BSN 266 HESI Med Surg Exam (New 2023/ 2024 Update) Questions and Verified Answers|100% Correct| Graded A- Nightingale

BSN 266 HESI Med Surg Exam (New 2023/ 2024 Update) Questions and Verified Answers|100% Correct| Graded A- Nightingale Q. Steps for Obtaining Informed Consent Client is recovering from a transurethral prostatectomy. Which activity should be limited until after the first postoperative visit with the healthcare provider? ANSWER Drink 3L Q. A client with stage IV bone cancer is admitted to the hospital for a 1-10 scale. Which intervention should the nurse implement? ANSWER Administer opioid and non-opioid medications simultaneously Q. A client experiences an AOB incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the health care provider? a. low back pain and hypotension b. rhinitis and nasal stuffiness c. delayed painful rash with urticarial d. arthritic joint changes and chronic pain a. low back pain and hypotension ANSWER (A) LOW BACK PAIN AND HYPOTENSTION Q. When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include? a. Have small frequent meals and sit up for at least two hours after meals. b. Eat a bland diet and avoid spicy foods. c. Eat a high fiber diet and increase fluid intake. d. Eat a soft diet with increased intake of milk and milk products c. Eat a high fiber diet and increase fluid intake. ANSWER (C) EAT A HIGH-FIBER DIET AND INCREASE FLUID INTAKE Q. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action? a. Provide additional oral fluid intake b. Measure the client's intake and output. c. Increase the flow of the bladder irrigation d. Administer a PRN dose of an antispasmodic agent ANSWER c. Increase the flow of the bladder irrigation ANSWER (C) Increase the flow of the bladder irrigation Q. A client wit lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and difficult to arouse. When performing a head ANSWER -to-toe assessment, the nurse discovers four analgesic patches on Remove all morphine patches Q. Coming down the basement steps, a client is brought to the emergency room X-ray ... cast, which assessment finding warrants immediate Intervention by the nurse? ANSWER Right foot pale with sluggish capillary refill Q. An overweight, young adult who was ANSWER recently Check finger stick glucose diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Q. Which actions should the nurse implement? (Select all that apply.) a. Check finger stick glucose b. Assess skin temperature and moisture c. Measure pulse and blood pressure a. Check finger stick glucose b. Assess skin temperature and moisture c. Measure pulse and blood pressure ANSWER (CAM) Q. A client who underwent cardiac stent placement four days ago arrives to the emergency department reporting a sudden onset of chest pressure and shortness of breath. Which action should the nurse take next? a. Listen for extra heart sounds, murmurs, and r hythm with the bell of the stethoscope. b. Evaluate upper and lower extremities for perfusion, pulse volume, and pitting edema. c. Verify troponin level assessments are scheduled every 3-6 hours for a series of three. d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring . ANSWER d. Obtain a 12-lead electrocardiogram and begin continuous cardiac monitoring Q. While completing a health assessment for a client with migraine headaches, the nurse assesses bilateral weakness in the clients hand grips. The client reports joint pain and trouble twisting a door knob due to weaknesses. Which action should the nurses take in response to these figures? a. Implement fall precautions to reduce the clients risk of injury. b. Explain that relief of the migraine pain will reduce related symptoms. c. Gather additional assessment data about the pain and weakness. d. Consult with the occupational therapist for a functional assessment ANSWER c. Gather additional assessment data about the pain and weakness. Q. The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving psoralen and ultraviolet A light (PUVA) treatment. Which assessment finding indicates that the client has been overexposed to the treatment? a. Thick skin plaques topped by silvery white scales b. Tenderness upon palpation and generalized erythema c. Brown, rough, greasy, wart-like papules on the face d. Requires sunglasses because sunlight hurts eyes ANSWER b. Tenderness upon palpation and generalized erythema Q. An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client's abdomen is tender to touch, and the vital signs are temperature 101 F (38 3 C). heart rate 130 beats/minute, Respiratory rate 26 breaths/minute, and blood pressure 100/50 mmHg. Which intervention is most important for the nurse to include in the client's plan of care? a. Encourage regular turning. b. Monitor skin for breakdown. c. Strict IV fluid replacement d. Assess wound drainage daily ANSWER c. Strict IV fluid replacement Q. A client who was recently diagnosed with Raynaud's disease is concerned about pain management. Which nursing instructions should the nurse provide? a. Painful areas should be rubbed gently until the pain subsides. b. Return appointments will be needed for IV pain medications. c. Enrolling in a pain clinic can provide relief alternatives. d. Wearing gloves when handling cold items guards against painful spasms. ANSWER d. Wearing gloves when handling cold items guards against painful spasms. Q. A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond? a. Explain that the need to restrict fluids is the primary limitation. b. Advise the client to limit foods that are high in calcium and iron. c. Instruct the client to avoid foods with gluten, such as wheat bread. d. Describe the use of an elimination diet to find trigger foods ANSWER d. Describe the use of an elimination diet to find trigger foods Q. The nurse is obtaining a health history from a new client who has a history of kidney stones. Which statement by the client indicates an increased risk for renal calculi.? a. Jogs more frequently than usual daily routine. b. Eats a vegetarian diet with cheese 2 to 3 times a day. c. Experiences additional stress since adopting a child. d. Drinks several bottles of carbonated water daily ANSWER b. Eats a vegetarian diet with cheese 2 to 3 times a day. