HESI RN FUNDAMENTALS EXAM

 HESI RN FUNDAMENTALS EXAM  MULTIPLE CHOICES RN STORE 1. The nurse teaching a health awareness class identifies which situation as being the highest risk factor for the development of a deep vein thrombosis (DVT)? Pregnancy 2. A client on hospice care is receiving palliative treatment. A palliative approach involves planning measures to: 1. Restore the client's health 2. Remove and dispose of the patch in an appropriate receptacle. 3.Have the family return the patch to the pharmacy for disposal. 4.Leave the patch in place for the mortician to remove. 3.A client is diagnosed with AIDS. When examining the client's oral cavity, the nurse assesses white patchy plaques on the mucosa. The nurse recognizes that this finding most likely represents what opportunistic infection? 1.Cytomegalovirus 2.Histoplasmosis 3.Candida albicans 4.Human papillomavirus 4. A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response bythe nurse? 1 "We have no record of that client on our unit. Thank you for calling." 2 "The new privacy laws prevent me from providing any client information over the phone." 3"The client has requested that no information be given out. You'll need to call the client directly." 4"It is against the hospital's policy to provide you with any information regarding any of our clients." 5.When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? 1. Negligence 2 Malpractice 3 .Breach of duty 4. False imprisonment 6.The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1. A physiological response to stress 2 A conscious defense against anxiety 3. An intentional attempt to gain attention 4. An unconscious means of reducing stress 7.A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? 1.Droplet precautions 2.Reverse isolation 3.Surgical asepsis 4Medical asepsis 8.Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. 1.Prayer 2. Hypnosis 3. Medication 4. Aromatherapy 5Guided imagery 9. A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. 1. "What is diabetes?" 2. "What will my friends think?" 3 "How do I give myself an injection?" 4. "Can you tell me how the glucose monitor works?" 5."How do I get the insulin from the vial into the syringe? 10.Place each step of the nursing process in the order that it should be used. Correct 1.Obtain client's nursing history. Correct 2.State client's nursing needs. Correct 3.Identify goalsfor care. Correct 4.Develop a plan of care. Correct 5.Implement nursing interventions. 11.In what position should the nurse place a client recovering from general anesthesia? 1. Supine 2. Side-lying 3. High Fowler 4. Trendelenburg 12.Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. 1. Difficulty in swallowing 2.Increased sensitivity to heat 3.Increased sensitivity to glare 4.Diminished sensation of pain 5.Heightened response to stimuli . 13.The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? 1. Institute the prescribed blood transfusion because the client's survival depends on volume replacement. 2. Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. 3 Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. 4. Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought 14. A female 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 two hours. What 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 an additional five centimeters. D) Administer an intravenous antiemetic prescribed for PRN use. 15.The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the rightside of the bed, and stand the client on the right foot 16.When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A) Complimentary healing practices interfere with the efficacy of the medical model of treatment. B) Conventional medications are likely to interact with folk remedies and cause adverse effects. C) Many complimentary healing practices can be used in conjunction with conventional practices. D) Conventional medical practices will ultimately replace the use of complimentary healing practices. 17.After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals. 18.The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A) The belief is held that the "evil eye" enters the child if anything cold is ingested. B) After surgery the child probably has refused all foods except broth. C) Eating broth strengthens the child's innate energy called "chi." D) Hot remedies restore balance after surgery, which is considered a "cold" condition. 19.Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A) Reassure the client that he will become accustomed to the stoma appearance in time. B) Instruct the client that the stoma will become smaller when the initial swelling diminishes. C) Offer to contact a member of the local ostomy support group to help him with his concerns. D) Encourage the client to handle the stoma equipment to gain confidence with the procedure 20.An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A) Position the client on the right side of the bed in reverse Trendelenburg. B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C) Reposition in a Sim's position with the client's weight on the anterior ilium. D) Raise the side rails on both sides of the bed and elevate the bed to waist level. 21.The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A) ½ tablet. B) 1 tablet. C) 1½ tablets. D) 2 tablets. 22.An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A) prone. B) Fowler's. C) Sims'. D) supine 23. A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified 24.While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion. 25.A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors 26.The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr D) Obtain a stat blood glucose level and notify the healthcare provider. 27.A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses 28. The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A) Genetic and familial health disorders. B) Chronic health problems. C) Reason for seeking health care. D) Undetected disorders. 29.Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A) 11,000 units. B) 13,000 units. C) 15,000 units. D) 17,000 units 30. A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A) demonstrates loss of remote memory. B) exhibits expressive dysphasia. C) has a diminished attention span. D) is disoriented to place and time. 31. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client’s oxygen saturation level is 92%. What intervention should the nurse implement? A) Decrease the flow rate to 1 L/minute. B) Discontinue the use of the nasal cannula. C) Apply lubricant to the cannula tubing. D) Place padding around the cannula tubing. 32. A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement? A) Ask a Spanish speaking staff member to talk with the family. B) Use a Spanish translation reference to interview the family. C) Close the door to client’s room to provide family privacy. D) Sit quietly with the family to offer comfort and support. 33. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze dressing covering the area. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing B) Increase the frequency of the dressing changes. C) Replace the gauze with transparent dressing. D) Leave the dressing off until consulting with the healthcare provider. 34. The healthcare provider prescribes haloperidol (Haldol) 1.5mg twice daily for a client with Tourette’s syndrome. The drug is available in a solution labeled, “2 mg/ml.” How many ml should the nurse administer? (Round to the nearest hundredth.) 0.75 35. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he can do for the swelling in his legs. Which should nurse implement? A) Encourage the client to take short walks around the block. B) Explain the need to keep the head of the bed elevated. C) Advise the client to dangle his feet during meals and before bedtime. D) Instruct the client to flex both of his feetseveral times a day. 36. The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of a deep vein thrombosis and is allergic to latex. When removing the adhesive bandages, the nurse observes skin redness surrounding the draining wound. What action should the nurse implemented? A) Replace dressing with cotton pads and silk tape. B) Measure and compare ankle-brachial pressure index. C) Obtain sample of the drainage for culture. D) Apply an antibiotic ointment to the wound. 37. The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply.) A) Retake the client’s blood pressure in the opposite arm. B) Ask another nurse to assist in assessing for an apical-radial pulse deficit. C) Assign the unlicensed assistive personal to recheck the BP in an hour. D) Immediately take 2 more readings on the same arm. E) Determine the client’s activity and feelings prior to the BP measurement. 38. A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room? A) The nurse’s stethoscope. B) Paper mask and gown. C) Bed linens D) A sputum. 39. A middle-aged male client tells the nurse that has weeks ago he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes an hour to fall asleep at night. What action should the nurse implement? A) Advice the client that lifestyle changes often take several weeks to be effective. B) Determine the amount of weight the client has lost since increasing his activity. C) Encourage the client to exercise every day to eliminate bedtime wakefulness. D) Ask the client to describe the exercise schedule that he has been following. 40. Which landmarks are useful to the nurse when administering an intramuscular injection in ventrogluteal site? A) The greater trochanter and anterior superior iliac spine. B) The knee and greater trochanter. C) D) The deltoid muscle. 41. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement? A) Determine what home remedies were used. B) Assess for the presence of an impaction. C) Obtain list of prescribed home medications. D) Evaluate stool sample for presence of blood. 42. What information is most important for the nurse to obtain in determining a client’s need for referral for obesity counseling? A) Body weight 10% over ideal body weight. B) Body mass index greater than 35. C) Daily caloric intake of 3500 calories. D) Client’s expressed desire to lose 50 pounds 43. 6.Which technique is most important for the nurse to implement when performing a physical assessment? A. A head-to-toe approach. B. The medical systems model. C. A consistent, systematic approach. D. An approach related to a nursing model. 44.A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A. Amount of liquid protein supplements consumed daily. B. Foods and liquids consumed during the past 24 hours. C. Usual weekly intake of milk products and red meats. D. Grains and legume combinations used by the client. 45. The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? A. Does not check capillary blood glucose as directed. B. Occasionally forgets to take daily prescribed medication. C. Cannot identify signs orsymptoms of high and low blood glucose. D. Eats anything and does not think diet makes a difference in health. 46.Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. The nurse will provide client instruction for daily foot care. B. The client will demonstrate proper trimming toenail technique. C. Upon discharge, the client will list three ways to protect the feet from injury. D. After instruction, the nurse will ensure the client understands foot care rationale. 47.A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. Generativity. B. Ego integrity. C. Identification. D. Valuing wisdom. 48.Which statement best describes durable power of attorney for health care? A. The client signs a document that designates another person to make legally binding healthcare decisions if client is unable to do so. B. The healthcare decisions made by another person designated by the client are not legally binding. C. Instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding. D. Directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding. 49.A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? A. Low fat and low sodium foods. B. Combination of plant proteins to provide essential amino acids. C. Limited complex carbohydrates and fiber. D. Increased amount of vitamin C and beta carotene rich foods. 