMP) was febuary 14. the client wants to know the expected date of birth (EDB) how should the nurse respond? Using Nägele's rule to calculate EDB, subtract 3 months and add 7 days to the first day of the last normal menstrual period. The client's LMP is February 14, so less 3 months + 7 days is November 21 (B) of the next year. (A, C, and D) are inaccurate. Two hours after vaginal devilry of a 7-pound 3 ounces infant, a clients fundus is 3 cm above the umbilicus, boggy, and located to the right of midline. Which action should the nurse take first? The clinic nurse identifies an elevation in the results of the triple marker screening test for a client who id in the first trimester of pregnancy . which action should the nurse prepare the client for? Which finding should the nurse idnetify as an early clinical manifestation of neonatal encephalopathy related to hyperbilirubinemia? Which action should the nurse implement when administering a prescription drug that should be given on an empty stomach? cramps. Which assessment information should the nurse obtain next? Which approach should the nurse use when preparing a toddler for a procedure? Prenatal diagnostic testing is recommended for a couple expecting their first child who have a family history of congenital disorders. The couple tells the nurse that they are opposed to abortion for religious reasons. Which concept should the nurse consider when responding to this couple? A nurse is planning to teach self-care measures to a female client about prevention of yeast infections. Which instructions should the nurse provide? During a well-woman exam, a sexually active female client asks the nurse about a recent vaginal infection and says she is afraid she has another sexually transmitted infection. The client discloses her history of previous STI. Which condition should the nurse identify as the most prevalent STI in the United States among women? A young adult female arrives at the emergency center with a black right eye and is bleeding from the left side of her head. She reports that her boyfriend has been abusing her physically. The nurse performs a history and physical examination. How should the nurse document these findings? A nurse takes a female client to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." How should the nurse respond? . A female client tells the nurse that she does not know which day of the month is best to do breast self-exams (BSE). Which instruction should the nurse provide? The nurse is planning a wellness program aimed at primary prevention in the community. Which action should the nurse implement? What information best supports the nurse's explanation for promoting the use of alternative or complementary therapies? A client who is one week postoperative after an aortic valve replacement suddenly develops severe pain in the left leg. On assessment, the nurse determines that the client's leg is pale and cool, and no pulses are palpable in the left leg. After notifying the healthcare provider, which action should the nurse take? A nurse whose tuberculosis (TB ) skin test result reveals an 8 mm induration obtains a negative chest radiograph, which indicates latent tuberculosis. The employee-health nurse should implement which intervention for this nurse? To assess a client's pupillary response to accommodation, a nurse should perform which activity? A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide? The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond? Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess? Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? The client A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take? A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse-manager take? A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem? The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema? During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client? A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement? In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition? The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg PO. The 10 mL vial is labeled "Mucomyst 20% solution (20 grams/100 mL)." What volume of medication in milliliters should the nurse administer? (Enter numeric value only.) The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands? The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest risk for developing external otitis? A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan? A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care? Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95 mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time? A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client? After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first? When engaging in planned change on the unit, what should the nurse-manager establish first? A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation? The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function? The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding? The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement? The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide? Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers? A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide? Which information should the nurse give a client with chronic kidney disease (CKD)? The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of the phototherapy? A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.) The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take? The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation? The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem? Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict? What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period? The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment? A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any more contact with the hospital. How should the nurse respond? During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first? A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent? to co-sign this form (D). Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit? A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care? - One chronic and one acute illness The plan of care should include goals that are specific for chronic and acute illnesses. Adult-onset diabetes is a life-long chronic disease, whereas influenza is an acute illness with a short term duration (C). (A, B, and D) do not include the correct duration categories for this situation. A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor? have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide?