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary system, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? a. Review the client's fluid intake prior to bedtime. b. Obtain a finger stick blood glucose level. c. Palpate the bladder above the symphysis pubis. d. Collect a urine specimen for culture analysis c. Palpate the bladder above the symphysis pubis. A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis? a. Nephrotic syndrome history. b. Latent hepatitis C. c. Crohn's disease with colectomy. d. Type 2 diabetes mellitus c. Crohn's disease with colectomy. When providing care for an unconscious client who has seizures. Which nursing intervention is most essential? a. Maintain the client in a semi-Fowler's position. b. Keep the room at a comfortable temperature. c. Ensure oral suction is available. d. Provide frequent mouth care c. Ensure oral suction is available. A client presents to the emergency department reporting chest pain that is radiation to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider? a. Fentanyl. b. Hydromorphone. c. Oxycodone. d. Morphine d. Morphine An adult who was recently diagnosed with glaucoma tells the nurse, "It feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurses to provide this client? a. Maintain prescribed eye drop regimen b. Eat a diet high in carotene. c. Wear prescription glasses. d. Avoid frequent eye pressure measurement. a. Maintain prescribed eye drop regimen Which information should the nurse include on the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? a. Adjust food intake to three full meals per day and no snacks. b. Sleep without pillows at night to maintain neck alignment. c. Minimize symptoms by wearing loose, comfortable clothing. d. Avoid participation in any aerobic exercise programs c. Minimize symptoms by wearing loose, comfortable clothing. A client arrives to the emergency department reporting an intermittent fever and night sweats for the past 3 weeks and has developed a productive cough containing small amounts of blood. Which intervention should the nurse prioritize? a. Move into airborne isolation b. Collect specimens for blood cultures. c. Arrange transport for radiographic imaging. d. Obtain a sputum sample a. Move into airborne isolation A client receives a prescription for 1 liter of Ringer's intravenously to be infused over 6 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only. If rounding is required, round to the nearest whole number.) 167 mL 1000mL/6(hours) =166.6=167mL The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? a. Activity level of bowel sounds. b. Eating patterns of dietary intake. c. Level and amount of physical activity d. Color and consistency of feces b. Eating patterns of dietary intake. An older adult client with a long hist ory of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. The client is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? a. Apply a tight flow venturi mask. b. Encourage client to drink water. c. Assist client to an upright position. d. Administer a prescribed sedative c. Assist client to an upright position. Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy? a. Monitor the client's intravenous site hourly during the treatment b. Keep the head of the bed elevated until the treatment is completed. c. Instruct the client to drink plenty of fluids during the treatment. d. Administer an antiemetic before starting the chemotherapy a. Monitor the client's intravenous site hourly during the treatment The home health nurse provides teaching about self injection to a client who was recently diagnosed with diabetes mellitus. When the client begins to perform a return demonstration of an insulin injection into the abdomen as seen in the video, which instruction should the nurse provide? (Please view the video to select the opt ion that applies. To repeat the video, click the play button again.) a. Continue with the insulin injection. b. Keep the skin flat rather than bunched. c. Lie down flat for better skin exposure. d. Select a different injection site a. Continue with the insulin injection. An older client who is agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular, respirations 38 breathe/minute. blood pressure 168/100 mmHg, wheezes, and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV. Which assessments should the nurse obtain to determine the client's response to treatment? Select at that apply. a. Oxygen saturation b. Pain scale c. Lung sounds d. Urinary output e. Skin elasticity a. Oxygen saturation c. Lung sounds d. Urinary output (LOU) While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? a. White blood cell (WBC) count b. Hematocrit. c. Platelet count. d. Blood pH level a. White blood cell (WBC) count The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review? a. Red blood cell count. b. Platelet count. c. White blood cell count. d. Hemoglobin levels. b. Platelet count. A client arrives to the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for the continuous bladder irrigation with normal saline is infused and the nurse observes dark-pink tinged outflow with blood clots in the tubing collection bag. Which action should the nurse take? a. Monitoring catheter drainage (pic one says this) b. irrigation the catheter manually. c. Decreasing the flow rate. d. Discounting infusing solution. a. Monitoring catheter drainage (pic one says this) The nurse is preparing a client for surgery who was admitted to the emergency center following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units subcutaneously daily. What is the priority nursing action? a. Notify the healthcare provider of the client's medication history. b. Observe the heparin injections sites for signs of bruising. c. Have the client sign the surgical and transfusion permits. d. Ensure that the potential for bleeding is explained to the client a. Notify the healthcare provider of the client's medication history. An obese client with emphysema who smokes at l east a pack of cigarettes daily is admitted after experiencing a sudden increase in dyspnea and activity intolerance. Oxygen therapy is initiated and its determined that the client will be discharged with oxygen. Which information is most important for the nurse to emphasize in the discharge teaching plan? a. Approaches to conserve energy. b. Guidelines for oxygen use. c. Methods for weight loss. d. Strategies for smoking cessation b. Guidelines for oxygen use. The healthcare provider prescribes penicillin 200,000 units intramuscularly for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/mL". How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round the nearest tenth.) 