50.A client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? A. The responses to biofeedback have not been well established and may be a waste of time and money. B. Biofeedback requires extensive training to retrain voluntary muscles, not involuntary responses. C. Although biofeedback is easily learned, it is mostly often used to manage exacerbation of symptoms. D. Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation. 51.A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? A. Most herbs are toxic or carcinogenic and should be used only when proven effective. B. There is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health. C. Herbs should be obtained from manufacturers with a history of quality control of their supplements. D. Herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is required during use. 52.A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? A. Sensory pattern, area, intensity, and nature of the pain. B. Trigger points identified by palpation and manual pressure of painful areas. C. Schedule and total dosages of drugs currently used for breakthrough pain. D. Sympathetic responses consistent with onset of acute pain. 53.A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? A. Continue gabapentin. B. Discontinue ibuprofen. C. Add aspirin to the protocol. D. Add oral methadone to the protocol. 54. To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? A. Can you describe where your pain is the most severe? B. What is your pain intensity on a scale of 1 to 10? C. Is your pain best described as aching, throbbing, orsharp? D. Which activities during a routine day are impacted by your pain? 55. On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription.When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment. -NEW HESI RN FUNDAMENTALS - REAL QUESTIONS&ANSWERS - HESI RN FUNDAMENTALS 1. The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? Provide written instructions that are easy to follow. 2. Which assessment finding is most significant in determining the level of assistance a client needs with personal care? Disorientation to time, place, and person 3. Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and palpation of the bladder indicates that it is distended and dull percussion. Even after assistingthe client to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the urinary catheter. 4. The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about his pain he denies having any pain. Which intervention should the nurse implement first? Askthe client what is making him grimace. 5. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first? Respiratory rate 6. The charge nurse observes a new graduate nurse demonstrate the administration of two differentliquid medications through a gastrostomy tube used for continuous feeding, as seen in the video. What actions should the nurse take? (SATA) Confirm that the nurse determined the amount of gastric residualAdd the liquid volumes when documenting fluid intake Instruct the nurse to administer each mediation separately 7. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action shouldthe nurse take nest? Apply intermittent suction 8. A client who is 2 days postoperative for thoracic surgery is complaining of incisional pain 2 hours after receiving his pain medication. He rates his pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, what action should the nurse implement? Instruct the client to use guided imagery and slow rhythmic breathing. 9. Am unlicensed assistive personnel (UAP) is assigned to help a female client with her bath who has viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the UAP? Wear gloves while giving a bath 10. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures? Puts on new gloves when entering a client’s room. 11. The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea? An older male with multiple problems, including obesity, diabetes, and hypertension. 12. It is most important for the nurse to recalculate the Braden scale for a client who has developed which problem? Urinary incontinence 13. A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths betweenthe top of the crutch and the client’s axilla. What action should the nurse take? Proceed with teaching the client how to walk with the crutches. 14. After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker, how shouldthe nurse respond? Encourage discussion about the concern and fears. 15. Prior to initiating digital removal of a fecal impaction, it isimportant for the nurse to perform which client assessment? Vital signs 16. The mother of a child with Tetrology of Fallot ask the nurse, “ Why did this happen to my baby? What did I do wrong?” Which response is most helpful? “This must be a very difficult time for you.” 17. The healthcare provider prescribes bladder irrigation to maintain patency of a client’s indwelling urinary catheter. Which intervention should the nurse implement? Use sterile syringe to irrigate the normal saline 20 ml 18. Two nurses assess a client for a pulse deficit and count an apical pulse for 72 beats/minute and a radial pulse of 88 beats/minute. What action should the nurses take? Obtain a second pulse deficit reading 19. A female who is 1 day post mastectomy is crying when the nurse enters the room. What action should the nurse take? Stay with the client in silence while touching her forearm 20. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was accidentally flushed instead of saving in the container. What intervention should the nurse initiate? Discard the urine and start another 24-hour period 21. A confused elderly male client is having trouble sleeping at night and is sometimes found wandering the hallway. What nursing intervention should the nurse implement first? Provide a back rub at bedtime 22. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save hislife. The healthcare provider knowsthe client has agood prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the nurse take? Initiate an ethics committee review of the case 23. The nurse is preparing to feed a newly admitted elderly male client who is debilitated, but is ableto respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain? Client's ability to chew and swallow 24. The nurse enters the room of a client with a Clostridium difficile infection to administer an intravenous antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning the client’sbuttocks and states the client has been incontinent with diarrhea. The UAP is wearing gloves but not a gown. What action should the nurse implement first? Tell UAP put a gown on 25. The computer documentation system shuts down while the nurse is entering the client’s physical assessment data. What should the nurse do first? Wait for notification services department of the situation 26. In assessing a client who has a nursing diagnosis ofspiritual distress, which action should thenurse take first? Assist and support the client in establishing short-term goals. 27. During transfer to the medical unit, a client who experienced an acute change in level of consciousness became increasingly confused and combative, justifying soft wrist restraints for the client’s upper and lower extremities. Which intervention is most important for the nurse to implement on admission? Determine baseline neuro status 28. (PICTURE OF EAR AND EAR DROPS) The nurse prepares to administer ear drops to an adolescent client as seen in the picture. What should the nurse do next? Pull ear auricle downward 29. The nurse measures the client’s blood pressure (BP) and notesthat it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply)Retake the pt's Bp in opposite arm** Determine the pt's activity and feelings prior to bp measurement 30. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he can do for the swelling in his leg. Which actin should the nurse implement? Instruct pt to flex both of his feet several times a day 31. Which information is most important for the nurse to consider when preparing to transfer a client from the bed to a chair? The pt's ability to bear weight on lower extremities 32. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The pulse oximeter alarm is flashing without displaying a percentage of oxygen. Which action should the nurse implement? exchange pulse ox for another monitor 33. Two days after surgery a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of, “Activity intolerance related to pain.” Based in this problem, which outcome statement is best for the nurse to include in the client’s plan of care? The client will Ambulate without discomfort 34. After assessing a client, the nurse identifies three nursing problems. When developing the client’s plan of care, which action should the nurse take next? Prioritize the identified nursing diagnoses 35. After reviewing the admission assessment of a client with chronic pain, which interventions should the nurse include in this client’s plan of care? (Select all that apply) Provide comfort measures such as topical warm application and tactile massageImplement a 24h schedule of routine administration of prescribed analgesic Determine client's subjective measure of pain using a numerical pain scale 36. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the client’s risk for infection related to the catheter? Encourage increased intake of oral fluids 37. The electronic medication system alerts the nurse that the medication dose scanned is two times higher than the dose prescribed. What action should the nurse implement? Convert the dose on hand to match the prescribed dose 38. A male client with chronic debilitating heart disease asks the nurse to help him die because he believes that he will be better off dead rather than living under the current circumstances. The nurse supports the client and considers providing the family with a does of medications that can result in the client’s death. If the nurse acts on this intention, what is the most likely consequence?The nurse will be prosecuted for the murder of the pt 39. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? Complete the intermittent suction of nasopharynx 40. The grandmother of a young adult male admitted to the psychiatric unit yesterday requests information about her grandson’s treatment plan. Before answering the family member’s question, what action should the nurse take? Ensure that the signed release of info includes thegrandmother 41. When providing health teaching to elderly clients, what action is most important for the nurse to implement? Use everyday language when explaining issue 42. A male client presents to the clinic stating that he has a high stress job and is having difficulty falling asleep at night. The client complains of a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement? Determine the client's sleep andactivity pattern 43. To assess the quality of an adult client’s pain. What approach should the nurse use? Ask the pt to describe pain 44. The nurse is planning a weight reduction teaching program to be implemented at a community health center. Which goal is best for clients who are approximately fifteen percent over their ideal wight and wish to participate in the weight loss program? Fat intake between 20 to 30 percent of total daily intake 45. The nurse prepares to irrigate the ear of an adult client. The client is positioned with the head tilted slightly toward the affected side and the emesis basin positioned under the ear. What actionshould the nurse take next? confirm the temperature of the irrigation solution 46. The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible etiologies for this value, what questions should the nurse ask the client? How much waterand ice chips do you have each day? 47. The healthcare provider prescribes hydroxyzine (Vistaril) 35 mg IM for a client who is vomiting. The available drug is labeled, 50 mg/ml. How many ml should the nurse administer? 