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HESI Hesi Comprehensive Review for the NCLEX-RN Examination - Pageburst E-Book on Kno (Retail Access Card)

Edición:2013
ISBN:9781455774746
Edición:Desconocido

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Institución: Colorado State University - Fort Collins
Grado: Science/ Medicine/ Surgery (HES207)

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Subido en: 20 de marzo de 2022
Número de páginas: 31
Escrito en: 2022/2023
Tipo: Otro
Personaje: Desconocido

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hes 207
evolve comprehensive exam hesi
evolve comprehensive exam hesi
hesi evolve comprehensive exam
a client with asthma receives a prescription for high blood pressure during a clinic visit which

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Evolve Comprehensive Exam (Hesi)
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which
prescription should the nurse anticipate the client to receive that is at least likely to exacerbate
asthma?
✅- Metoprolol Tartrate( Lopressor)

The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2
blocking agent which is also cardioselective and less likely to cause bronchoconstriction.
Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic
symptoms. Although carteolol (B) is a beta blocking agent and an effective antihypertensive
agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its
nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs,
causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive
pulmonary disorders.

A male client who has been taking propranolol ( inderal) for 18 months tells the nurse the
healthcare provider discontinued the medication because his blood pressure has been normal for
the past three months. Which instruction should the use provide?
✅- Ask the health care provider about tapering the drug dose over the next week.

Although the healthcare provider discontinued the propranolol, measures to prevent rebound
cardiac excitation, such as progressively reducing the dose over one to two weeks (C), should be
recommended to prevent rebound tachycardia, hypertension, and ventricular dysrhythmias.
Abrupt cessation (A and B) of the beta-blocking agent may precipitate tachycardia and rebound
hypertension, so gradual weaning should be recommended.

A client who is taking clonidine ( Catapres, Duraclon) reports drowsiness. Which additional
assessment should the nurse make?
✅- How long has the client been taking the medication

Drowsiness can occur in the early weeks of treatment with clonidine and with continued use
becomes less intense, so the length of time the client has been on the medication (A) provides
information to direct additional instruction. (B, C, and D) are not relevant.

The nurse is preparing to admister atropine, an anticholinergic, to a client who is scheduled for a
cholecystectomy. The client asks the nurse to explain th reason for the prescribed medication.
What response is best for the nurse to provide?
✅- Decrease the risk of bradycardia during surgery

,Atropine may be prescribed preoperatively to increase the automaticity of the sinoatrial node and
prevent a dangerous reduction in heart rate (B) during surgical anesthesia. (A, C and D) do not
address the therapeutic action of atropine use perioperatively.

An 80 year old client is given morphine sulphate for postoperative pain. Which concomitant
medication should the nurse question that poses a potential development of urniary retention in
this geriatric client. ?
✅- Tricyclic antidepressants

Drugs with anticholinergic properties, such as tricyclic antidepressants (C), can exacerbate
urinary retention associated with opioids in the older client. Although tricyclic antidepressants
and antihistamines with opioids can exacerbate urinary retention, the concurrent use of (A and B)
with opioids do not. Nonsteroidal antiinflammatory agents (D) can increase the risk for bleeding,
but do not increase urinary retention with opioids (D).

The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a
scheduled dose of verapamil (Calan) for a client with atrial flutter Which action should the nurse
implement?
✅- Admister the dose as prescribed

Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal
conduction, which slows the ventricular rate, and is used to treat atrial flutter, so (A) should be
implemented, based on the client's heart rate and blood pressure. (B and C) are not indicated. (D)
delays the administration of the scheduled dose.

following an emergency Cesarean delivery the nurse encourages the new mother to breastfed her
newborn . the client asks why she should breastfeed now. Which info should the nurse provide?
✅- Stimulate contraction of the uterus

When the infant suckles at the breast, oxytocin is released by the posterior pituitary to stimulates
the "letdown" reflex, which causes the release of colostrum, and contracts the uterus (C) to
prevent uterine hemorrhage. (A and B) do not support the client's need in the immediate period
after the emergency delivery. Although maternal-newborn bonding (D) is facilitated by early
breastfeeding, the priority is uterine contraction stimulation.