0.4 The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes the following vital signs; heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? a. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter. b. Medicate for pain and monitor vital signs according to protocol. c. Administer intravenous fluid bolus as prescribed by the healthcare provider. d. Encourage the client to splint the incision with a pillow to cough and deep breathe b. Medicate for pain and monitor vital signs according to protocol. While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take? a. Assesses the client's radical pulses and capillary refill time. b. Discuss approaches to chronic pain control with the client. c. Notify the healthcare provider of the finding immediately. d. Review the client's dietary intake of high- protein foods b. Discuss approaches to chronic pain control with the client. A client with draining skin lesions of the lover extremity is admitted with possible Methicillin-Resistant Staphylococcus Aureus (MRSA). Which nursing interventions should the nurse i include in the plan of care? (Select all that apply.) a. Explain the purpose of a low bacteria diet. b. Monitor the client's white blood cell count. c. Send wound drainage for culture and sensitivity d. Use standard precautions and wear a mask e. Institute contact precautions for staff and visitors b. Monitor the client's white blood cell count. c. Send wound drainage for culture and sensitivity e. Institute contact precautions for staff and visitors (MIS) The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough and shortness of breath. Which action is most important for the nurse to take? a. Counsel family members to monitor for illness symptoms for 2 weeks after last contact with patient. b. Move the client to a private room, keep the door closed, and initiate droplet precautions. c. Start an intravenous infusion for antiviral drug to be administered for positive COVID-19 test results. d. Assist the client to recall everyone possibly exposed since onset symptoms. b. Move the client to a private room, keep the door closed, and initiate droplet precautions A client with multiple sclerosis has urinary retention related to sensorimotor details. Which action should the nurse include in the client's plan of care? a. Remind the client to practice pelvic floor (Kegel) exercises regularly. b. Provide a bedside commode for immediate use in the client's discomfort. c. Explain the need to limit intake of oral fluids to reduce client discomfort. d. Teach the client techniques for performing intermittent catheterization. d. Teach the client techniques for performing intermittent catheterization A client who has a history of hypothyroidism was initially with lethargy and confusion. Which additional finishing warrants finding warrants the most immediate action by the nurse? a. Facial puffiness and periorbital edema. b. Further decline in level consciousness. c. Hematocrit of 30% (0.30). d. Cold and dry skin. b. Further decline in level consciousness. The nurse is caring for a client with human immunodeficiency virus (HIV) who has developed oral thrush and is experiencing burning and soreness in the south, Which intervention should the nurse implement first. a. Cleanse the mouth with swabs. b. Encourage frequent mouth care. c. Obtain a soft diet for the client. d. Administer a topical analgesic d. Administer a topical analgesic The healthcare provider prescribes diagnostic tests for a client whose chest ray indicates pneumonia. Which diagnostic test should the nurse review for implementation in the most therapeutic treatment of the pneumonia? a. Sputum culture and sensitivity. b. Arterial blood gases (ABG). c. Computerized tomography (CT) of the chest. d. Blood cultures. a. Sputum culture and sensitivity. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? a. Carotid bruit. b. Jugular vein distention. c. Palpable cervical lymph node. d. Nuchal rigidity a. Carotid bruit. A client with gouty arthritis reports tenderness and swelling of the right ankle and great toe. The nurse observes the area of inflammation extends above the ankle area. The client receives prescriptions for colchicine and indomethacin. Which instruction should the nurse include in the discharge teaching? a. Eat high protein foods to achieve ideal body weight. b. Use electric heating pad when pain is at its worse. c. Encourage active range of motion to limit stiffness. d. Drink at least 8 cups (1920 mL) of water per day. d. Drink at least 8 cups (1920 mL) of water per day. A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next? a. Capillary glucose. b. Oxygen saturation. c. Body temperature. d. Blood pressure d. Blood pressure The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis? a. Hypoalbuminemia that results in a decreased colloidal onoctic pressure. b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubules. c. Decreased renin-angiotensin response related to an increase in renal blood flow. d. Decreased portacaval pressure with greater collateral circulation a. Hypoalbuminemia that results in a decreased colloidal onoctic pressure. A client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? a. Determine if the client is using an inhaler before exercising. b. Teach client to use pursed lip breathing when episodes occur. c. Review the client's routine asthma management prescriptions. d. Assess client for signs and symptoms of upper airway infection. a. Determine if the client is using an inhaler before exercising. Question about dry feet apply lotion to prevent cracks The nurse is evaluating a male client's understanding of diet teaching about the DASH eating plan. Which behavior indicates that the client is adhering to the eating plan? Low fat yogurt A client with operating room received succinylcholine. The client is experiencing muscle rigidity and has an extremely high temperature. Which action should the nurse implement? Prepare ice packs for placement in the client's axillary area The nurse is obtaining the ad mission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this medical diagnosis? Upper mid abdominal pain described as gnawing and burning An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? a. Administer