0.7ml 48. The nurse finds a confused female client wandering in the hallway during the night. What actionshould the nurse implement? (Select all that apply) Raise the side rails of bed Escort her back to room Secure bed alarm on mattress 49. A client in the outpatient clinic complains of experiencing hard, infrequent stools. Which instruction should the nurse provide this client? Drink 6-8 large glasses of water daily 50. The nurse reviews discharge instructions for a male client with obstructive sleep apnea syndrome (OSAS). The client tells the nurse that he likes to drink a glass of wine before going to bed. How should the nurse respond? Offer to contact healthcare provider about a prescription for a sleepingaid 51. The home care nurse has identified the problem “Risk for hopelessness” for a male client who is terminally ill with a life expectancy for several days. Which instruction should the nurse provide the client’s spouse? Listen for changes in what the client hopes for and try to help meet his goals 52. The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle upand back and prepares the thermometer. What action should the nurse implement? A Demonstrate the correct technique for pulling the ear down and back 53. A journalist asks the nurse working in the Emergency Department about condition of a local politician recently admitted to the medical center following a publicly reported building fire. What action should the nurse take? Obtain verbal consent from family member before discussing the client’s condition 54. Which outcome statement can be used in the planning stage of the nursing process? The clientwill demonstrate ability to change ostomy bag in two days 55. The nurse observes an adult woman perform a return demonstration of diaphragmatic breathing. The client inhales while holding her abdomen, then removes her hand to allow expansion of the abdomen during exhalation. What action should the nurse take after observing the client’s demonstration? Demonstrate how to expand the abdomen while inhaling and let it sink in while exhaling 56. The nurse begins to suction a client’s oropharynx as seen in the picture. What action should the nurse take next? Observe the suctioned secretions 57. The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluidssince admission. An increased in which parameter indicatestothe nurse that the client is rehydrating? Pulse rate 58. The charge nurse is observing a new graduate’s performance of wound care. Which technique indicates that the employee is effectively cleansing the wound? Starts at wound site and moves outward using circular motions 59. While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Whataction should the nurse take in response to thisfinding? Provide the client an incentive spirometerto increase respiratory effort 60. What assessment is most important for the nurse to perform to the application of a heating pad? Degree of neurosensory impairment 61. The healthcare provider prescribes acetaminophen (Tylenol) elixir 325 mg PO for an older adult who has difficulty swallowing pills. The available oral solution is labeled, acetaminophen elixir 325mg/5ml. How many teaspoons should the nurse administer with each does? 1 teaspoon 62. An elderly woman comesto the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan? The importance of using vaginal lubricants. 63. A client who lives in an assisted living facility develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should the nurse contact?A daughter in law designated as the client’s Durable power of Attorney (DPOA) 64. The unlicensed assistive personnel (UAP) describe the appearance of the bowel movement of several clients. Which description warrant additional follow-up be the nurse? (Select all that apply) multiple hard pellets, tarry appearance, and brown liquid -I ALSO ADVISE YOU TO STUDY THIS 2018/2019 FILE-MOST SCHOOLS ARE USING THIS!!!!! 1. A client at an outpatient clinic submits a clean- catch midstream urine specimen for a routine urinalysis. In later review of the client's medical record, which data indicates to the nurse that the specimen collection should be repeated? A. The urine specimen shows multiple organisms in low colony counts. B. The client reported eating a meal before voiding the urine specimen C. There was a total of 30 ml of urine voided into the specimen cup D. The medical record indicates the client is allergic to most antibiotics 2. When assessing a client who starts to wheeze which related data should the nurse obtain? A. Precipitating factors B. Body Temperature C. Presence of radiation D. Heart sounds 3. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to include in this client’s teaching? A. “Administer the medication directly on the cornea.” B. “Wash your hands after each administration of eye drops.”C. “Do not allow the dropper bottle to touch the eye.” D. “Squeeze your eye closed after administering the drops.” 4. The nurse observes that a male client on a clear liquid diet has a cup of coffee on his breakfast tray. What action should the nurse implement? A. Consult with the dietician to learn if the client is allowed to drink coffee B. Determine which member of the nursing staff brought the cup of coffee to the client C. Remind the client that no milk, or creamer can be added to the coffee. D. Remove the coffee from the tray, advising the client that it is not included in the diet. 5. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? A. Determine if the expected outcomes were realistic B. Modify the nursing interventions to achieve the client’s goals C. Obtain current client data to compare with expected outcomes D. Review related professional standards of care. 6. The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. In designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use? A. Return demonstration B. Journaling C. Analogies D. Role playing 7. The nurse observes the skin over a client's greater trochanter as seen in the picture. What actions should the nurse implement? (select all that apply) A. Remove the eschar before applying and securing a hydrocolliod B. Prepare to implement a pressure redistribution mattress C. Obtain a specimen of the site for culture and sensitivity D. Instruct the Unlicensed assistive personnel to frequently offer oral fluids E. Explain to the client that the wound needs debridement 8. The nurse has removed the barbiturate capsule from the unit dose wrapper to administer to a male client. The client decides he wants to watch a television program and requests not to take the medication. Which action should the nurse implement? A. Credit the medication back and put in the client’s medication box B. Keep the medication and see if the client will want to take it later. C. Have another nurse watch disposal of the medication into disposal container D. Explain that since the medication is a controlled substance it must be taken. 