HESI PN FUNDAMENTALS 3

HESI PN FUNDAMENTALS 3 Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of aqueous humor for a client with glaucoma? Chlorothiazide (Diuril) Acetazolamide (Diamox) Bendroflumethiazide (Naturetin) Demecarium bromide (Humorsol) A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem.Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem.Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains thatthe rationale for these interventions is to: Promote equalization of osmotic pressures. Prevent hypoxia associated with diaphoresis. Promote integrity of intracerebral neurons. Reduce brain metabolism and limit hypoxia. A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. mL 1.5 The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? Risk for pressure ulcer Risk for impaired skin integrity Impaired skin integrity, related to infrequent turning and repositioning Impaired skin integrity, related to the effects of pressure and shearing force A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissuedown to the underlying fascia. The nurse should document the assessment finding as whichstage of pressure ulcer? Stage I Stage II Stage III Unstageable A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneousfat. Bone, tendon, and muscle are not exposed. A client is being admitted for a total hip replacement. When is it necessary for the nurse toensure that a medication reconciliation is completed? Select all that apply. After reporting severe pain On admission to the hospital Upon entering the operating room Before transfer to a rehabilitation facility At time of scheduling for the surgical procedure Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted. A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? White blood cell (WBC) count of 15,000 mm3 Negative protein in the urine Blood urea nitrogen (BUN) of 20 mg/dL Prothrombin of 12.0 seconds White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these arenormal values. Often when a family member is dying, the client and the family are at different stages ofgrieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? Anger Denial Depression Acceptance In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs. The client asks the nurse to recommend foods that might be included in a diet for diverticular disease.Which foods would be appropriate to include in the teaching plan? Select all that apply. Whole grains Cooked fruit and vegetables Nuts and seeds Lean red meats Milk and eggs With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggshave no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats. A nurse is obtaining a health history from the newly admitted client who has chronic pain inthe knee. What should the nurse include in the pain assessment? Select all that apply. Pain history, including location, intensity, and quality of pain Client's purposeful body movement in arranging the papers on the bedside table Pain pattern, including precipitating and alleviating factors Vital signs such as increased blood pressure and heart rate The client's family statement about increases in pain with ambulation Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members. While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? Immediately stop the infusion. Lower the height of the enema bag. Advance the enema tubing 2 to 3 inches. Clamp the tube for 2 minutes, then restart the infusion. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps. During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? The nurse also should have instituted a plan to increase activity. The nurse provided supportive nursing care for the well-being of the client. Debridement of the pressure ulcer should have been done before the dressing was applied Treatment should not have been instituted until the health care provider's prescriptions were received. According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. An activity level is prescribed by a health care provider; this is a dependentfunction of the nurse. There is not enough information to come to the conclusion that debridement should have been done before the dressing was applied. Application of an emollient and reinforcing adressing are independent nursing functions. A visitor comes to the nursing station and tells the nurse that a client and his relative had afight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? Ask the client if he is okay. Call security from the room. Find out if there is anyone else in the room. Ask security to make sure the room is safe Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and make sure that any other people in the room are safe To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: 4 to 8 hours 12 to 24 hours 24 to 48 Hours 72 to 96 hours Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48hours is not a cost-effective practice A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select allthat apply. Ask the client what is the client's acceptable level of pain. Eliminate all activities that precipitate the pain. Administer the pain medications regularly around the clock. Use a different pain scale each time to promote patient education. Assess the client's pain every 15 minutes The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to thetolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide the stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level helps to ensureconsistency and accuracy in the pain assessment. Only management of acute pain such as postoperative pain requires the pain assessment at frequent intervals. The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. Allergy to the medication Itching in the ear canal Drainage from the ear canal Tympanic membrane rupture Partial hearing loss in the affected ear Contraindications to eardrops include allergy to the medication, drainage from the ear canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted cerumen and is not acontra indication to the use of eardrops. Itching may occur with some ear conditions and is not a contraindication to the use of eardrops. What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. Tetany Seizures Diarrhea Weakness Dysrhythmias Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias. A health care provider has prescribed isoniazid (Laniazid) for a client. Which instructionshould the nurse give the client about this medication? Prolonged use can cause dark concentrated urine. The medication is best absorbed when taken on an empty stomach. Take