IV antibiotics as prescribed A client who has developed acute kidney injury (AKI) due to aminoglycoside antibiotics has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor? a. Uremic irritation of mucous membranes and skin surfaces. b. Hypovolemia and electrocardiographic (ECG) changes. C. Side effects of total parental nutrition (TPN) and Intralipids. d. Elevated creatinine and blood urea nitrogen (BUN) b. Hypovolemia and electrocardiographic (ECG) changes. The nurse is providing teaching to a client with Type 2 diabetes mellitus and peripheral neuropathy. Which information should the nurse provide? a. Aching feet may be soaked in lukewarm water for one hour or more. b. Shoes should be worn outside the house, but it is fine to be barefoot inside. c. Family members can help with regular foot exams. d. Heating pads are useful if on the lowest setting c. Family members can help with regular foot exams. Question about facial droop prepare for fiberlyntic therapy Client is hospitalized with Heart failure. What nursing interventions will be implemented for patient to improve ventilation and reduce venous return? Place in high fowlers Dialysis access bruit heard in R arm normal/ document math (drops question) 42 gtt/min TURP QUESTION decrease urinary output Assessment question Guillan Barre loss of sensation at T-8 Addison's question educate to take steroids Peritoneal dialysis can't be started on patient with necrotic syndrome post op w/ elevated temperature apply ice packs a client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse recognize as a possible complication? a. anxiety and sighing b. myalgia in wrists and hands c. hyperactive bowel sounds d. dark yellow urine b. myalgia in wrists and hands The nurse has conducted a cancer prevention community education program. In evaluating the participants' understanding of the carcinogens, which statement indicates an accurate understanding? a. Environmental factors such as sunlight and chemicals can cause cancer to spread. b. Carcinogens are substances that contain cancerous cells. c. Substances that change a cell so that it becomes cancerous are potential sources of cancer d. Carcinogens are in the environment and cannot be avoided. c. Substances that change a cell so that it becomes cancerous are potential sources of cancer A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response? a. Hydration of affected dry skin areas b. Reduced pain in eczematous areas. c. Decreased weeping of ulcerations in affected areas. d. Healing with a return to normal skin appearance. a. Hydration of affected dry skin areas A client with hyperparathyroidism reports a sudden monster of severe flank pain. Which intervention should the nurse include in the client's plan of care? a. Implement seizure precautions. b. Initiate cardiac telemetry. c. Administer a PRN dose of a laxative. d. Begin straining all urine d. Begin straining all urine After falling down the basement steps, a client is brought to the emergency room. X-ray confirms that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse? a. Circumferential edema of right foot. b. Complaint of throbbing right leg pain. c. Right foot pale with sluggish capillary refill. d. Increased temperature to lower extremity b. Complaint of throbbing right leg pain. A female college student comes to the school's health clinic complaining of urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first? a. Palpate the right flank for tenderness. b. Test her urine for the presence of hematuria c. Evaluate the urine for a strong odor. d. Measure her temperature and pulse rate. d. Measure her temperature and pulse rate. The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headache or trauma. Which intervention should the nurse should perform in the immediate management of the client? a. Place an indwelling urinary catheter and measure strict output. b. Notify the stroke team to assist with acute assessment and management. c. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. d. Begin continuous observation for transient episodes of neurologic dysfunction b. Notify the stroke team to assist with acute assessment and management. Four days following and abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first? a. Wrap the feet with warmed blankets. b. Elevate extremities on pillows. c. Assess pulses with a vascular Doppler. d. Evaluate edema for pitting c. Assess pulses with a vascular Doppler While car ing for a client with Amyotrophic Lateral Sclerosis (ALS), the nurse performs a neurological assessment every four hours. Which assessment finding warrants immediate intervention by the nurse? a. Inappropriate laughter. b. Weakened cough effort. c. Asymmetrical weakness. d. Increasing anxiety. b. Weakened cough effort. The nurse is performing the preoperative assessment for a client scheduled for a vertebroplasty of the cervical spine. Which finding should the nurse alert the healthcare provider prior to the procedure? a. Hemoglobin 12 g/dL (120 g/L). b. Platelet count 40,000 x109/pL (40,000 x107L). c. Hematocrit 38% (0.38). d. White blood cells 9,000/pL (9x109L) b. Platelet count 40,000 x109/pL (40,000 x107L). A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehiscence's and eviscerates. The nurse moistens an a available sterile dressing and places over the wound. Which intervention should the nurse implement next? a. Prepare the client to return to the operating room. b. Auscultate the abdomen for bowel sound activity. c. Obtain a sample fo the drainage to send to the lab. d. Bring additional sterile dressing supplies to the room d. Bring additional sterile dressing supplies to the room Meningitis test to anticipate lumbar puncture Athlete's feet clean and dry socks COPD doing HUFF cough Re-learn exercise Burn (brown yellow) Full thickness Colon & rectal diet Oatmeal/raisin An older adult client with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? A. Administer a prescribed sedative B. Assist client to an upright position C. Encourage client to drink water D. Apply a high flow venturi mask B. Assist client to an upright position A client with multiple sclerosis (MS) is admitted to the medical unit, The client reports fatigue, muscle weakness, and diplopia. Which action should the nurse implement to reduce the clients risk for falls? SATA A. Provide assistance to bedside commode