The nurse identifies a clients needs and formulates th nursing problem of " Imbalancee nutrition:
Less than body requirements, related to mental impairment and decreased intkae, as evidence by
increasing confusion and weight loss of more than 30 pounds over the last 6 months. " which
short-term goal is best for this client?
✅- Eat 50% of six small meals each day by the end of the week

,Short-term goals should be realistic and attainable and should have a timeline of 7 to 10 days
before discharge. (A) meets those criteria. (B) is nurse-oriented. (C) may be beyond the
capabilities of a confused client. (D) is a long-term goal.

the nursie is caring for a client who is unable to void. The plan of care establishes an objective
for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30pm. Which client
response should the nurse document that indicates a successful outcome?
✅- Drinks 240 mL of fluid five times during the shift.

The nurse should evaluate the client's outcome by observing the client's performance of each
expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a
fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the
designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective,
which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid
intake.

a client who has active tuberculosis ( TB) is admitted to the medical unit. What action is most
important for the nurse to implement?
✅- Assign the client to a negative air-flow room

Active tuberculosis requires implementation of airborne precautions, so the client should be
assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented
for clients in isolation with contact precautions, it is most important that air flow from the room
is minimized when the client has TB. (B) should be implemented when the client leaves the
isolation environment.

A client is receiving atonal (tenormin) 25 mg PO after a myocardial infraction. The nurse
determines the clinents apical pulse is 65 beats per minute. What action should the nurse
implement next?
✅- Administer the medication

Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate,
so the medication should be administered (C) because the client's apical pulse is greater than 60.
(A, B, and D) are not indicated at this time.

A 6 year old child is alert but quiet when brought to the emergency center with periobital
ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and
continues to assess the child for additional manifestations of a basilar skull fracture. What
assessment finding would be consistent with the basilar skull fracture?
✅- Rhinorrhoea or otorrhoea with halo sign

, Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the
mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible
meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is
consistent with orbital fractures. (B) occurs with wrenching traumas of the shoulder or arm
fractures. (C) occurs with blunt abdominal injuries.

The nurse is assessing a client who complains of weight loss, racing heart rate and difficulty
sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid
retrace, and a staring expression. These findings are consistent with which disorder? ✅- Graves
disease

This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease (A),
which is an autoimmune condition affecting the thyroid. (B, C, and D) are not associated with
these symptoms.

The nurse is assessing an older adult client and determines that the client's left upper eyelid
droops, covering more of the iris than the right eyelid. Which description should the nurse use to
document this finding? ✅- Ptosis on the left eyelid

Ptosis is the term to describe an eyelid droop that covers a large portion of the iris (A), which
may result from oculomotor nerve or eyelid muscle disorder. (B) is characterized by rapid,
rhythmic movement of both eyes. (C) is a distortion of the lens of the eye, causing decreased
visual acuity. (D) is a term used to describe a protrusion of the eyeballs that occurs with
hyperthyroidism.

The nurse obtains the pluse rate of 89 beats/min for an infant before administering digoxin
(Lanoxin) which action should the nurse take? ✅- Withhold the medication and contact the
healthcare provider

Bradycardia is an early sign of digoxin toxicity, so if the infant's pulse rate is less than 100
beats/minute, digoxin should be withheld and the healthcare provider should be notified (D).
Assessing the respiratory rate (A) is not indicated before administering Lanoxin. (B and C) place
the infant at further risk for digoxin toxicity.

The nurse is developing a teaching plan for an adolescent with a milwaukee brace. Which
instruction should the nurse include? ✅- Wear the brace over a T-shirt 23 hours a day.

Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Early
treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature, under
the neck, and against the iliac crest, so it should be worn for 23 hours per day over a T-shirt (D)

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I know how frustrating it can get with all those assignments mate. Nursing Being my main profession line, i have essential guides that are A graded, I am a very friendly person so 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