the medication with aluminum hydroxide to minimize GI upset. Drinking alcohol daily can cause drug-induced hepatitis Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clients should avoid taking aluminum antacids at the same time as this medication because it impairs absorption. To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what doesthe nurse expect the dietary plan to include? Low in fat High in iron High in fluids Low in residue A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep thestool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietaryplans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine. A postoperative client says to the nurse, "My neighbor, I mean the person in the next room,sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? Tell the neighboring client to stop singing. Close the doors to both clients' rooms at night. Give the complaining client the prescribed as needed sedative. Move the neighboring client to a room at the end of the hall Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention The nurse is providing postoperative care to a client who had a submucosal resection (SMR)for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? Occipital headache Periorbital crepitus Expectoration of blood Changes in vocalization After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently orexpelling blood with saliva. A headache in the back of the head is not a complication of a submucosalresection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However,the sound of the voice is altered temporarily by the presence of nasal packing and edema. A nurse is reviewing a plan of care for a client who was admitted with dehydration as a resultof prolonged watery diarrhea. Which prescription should the nurse question? Oral psyllium (Metamucil) Oral potassium supplement Parenteral half normal saline Parenteral albumin (Albuminar) Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oralpsyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplementis appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration. A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the nurse monitor this client? Curling ulcer Renal shut down Metabolic acidosis Hemolysis of red blood cells Mafenide interferes with the kidneys' role in hydrogen ion excretion, resulting in metabolic acidosis.Curling ulcer, renal shutdown, and hemolysis of red blood cells are not adverse effects of the drugs. A nurse is preparing to administer an ophthalmic medication to a client. What techniquesshould the nurse use for this procedure? Select all that apply. Clean the eyelid and eyelashes. Place the dropper against the eyelid. Apply clean gloves before beginning of procedure. Instill the solution directly onto cornea. Press on the nasolacrimal duct after instilling the solution. Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes in order to prevent contamination of the medicationin the dropper. The medication should not be instilled directly onto the cornea because cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac. The nurse recognizes that which are important components of a neurovascular assessment?Select all that apply. Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate arecomponents of a neurological assessment. A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? Apathy Euphoria Detachment Emotionalism When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic but still may be concerned and use time constructively. Although resigned todeath, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed. A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? Anger Denial Bargaining Acceptance Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding the client's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication. When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. Thisis known as: Evidence Tort discovery Proximate cause Common cause Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which may include witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's. Following a surgery on the neck, the client asks the nurse why the head of the bed is up sohigh. The nurse should tell the client that the high-Fowler position is preferred for what reason? To avoid strain on the incision To promote drainage of the woundTo provide stimulation for the client To reduce edema at the operative site This position prevents fluid accumulation in the tissue, thereby minimizing edema. This position will neither increase nor decrease strain on the suture line. Drainage from the wound will not be affected by this position. This position will not affect the degree of stimulation. The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? Contact the client's children and ask them to hire a private duty aide who will provide round-theclockcare. Develop a chart for the client, listing the times the medication should be taken. Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. Instruct the client and client's children to put medications in a weekly pill organizer. Contacting a medical care provider and discussing the possibility of simplifying the client's Medication regimen will make it possible to use a weekly pill organizer : an empty pill box will remind the client who has a short- term memory deficit due to Alzheimer dementia that medication was taken and will prevent medication being taken multiple times. The client does not require 24-hour supervision because the client is in the outset of the Alzheimer dementia and the major issue is a short-term memory loss. A chart may be complex and difficult to understand for the client and will require the client to perform cognitive tasks multiple times on daily basis that may be beyond the client's ability. Use of the weekly pill organizers will be difficult with the current medication regimen when the client has to take medications six times a day; the medication regimen has to be simplified first. The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Dyspnea Flushed face Precordial pain Increased pulse rate Increased blood pressure Increased body heat dilates blood vessels, causing a flushed face. The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may not cause difficult breathing. Pain is not related to fever. Blood pressure is not expected to increase with fever. The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: Force urine to back up into the kidneys. Suppress production of urine. Cause the device to pull away from the skin.