B. Provide frequent rest periods. C. Offer to assist with warm baths in the morning D. Monitor pulse ox during activities E. Teach to patch one eye while walking A. Provide assistance to bedside commode C. Schedule frequent rest periods. E. Teach to patch one eye while walking A client arrives to the ED following a motor vehicle collision, The nurse observes the client experiencing increasing dyspnea and notes absent breath sounds on the left side, which procedure should the nurse prepare for the client? A. Bronchoscopy B. Chest tube insertion C. Endotracheal intubation D. Pulmonary function test B. Chest tube insertion Following a transurethral resection of the prostate (TURP) a client is discharged from the hospital with an indwelling urinary catheter, Which instruction is most important for the nurse to include in the discharge teaching plan? A. Eliminate all spicy foods from your diet B. Drink 3 liters of water each day C. Clamp the catheter when taking a shower D. Avoid driving a car for 2 weeks B. Drink 3 liters of water each day An adult woman with Graves disease is admitted with severe dehydration and malnutrition, She is currently restless and refusing to eat. Which action is most important for the nurse to implement? A. Teach client relaxation techniques B. Determine the clients food preferences C. Maintain a patent Intravenous site D. Keep room temperature cool C. Maintain a paten intravenous site A client tells the clinic nurse about experiencing burning on urination, and assessment reveals that the client had sexual intercourse four days ago with a person who was a casual acquaintance, Which action should the nurse implement? A. Obtain a specimen of urethral drainage for culture B. Observe the perineal area for a chancre like lesion C. Identify all sexual partners in the last four days. D. Assess for perineal itching erythema and excoriation A. Obtain a specimen of urethral drainage for culture The nurse is caring for a client admitted to the hospital with a tentative diagnosis of bacterial meningitis, which diagnostic procedure should the nurse prepare the client for? A. Lumbar puncture B. Skull radiography C. MRI D. CT A Lumbar puncture An older adult client with long term type 2 DM is seen in the clinic for a routine health assessment, which assessment would the nurse complete to determine if a patient with type 2 DM is experiencing long term complications? SATA A. Sensation in feet and legs B. Skin condition of lower extremities C. Visual acuity D Serum creatinine and blood urea nitrogen (BUN) E. Signs of respiratory tract infection A. Sensation in feet and legs B. Skin condition of lower extremities C. Visual acuity D. Serum Creatinine and blood urea nitrogen (BUN) The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites, Which mechanism contributes to edema and ascites in a client with cirrhosis? A. Decreased portacaval pressure with greater collateral circulation B. Hypoalbuminemia that results in decreased colloidal oncotic pressure C. Decreased renin angiotensin response related to an increase in renal blood flow D. Hyperaldosteronism causing an increased sodium absorption in renal tubes B. Hypoalbuminemia that results in decreased colloidal oncotic pressure Hypoalbuminemia that results in a decreased colloidal oncotic pressure, this is correct, in cirrhosis liver damage leads to decreased synthesis of albumin, Albumin plays a crucial role in maintaining colloidal oncotic pressure and when it is decreased (hypoalbuminemia) fluid is more likely to leak out of blood vessels resulting n edema, the same mechanism contributes to the development of ascites in the abdominal cavity. D: Incorrect hyperaldosteronism is characterized by an excess of aldosterone a hormone that regulates sodium and water balance in cirrhosis sodium retention is often related to other mechanisms such as portal hypertension and hypoalbuminemia rather than hyperaldosteronism. C. Cirrhosis is more commonly associated with an activated renin angiotensin aldosterone system, leading to increased sodium and water retention, the increased renin angiotensin response is a compensatory mechanism to maintain perfusion in the setting o cirrhosis and does not contribute to decreased renal blood flow The nurse is planning care for an older adult client who experiences a cerebrovascular accident several weeks ago. The client has expressive aphasia (Broca's aphasia) and often becomes frustrated with the nursing staff. Which intervention should the nurse implement? A. Encourage clients use of picture charts B. Speak slowly to the client C. Ask the client simple questions D, Teach the client use of basic sign language A. Encourage the clients use of picture charts. which client has the highest risk for developing skin cancer? A. A 70 year old fair skinned client who works as a secretary. B, A 65 year old fair skinned client who works as a construction worker C. a 25 year old dark skinned client whose mother had skin cancer D. A 16 year old dark skinned client who tans in tanning beds once a week. B. A 65 year old fair skinned client who works as a construction worker which intervention should the nurse include in the teaching plan for a client with pruritis? A. Explain the importance of not taking any type of tub bath B Discourage the use of any type of skin lubricant C. Encourage the client to keep warm sleeping environment D. Instruct client to keep fingernails trimmed short D. Instruct the client to keep fingernails trimmed short One hour after major abdominal surgery a client in the post anesthesia care unit (PACU) has a BP of 136/80. Fifteen minutes later it is 114/72 which actions should the nurse take first? A. Increase frequency of BP assessments B. Encourage the client to breathe deeply C. Check abdominal surgical dressing D. Review the clients baseline BP trends C. Check the abdominal surgical dressing When explaining dietary guidelines to a client with acute glomerulonephritis (AGN) which instruction should the nurse include in the dietary teaching? A. select a protein rich food daily B. Restrict sodium intake C. Eat high potassium foods D. Avoid foods high in carbohydrates B. Restrict sodium intake Two days after a nephrectomy the client reports abdominal pressure and nausea. which assessment should the nurse implement? A. Auscultate bowel sounds B. Ambulate the client in the hallway C. Palpate