9. The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign an unlicensed assistive personal (UAP) to provide routine foot care and file the client’s toenails? (Select all that apply). A. Shuffling gait. B.Diminished visual acuity. C. Syncope when bending. D. hands tremors. E.Urinary incontinence 10. The charge nurse observes a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound? A. Starts at the wound site and moves outward using circular motions. B. Cleanses from the outer area of the wound toward the center C. Uses a sterile swab to go over the wound site twice. D. Scrubs wound vigorously for at least two minutes 11. The nurse is evaluating the fluid balance of the client who was admitted yesterday with dehydration and who has been receiving iv fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating. A. Serum haematocrit. B. Urine specific gravity. C. Pulse Rate. D. Urinary output. 12. In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client verbalizes concerns about pain. What action should the nurse implement? a. Explain the respiratory problems that can occur with morphine use. b. Teach family how to evaluate the effectiveness of analgesics. c. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump. d. Provide client with a schedule of around-the-clock prescribed analgesic use. 13. The nurse begins to suction a client’s oropharynx as seen in the picture. What action should the nurse take next? a. Position suction in the trachea. b. Apply nasal cannula oxygen. c. Insert a tongue blade. d. Observe the suction secretion. 14. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview? a. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace. b. Completing the electronic record during an interview is a legal obligation of the examining nurse. c. The nurse has limited ability to observe non-verbal communication while entering the assessment electronically. d. The client’s comfort level is increased when the nurse breaks eye-contact to type notes into the record. 15. The nurse measures the client’s blood pressure(BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply). a. Determine the client’s activities and feelings prior to the BP measurement. b. Retake the Client's blood pressure in the opposite arm c. Assign the unlicensed assistive personnel to recheck the BP in an hour. (not the answer because it should be rechecked sooner) d. Ask another nurse to assist in assessing for an apical-radial pulse deficit. e. Immediately take two more readings on the same arm. 16. A male Native American presents to the clinic with complaints of frequent abdominal cramping and Nausea. He states that he has chronic constipation and has not had a bowel movement in 5 days, despite trying several home remedies. Which intervention is most important for the nurse to implement. a. Access for the presence of an impaction. b. Evaluate stool sample for the presence of blood. c. Obtain list of prescribed home medications. d. Determine what home remedies where used. 17. The Practice Nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the Charge Nurse (CN) observes the PN, what actions should the charge nurse take? a. Confirm that PN is ready to assist with the planned procedure. b. Obtain all new supplies and directly assist with the procedure. c. Remove the contaminated package of sponges from the table. d. Instruct the PN to remove the gloves that are now contaminated. 18. A male client with limited mobility is discharged with home-health services. When the home-health nurse arrives, the client asks what he can do for the swelling in his leg. What action should the nurse implement? a. Encourage the client to take short walks around the block. b. Advice the client to dangle his feet during meals and before bedtime. c. Ensure the clients to flex both of his feet, several times a day. d. Explain the need to keep the head of the bed elevated. 19. A male client with a recent diagnosis of terminal cancer, tells his nurse that he wishes to die naturally. The client states that he’s tired of fighting this illness and is only continuing treatment because of his family’s wishes. What actions should the nurse take? a. Request a consultation for a psychologist to talk with the client. b. Call a clergy to discuss end-of-life decisions with the client. c. Determine if he wants to stop radiation and chemotherapy. d. Arrange a meeting with the client, his family and the healthcare provider. 20. A male client who had emergency gallbladder surgery yesterday is getting ready for discharge. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home? a. Have the client demonstrate prescribed wound care. b. Provide written instructions in the client’s native language. c. Have an interpreter repeat the wound care instructions. d. After each instruction, ask the client if he understands. 21. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? a. Access for side effects of the medication. b. Document the client’s responses. c. complete a medication error report. d. Determine if the pain was relieved. 22. The nurse is evaluating a client who is admitted to an adult medical unit, and notes that a client’s urine output has been 70 ml/hr. Which action should the nurse implement? a. Recommend drinking cranberry juice with meals. b. Encourage the client to drink more fluids. c. Document the client’s urinary output every hour. (NORMAL RANGE) d. Notify the healthcare provider immediately. 23. A client is admitted with Pneumonia and has a recent history of Methicilline-resistance Staphylococcus aureus (MRSA). The Client is placed in isolation while caring for the client, which client should the nurse place in a designated bio-hazard bag before it is removed from the room? a. A sputum specimen. (BODILY FLUIDS=BIOHAZARD) b. Paper mask and gown. c. The nurse’s stethoscope. d. Bed linens. 24. A client is receiving Ketorolac (Toradol) IM 45mg IM every 6 hours for post operative pain. The available 2ml vile is labeled, Toradol 30mg / ML. How many ML should the nurse administer? (enter numerical value only, If rounding is required round to the nearest Tenths). [1.5 x] 25. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first. a. blood pressure. b. Respiratory rate. (Cyanosis caused by low oxygen levels in the RBCs) c. Pulse Rate. d. Temperature. 26. An older male client returns to the clinic for chronic pain management after taking morphine sulphate (MS contin) 25mg every 12hrs. He states he took the medication only when the pain was too severe to sleep. What action should the nurse implement? a. Explain the risk of drug addiction from long term pain medication. b. Tell the client to continue taking the MS contin with severe pain. c. Instruct the client to take the MS Contin every 12 hours as prescribed. d. Teach the client alternative ways to manage his chronic pain. 27. A client is admitted with complaints of shortness of breath (Dyspnea) on exertion, and chest pressure The healthcare provider prescribes a medication that is unfamiliar to the nurse. When checking the drug handbook, the nurse reads that the prescribed amount is an unusually large dose. What actions should the nurse take? a. Consult pharmacists for those clarification. b. Verify the prescribed dosage with a healthcare provider. c. Administer the medication as prescribed. d. Give the dosage recommended in the drug handbook. 28. A client who lives in an assisted living facility; develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should the nurse contact? a. The client’s youngest son was identified by family members as the family’s spokesperson. b. A daughter-in-law designated as the client’s durable power of attorney (DPOA) c. The client’s spouse who lives in the independent living unit of the facility. d. The client's oldest living child, a lawyer who is visiting from out of town. 29. What explanation is best for the nurse to provide a client who asked the purpose of using the log-rolling technique for turning? a. Working together can decrease the risk of back injury to the nurses. b. Turning instead of pulling reduces the likelihood of skin damage. c. The technique is intended to maintain straight spinal alignment. d. Using two or three people increases client’s safety. 30. The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side. What style shoes does the nurse recommend the client wear when ambulating with her husband’s assistance? a. Slip-on rubber shower shoes. b. Tennisshoes with Velcro. (FALL PRECAUTION) c. Rubber sole slippers. d. Leather sole loafers. 31. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a “Do Not Resuscitate”(DNR Prescription). What actions should the nurse take? a. Ensure resuscitation equipment is available. b. Ask the family to review options with the client. c. Place a DNR bracelet on the client’s arm. d. Initiate an ethics committee review of the case. 32. A client newly diagnosed with stage 3 lung cancer becomes angry with the healthcare provider and nursing staff. Which intervention is most important for the nurse to implement? a. Arrange for the client to meet with another client who has lung cancer. b. Request a consultation from an oncology social worker. c. Acknowledge the client’s anger and attempt to address its source. d. Allow the client and family time to be alone. 33. Two days after surgery, a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of “activity intolerance related to pain”. Which outcome statement is best for the nurse to include in the client’s plan of care? a. To take analgesic as prescribed. b. To ambulate without discomfort. c. To show evidence of incision healing. d. To avoid pain-causing activity. 34. An adult client complains of insomnia and asks the nurse to recommend a sleeping pill. What reply is best for the nurse to provide? a. “Have you discussed this with your healthcare provider?” b. “Zolpidem Tartate (ambien) is used for insomnia.” c. “Sleeping medication require side effects that require caution” d. “Tell me about your insomnia and how you treat it” 35. The healthcare provider prescribes Haloperidol (Haldol) 1.5mg twice daily for a client with Tourette’s syndrome. The drug is available in a Potassium 3.1 mEq/L (3.1 mmol/L) (LOW) solution labeled “2mg / ml” How many ml should the nurse administer?(enter numerical value only, If rounding is required round to the nearest Tenths). 36. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider. a. Total calcium 9.2 mg/dl (2.3 mmol/L) b. c. Chloride 98 mEq/L (98 mmol/L) d. Sodium 142mEq/L (142 mmol/L) 37. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement of several clients. Which description warrants additional follow up by the nurse? (select all that applies). a. Solid with red streaks. b. Brown liquid. c. Multiple hard pellets. d. Formed but soft. e. Tarry appearance. 38. During the admission assessment of a terminally ill male client, The client states that he is an agnostic. What is the best nursing action in response to this statement. a. Provide information about the hours and location of the chapel. b. Document the statement in the client’s spiritual assessment. c. Offer to contact a spiritual advisor of the client’s choice. d. Invite the client to a healing service for people of all religions. 39. A client is discharged to a long-term care facility. With an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the client’s risk of infection related to the catheter. a. Secure the drainage bag at bladder level during transport. b. Flush the catheter daily with sterile saline solution. [0.75 X] c. Administer PRN Antipyretic if a fever develops. d. Encourage increased intake of oral fluids. 40. The community healthcare nurse is making a home visit when the client, who is sitting at the kitchen table begins to have a seizure. What action should the nurse take first? a. Assist the client to the floor. b. Access the client’s vital signs. c. Call 911 for an ambulance. d. Remove nearby furniture. 41. The nurse prefers to implement a prescription for oxygen at 4 L/minute per nasal cannula. For a client with an oxygen saturation of 90%. The nurse observes the flow meter set up provided by the respiratory therapist, as seen in the picture. What action should the nurse take next? a. Adjust the flow rate to 4 L/minute b. Attach oxygen tubing to the flow meter. c. Drain the water out of the humidifier. d. Document the presence of breath sounds. 