the abdomen D. Measure hourly urine output A. Auscultate bowel sounds A client with urolithiasis is preparing for discharge after lithotripsy. which intervention should the nurse include in the clients postoperative discharge instructions? A. Report when hematuria becomes pink tinged B. Use an incentive spirometer C, Monitor urinary stream for decrease in output C. Monitor urinary stream for decrease in output A male client who had abdominal surgery 5 days ago and hospitalized because of a surgical wound infection, tells the nurse that he feels like insides just spilled out when he coughed. What action should the nurse take first? A. Visualize the abdominal incision B. Notify the healthcare provider C. Obtain sterile towels soaked in saline D. Assure the client that such feelings occur with wound infections. A. Visualize the abdominal incision A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions how should the nurse respond? A. Describe the use of an elimination diet to find trigger foods. B. Instruct the client to avoid foods with gluten such as wheat bread C. Explain that the need to restrict fluids is the primary limitation D. Advise the client to limit foods that are high in calcium and iron A. Describe the use of an elimination diet to find trigger foods A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic which assessment data should the nurse obtain next? A. Blood pressure B. Capillary glucose C. Oxygen saturation D. Body temperature A. Blood pressure A client with type 1 diabetes mellitus reports blood glucose levels between 180 and 210 upon wakening each time also reports experiencing an increase in disturbing dreams and diaphoresis during the night. Which instruction should the nurse include for the client? A. Check blood glucose during the night B. Have the glucose monitor recalibrated C. Eat a high carbohydrate snack before bed D. Report to the clinic for a fasting serum glucose A. Check blood glucose during the night which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers? A. Lean beef, salads, and baked potatoes B. Chicken, rice, and wheat products, C. Potatoes, low fat breads and applesauce D. Oatmeal, raisins, and fruit with skin D. Oatmeal, raisins, and fruit with skin A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self monitoring blood glucose (SMBG) and hemoglobin A1C. which statement by the client indicates teaching has been effective? A. I will use a lancing device on the center of my finger pad for a drop of blood B. I will inform the healthcare provider (HCP) of my average HbA1C results weekly. C. I will wash my hands with warm soapy water before sticking my finger D. I will document my HbA1C results from SMBG monitor every morning, C. I will wash my hands with warm soapy water before sticking my finger Which instruction should the nurse include in the discharge teaching plan of a client who has started treatment for a newly diagnosed diabetes insipidus? A. weigh yourself every day at the same time B. Check your blood sugar prior to each meal C. Keep legs elevated to reduce swelling D. Restrict fluids to half the volume of urine output A. weight yourself everyday at the same time While performing a neurovascular assessment distal to a clients fracture site the nurse determines that the clients pulse is present, regular and full. Which nursing action should be taken next? A. Notify the healthcare provider of assessment finding B. Document the neurovascular assessment as normal C. Discontinue elevating the clients affected extremity D. Assess for color, feeling, discomfort, and movement D. Assess for color, feeling, discomfort and movement Two hours before a clients scheduled surgery the nurse is completing the preoperative checklist. Which information requires the most immediate actin by the nurse Reference range 3.5-5.0 A. Surgical consent form is not signed B. Clients pulse oximeter reading is 96% C. Preoperative chest xray report is not available D. Preoperative serum potassium level 2.8 D. Preoperative serum potassium level 2.8 The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum? A. Breathe deeply followed by coughing up the sputum B. Restrict fluids before expectorating the sputum specimen C, Obtain the specimen before bedtime D. Avoid mouth care prior to collecting the sputum. A. Breath deeply followed by coughing up the sputum The nurse is obtaining the admission history for a client with suspected ulcer disease (PUD) which objective data reported by the client supports this medical diagnosis? A. Severe abdominal cramps and diarrhea after eating spicy foods B. Frequent use of chewable and liquid antacids for indigestion C. Upper and mid abdominal pain is described as gnawing and burning D. Marked loss of weight and appetite over the last 3 or 4 months A. Upper and mid abdominal pain is described as gnawing and burning Five months following treatment for herpes zoster (shingles) an older adult client tells the home health nurse of continuing to experience pain where the rash occurred. which action should the nurse A. Complete an assessment of the clients pain B. Determine if the client has had a shingles vaccination C. Teach the client about phantom pain symptoms D. Perform a complete mental status exam A. Complete an assessment of the clients pain The nurse calls the health care provider because a client diagnosed with an aortic aneurysm (AAA) is reporting of low back pain Which additional information about the client would be important for the nurse to tell the health care provider? A. Calcium level and skin condition B. Serum amylase and level of consciousness C. Hematocrit and blood pressure D. White blood cell count and heart rate C. Hematocrit and blood pressure A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI which parameters are most important for the nurse to plan to carefully monitor? A. Elevated creatinine and blood urea nitrogen (BUN) B. Side effects of total parenteral nutrition (TPN) and intralipids C. Uremic irritation of mucous membranes and skin surfaces D. Hypovolemia and ECG Changes D. Hypovolemia and ECH changes An adult woman with primary Raynaud's phenomenon develops pallor and then cyanosis of her fingers. After warming her hands the fingers turn red and the client reports burning sensation. What action should the nurse take? A, Report the finding to the healthcare provider as soon as possible B. Continue to monitor the fingers until color returns to normal C. Secure a pulse oximeter to clients oxygen saturation D. Apply a cool compress to the affected fingers for 20 minutes B. Continue to monitor the fingers until color returns to normal Which information should the nurse include when giving discharge instructions to a client following a left eye cataract extraction with a lens implant? A. Administer a stool softener B. Observe pupil response of the right eye C. Turn, cough and deep breathe every 2 hours D. Sleep flat in a supine position A. Administer a stool softner A client receives a prescription for ciprofloxacin 400 mg intravenously (IV) every 12 hours to be infused over an hour. The IV bag contains ciprofloxacin 400 mg in dextrose 5% in water (DW) 200 mL. The nurse should program the infusion pump to deliver how many mL/hr? 200 while assessing a client with degenerative joint disease the nurse observes Heberden's nodes, large prominences on the clients fingers that are reddened the client reports that the nodes are painful which action should the nurse take? A. Discuss approaches to chronic pain control with the client B. Review the clients dietary intake of high protein foods. C Notify the healthcare provider of the finding immediately D. Assess the clients radial pulses and capillary refill time A. Discuss approaches to chronic pain control with the client A nurse is performing a physical assessment on a client who has systemic lupus erythematosus (SLE). Which of the following finding should the nurse associate with SLE? SATA A. Arthralgia B. Hirutism C. Light tan stools D. Proteinuria E. Thrombocytopenia A. Arthralgia D. Proteinuria E. Thrombocytopenia A client with a right ulnar fracture and cast placement reports an increase in arm pain. which action should the nurse take next? A. Implement distraction techniques B. Assess right radial pulse volume C. Administer a PRN analgesic D. Measured the blood pressure B. Assess radial pulse volume A client tells the clinic nurse about experiencing burning on urination and assessment reveals that the client had sexual intercourse four days ago with a person who was a casual acquaintance, which action should the nurse implement? A. Observe the perineal area for chancroid like lesion B. Assess for perineal itching, erythema, and excoriation C. Identify all sexual partners in the last four days D. Obtain a specimen of urethral drainage for culture D. Obtain a specimen of urethral drainage for culture The nurse observes that a client with Parkinson's disease (PD) has a mask like face. Which follow up assessment is most important for the nurse to implement? A. Note the frequency of drooling B. Observe the appearance of oral mucosa C. Assess patterns of speech D. Determine the ability to chew and swallow D. Determine the ability to chew and swallow A client is admitted with a history of hypertension and an acute myocardial infarction 2 years ago. The client reports I am feeling weak and tired so I cannot exercise at all I feel out of breath when I walk even a short distance Since I cannot exercise I am gaining weight My shoes are even getting tight the cardiac monitor displays sinus tachycardia which cue should lead the nurse to further assess the client for other symptoms of right sided heart failure? A. Breathlessness B. Report of tight shoes C. Lack of exercise D. Weakness B. Report of tight shoes A client with orthopnea expresses concern about the ability to get enough air during a scheduled thoracentesis. On which information should the nurses response be based? A. Extra pillows can be used if needed to elevate the clients head B. The procedure is performed with the client in an upright position C. A thoracentesis is a brief procedure that has minimal discomfort D. Orthopnea is frequently caused by a clients uncontrolled anxiety B. The procedure is performed with the client in an upright position A client is to receive progesterone 10mg IM Daily The medication is labeled progesterone 50 mg/mL how many mL should the nurse administer 0.2 When caring for a client with a cervical spinal cord injury which intervention is the most important for the nurse to implement? A. Assess the extremity reflexes B. Logroll to change positions C. Immobilize the head in anatomical alignment D. Obtain hourly neurological assessments C. Immobilize the head in anatomical alignment NGN A 52 year old male is brought to the emergency department by his partner after noting he had a yellow tinge to his skin and eyes. Is alert but disorientated and not able to provide a history at this time, Currently has slurred speech and balance disturbance and the partner reports that the client has had about 12 beers today and also informs of alcohol use of approximately 12-16 beers Highlight nursing assessment Cardiovascular: Tachycardia, 2_ radial and pedal pulses. 2 second cap refill Respiratory: Clear breath sounds throughout bilateral lungs Gastrointestinal: Distended abdomen, reported diarrhea, denies nausea Genitourinary: Within normal limits (WL) per report of client Integumentary: Jaundice. Spider angiomas to the chest and abdominal generalized bruising in various states of healing Cardiovascular: Tachycardia Gastrointestinal: Distended abdomen Reports diarrhea Integumentary: Jaundice, spider angiomas to the chest and abdominal generalized bruising in various states of healing NGN A 52 year old male is brought to the emergency department (ED) by his partner after for each assessment finding click to indicate whehter findings from the clients assessment are associated with cerebral vascular accident, liver disorder or thrombocytopenia. Symptom or finding Thrombocytopenia Liver disorder Cerebral vascular accident Jaundice Generalized bruising Disorientation Hepatomegaly Slurred speech Jaundice: Liver disorder Generalized bruising: Liver disorder and thrombocytopenia Disorientation: CVA and liver disorder Hepatomegaly: liver disorder Slurred speech: CVA NGN: A 52 year old male is brought to the emergency department (ED) by his partner after For each potential nursing action click to indicate whether the action is indicated or contraindicated for this clients plan of care. Each row must have one response Assist with ambulation with 1 person assist Prepare to insert an esophageal balloon tamponade tube: Monitor for bleeding: Encourage a high calorie diet: Assess level of consciousness: Assist with ambulation with 1 person assist: Indicated Prepare to insert an esophageal balloon tamponade tube Indicated Monitor for bleeding: Indicated Encourage a high calorie diet: Contraindicated Assess level of consciousness: Indicated A 52 year old male is brought to the emergency department by his partner after The client is receiving care on the medical unit for two days the nurse completes a physical assessment and record the clients vital signs the client is evaluated to determine his response to treatment. which indicates that the client is responding to care SATA A. Jaundice of sclera B. Blood pressure 136/80 C. 180 mL clear amber urine in 4 hours D. Mild intermittent headaches e. Medium bowel movement that is soft brown F. Alert and orientated to person, place, time, and situation G. Nausea with meals H Mild dyspnea with exertion B: BP 136/81 C. 180 mL clear amber urine in 4 hrs E. Medium bowel movement that is soft brown F. Alert and orientated to person, place, time, and situation NGN: A 52 year old male is brought to the emergency by his partner after the health care provider places prescriptions for further diagnostics click to indicate if the listed symptoms are consistent with angina, myocardial, infarction or both Feeling of fear Pain only relieved by opioids Pain relieved by nitroglycerin Epigastric distress Occurring without cause Chest pain radiating down arm Feeling of fear: Both Pain only relieved by opioids: MI Pain relieved by nitroglycerin: Angina Epigastric distress: MI Occurring without cause : both Chest pain radiating down arm: MI NGN 36 year old female For each body system clinc to Hight light the findings that require follow up Neurological: Alert and orientated to person place time and situation Report generalized fatigue Mild headache Ringing in described as roaring Cardiovascular: Normal heart tones Denies chest pain Pulses 3_ Pedal pulses 2_ Dorsalis pedis 2_ Capillary n seconds Gastrointestinal: Denies nausea, vomiting and diarrhea, anorexia with 8lbs unintentional Weight loss over 2 m denies blood in stool Genitourinary: Reported chronic dysmenorrhea with menstrual bleeding Denies pain with urination Denies urine Uterus is palpated one finger breadth above symphysis Neurological: reported generalized fatigue Mild headache Ringing in ears described as roaring Gastrointestinal: Anorexia with 8lbs unintentional weight loss over 2 months Genitourinary: Chronic dysmenorrhea with menstrual bleeding NGN: 36 year old female Each column must have a least one response option selected. Statement Iron deficiency anemia Folic acid deficiency Vitamin B12 deficiency Often associated with chronic alcoholism Can be caused by malabsorption syndrome Uptake often impeded by medications Result of dietary deficiency Decreased hemoglobin and hematocrit levels Often associated with chronic alcoholism: Folic acid, vitamin b12 can be caused by malabsorption syndrome: Folic acid, vitamin b12 Uptake often impeded by medications: Iron deficiency, folic acid, vitamin b12 Result of dietary deficiency: Iron deficiency, folic acid, Vitamin b12 Decreased hemoglobin and hematocrit levels: Iron deficiency, folic acid, vitamin b12 NGN: 36 year old female The nurse reviews the results of the testing and is preparing a plan of care for the client Choose the most likely option for the information missing from the statement by selecting from the list of options provided. The nurse recognizes that the client is most at risk for Select response (Drop down) anemia as evidenced by increased mean corpuscular volume and decreased folate Folic acid deficiency NGN: 36 year old female Select 5 foods that the nurse should encourage the client to integrate into her diet to best address the diagnosis of folic acid deficiency anemia A. Potatoes B. Beef C. Vegetable oil D. Enriched grains E. Peanuts F. Avocado G. Green leafy vegetables H. Orange juice D. Enriched grains E. Peanuts F. Avocado G. Green leafy vegetables H. Orange juice NGN: 36 year old female Which findings indicate that the client is adhering to the treatment plan? SATA A. Complete blood count B. Subjective report from client C.. Vital signs D. Body mass index E. Record of medication administration F. Physical assessment G. Meal diary B. Subjective report client E. Record of medication administration G. Meal diary A 76 year old female was brought to the ED by ambulance, She had been receiving home health care due to decreased mobility and poorly controlled type 2 diabetes BOWTIE Condition the client is most likely experiencing two actions the nurse should take to address that condition and two parameters the nurse should monitor to assess the clients progress Actions to take: Consult diabetic education Encourage ambulation Draw blood for STAT laboratory Prescriptions Educate on foot care Potential conditions: DVT Diabetic neuropathy Vascular disease Pulmonary embolism Parameters to monitor: Foot ulcer development Blood glucose Heparin therapy lung sounds Telemetry Actions to take: Draw blood for stat laboratory prescriptions Consult diabetic educator Potential conditions DVT Parameters to monitor Blood glucose Lung sounds A 78 year old male visits his primary healthcare provider reporting an increase in urinary urgency and frequency Choose the most likely options for the information missing from the statment by selecting from the lists of options provided The nurse recognizes that the client has _______ and________incontinence which may be caused by benign prostate hyperplasia (BPH) Stress Bladder retention Decreased urine production Overflow UTI functional overflow functional a 43 year old female arrives to the emergency department reporting pain in her abdomen BOWTIE Condition the client is most likely experiencing two actions the nurse should take to address that condition two parameters the nurse should monitor to assess the clients progress Actions to take Prepare for surgery Apply an abdominal binder Order low fat diet Transfer to high risk level of care Educate on Potential conditions Abdominal hernia Gallstones GERD Peptic ulcer disease Parameters to monitor: Surgical site signs and symptoms of abdominal perforation reflux pain Actions to take: Prepare for surgery Order low fat diet Potential conditions Gallstones Parameters to monitor Pain Signs and symptoms of abdominal perforation