43. The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bed side rails. Which action is most important for the nurse to implement? a. Initiate the facility’s restraint flow sheet. b. Demonstrate proper securing of the restraint. c. Ensure that the restraints are not too tight. d. Complete an adverse occurrence/incidence report. 44. A nurse administers an opioid analgesic to a post operative client who also has severe obstructive sleep apnea (OSA). What intervention is most important for the nurse to implement before leaving the client alone? a. Apply the client’s positive airway pressure device. b. Lift and lock the side rails in place. c. Remove dentures or other oral appliances. d. Elevate the head of the bed to 45 degree angle (MORE RISK FOR RESPIRATORY COMPLICATIONS) 45. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved. a. Number of staff induced injury b. Client satisfaction survey c. Health care-associated infection rate. d. Rate of needle-stick injuries by nurse. 46. While suctioning a client’s nasopharynx the nurse observes that the client’s oxygen saturation remains at 94% which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? a. Complete the intermittent suction of the nasopharynx. b. Reposition the pulse oximeter clip to obtain a new reading. c. Stop suctioning until the pulse oximeter reading is above 95%. d. Apply an oxygen mask over the client’s nose and mouth 47. The nurse is preparing a teaching plan for a client with low back pain. Which sleeping position should be included in the teaching? a. Side-lying with hips and knees flexed. b. Supine with hips and knees and neutral straight position. c. Head of bed elevated to 30 degrees. d. Prone with a pillow under the lower abdomen. 48. What self-care outcome is best for the nurse to use in evaluating a client’s recovery from a stroke that resulted in left-sided hemiparesis? a. Self-care needs to be completed by the unlicensed assistive personnel. b. Participate in self-care to an optimal level of capacity. c. Promote independence by allowing clients to perform all self-care activities. d. Client verbalizes importance of hygienic practices in the recovery process. 49. It is most important for the nurse to recalculate the braden scale score for a client who has developed which problem. a. Urinary incontinence. b. Hypo-active Bowel sound. c. Plus Two ankle Edema. d. Weakened cough efforts. 50. When performing blood pressure measurement to assess for orthostatic hypotension, Which action should the nurse implement first? a. Apply the blood pressure cuffs securely. b. Assist the client to stand at the bedside. c. Position the client supine for a few minutes. d. Record the client’s pulse rate and rhythm . 51. A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, What intervention is most important for the nurse to implement? a. Sit quietly with the family to offer comfort and support. b. Ask a Spanish speaking staff member to talk with the family. c. Use a Spanish translation reference to interview the family. d. Close the door to the client's room to provide family privacy. 52. The nurse uses a sterile syringe to obtain a urine specimen, from a client’s indwelling urinary catheter. After placing the specimen in a biohazard bag, the nurse transports the specimen to the lab. During what part of this procedure should the nurse wear gloves? a. Transporting the urine specimens to the laboratory. b. Using the remove the specimen from the catheter. c. Clamping the urinary catheter prior to the collection. d. Recording the output on the flowsheet in the client’s room. 53. A male hospice client with bone cancer reports to the nurse that his bone pain is not adequately controlled with his current dose of morphine sulfate, and he is experiencing difficulties with constipation. In addition to increasing the client’s dose of laxative, what plan of treatment should the nurse anticipate? a. Reduce the dose of morphine b. Increase the dose of morphine c. Switch from morphine to codeine d. Take no additional morphine 54. What is the best approach for the nurse to use when interviewing a client about sexuality/ reproductive function? a. Ask questions in a vague, non-specific format b. Share personal values to put the client at ease c. Begin with questions that are less sensitive in nature d. Get the most difficult questions over with first 55. A female client’s significant other has been at her bedside providing reassurances and support for the past 3days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? a. Obtain a perception from the healthcare provider regarding visitation privileges b. Request a consultation with the ethics committee for resolution of the situation c. Encourage the client to speak with her husband regarding his disruptive behavior d. Communicate the client’s wishes to all members of the multidisciplinary team An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in the client's teaching plan? A: The importance of using vaginal lubricants. B: Methods used to practice safe sex. C: Information about alternative ways to express sexuality. D:Intercourse positions that help prevent tears. A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take? A) Have the client put both arms around the nurse's neck for support. B) Place the wheelchair on the client's left side. C) Instruct the client to look at his feet. D) Instruct the client total slow, deep breaths while transferring The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A) Complete a full fall risk assessment of the client. B) Teach the client to take longer steps at a faster pace. C) Suggest that the client use a wheelchair instead of a walker. D) Place the client on bed rest until the healthcare provider is notified. An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A) Discuss with the client her meaning of heroic measures. B) Obtain a "do not resuscitate" (DNR) prescription. C) Set up a family conference to discuss the clients. D) Consult the palliative care team about the client's care. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml via