MED SURG HESI EXIT EXAM Latest Update 2023/2024 Test Bank with Latest Questions

MED SURG HESI EXIT EXAM Latest Update 2023/2024 Test Bank Following discharge teaching, a male client with duodenal ulcer tells the nurse thehe will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse? (ANS- Review with the client the need to avoid foods that are rich in milk andcream A male client with hypertension, who received new antihypertensive prescriptionsat his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? (ANS- Stroke secondary to hemorrhage The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing soft pillows along the side rails. What action should the nurse implement? (ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead ofpillows. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediatefollow-up? (ANS- Describes life without purpose A client who recently underwear a tracheostomy is being prepared for discharge tohome. Which instructions is most important for the nurse to include in the discharge plan? (ANS- Teach tracheal suctioning techniques In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client'srespiratory rate is 14 breaths / minute. What action should the nurse implement? (ANS- Document the assessment data Rationale: reservoir bag should not deflate completely during inspiration and theclient's respiratory rate is within normal limits. During shift report, the central electrocardiogram (EKG) monitoring systemalarms. Which client alarm should the nurse investigate firs? (ANS- Respiratory apnea of 30 seconds During a home visit, the nurse observed an elderly client with diabetes slip andfall. What action should the nurse take first? (ANS- Check the client for lacerations or fractures At 0600 while admitting a woman for a schedule repeat cesarean section (C- Section), the client tells the nurse that she drank a cup a coffee at 0400 because shewanted to avoid getting a headache. Which action should the nurse take first? (ANS- Inform the anesthesia care provider After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2heart sounds. To determine if an S3 heart sound is present, what action should thenurse take first? (ANS- Listen with the bell at the same location A 66-year-old woman is retiring and will no longer have a health insurance through her place of employment. Which agency should the client be referred to bythe employee health nurse for health insurance needs? (ANS- Medicare A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer.Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client's teaching plan? (ANS- Further evaluation involving surgery may be needed A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline?(ANS- Toasted wheat bread and jelly Following a lumbar puncture, a client voices several complaints. What complaintindicated to the nurse that the client is experiencing a complication? (ANS- "I have a headache that gets worse when I sit up" "I am having pain in my lower back when I move my legs""My throat hurts when I swallow" "I feel sick to my stomach and am going to throw up" An elderly client seems confused and reports the onset of nausea, dysuria, andurgency with incontinence. Which action should the nurse implement? (ANS- Obtain a clean catch mid-stream specimen The nurse is assisting the mother of a child with phenylketonuria (PKU) to selectfoods that are in keeping with the child's dietary restrictions. Which foods are contraindicated for this child? (ANS- Foods sweetened with aspartame Before preparing a client for the first surgical case of the day, a part-time scrub nurse asks the circulating nurse if a 3 minute surgical hand scrub is adequate preparation for this client. Which response should the circulating nurse provide? (ANS- Direct the nurse to continue the surgical hand scrub for a 5 minute duration Which breakfast selection indicates that the client understands the nurse'sinstructions about the dietary management of osteoporosis? (ANS- Bagel with jelly and skim milk The charge nurse of a critical care unit is informed at the beginning of the shift thatless than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)? (ANS- An 82-year-old client with Alzheimer's disease newly-fractures femur whohas a Foley catheter and soft wrist restrains applied A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician's office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child's foot. Which action should the nurseimplement first? -Cleanse the foot with soap and water and apply an antibiotic ointment -Provide teaching about the need for a tetanus booster within the next 72hours. -have the mother check the child's temperature q4h for the next 24 hours -transfer the child to the emergency department to receive a gamma globulininjection (ANS- Cleanse the foot with soap and water and apply an antibiotic ointment The mother of an adolescent tells the clinic nurse, "My son has athlete's foot, I have been applying triple antibiotic ointment for two days, but there has been noimprovement." What instruction should the nurse provide? (ANS- Stop using the ointment and encourage complete drying of the feet andwearing clean socks. A 26-year-old female client is admitted to the hospital for treatment of a simplegoiter, and levothyroxine sodium (Synthroid) is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client? The client experiences Bradycardia and constipation Lethargy and lack of appetite Muscle cramping and dry, flushed skin Palpitations and shortness of breath (ANS- Palpitations and shortness of breath A client with a history of heart failure presents to the clinic with nausea, vomiting,yellow vision and palpitations. Which finding is most important for the nurse to assess to the client? (ANS- Obtain a list of medications taken for cardiac history The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pumpto deliver how many ml/hour? (Enter numeric value only.) (ANS- 75 Rationale: Convert mg to mcg and use the formula D/H x Q. 300 mcg/hour / 1,000mcg x 250 ml = 3/1 x 25 = 75 ml/hour The pathophysiological mechanisms that are responsible for ascites related to liverfailure? (Select all that apply) (ANS- Fluid shifts from intravascular to interstitial area due to decreased serumprotein Increased hydrostatic pressure in portal circulation increases fluid shifts intoabdomen Increased circulating aldosterone levels that increase sodium and water retention The nurse is auscultating a client's heart sounds. Which description should thenurse use to document this sound? (Please listen to the audio first to select theoption that applies) (ANS- Murmur Rationale: A murmur is auscultated as a swishing sound that is associated with theblood turbulence created by the heart or valvular defect. The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500 mg vial is labeled with the instruction to add 5.3 ml diluentto provide a concentration of 100 mg/ml. How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is required, round to the nearest tenth) (ANS- 0.4 Rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml The nurse notes that a client has been receiving hydromorphone (Dilaudid) everysix hours for four days. What assessment is most important for the nurse to complete? Auscultate the client's bowel sounds Observe for edema around the ankles Measure the client's capillary glucose level Count the apical and radial pulses simultaneously(ANSAuscultate the client's bowel sounds Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis andfrequently causes constipation, so it is most important to Auscultate the client's bowel sounds A female client is admitted with end stage pulmonary disease is alert, oriented, andcomplaining of shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops breathing, and she asks the nurse to document this in her medical record. What action should the nurse implement? (ANS- Ask the client to discuss "do not resuscitate" with her healthcare provider A client is receiving a full strength continuous enteral tube feeding at 50 ml/hourand has developed diarrhea. The client has a new prescription to change the feeding to half strength. What intervention should the nurse implement? (ANS- Add equal amounts of water and feeding to a feeding bag and infuse at50ml/hour A female client reports that her hair is becoming coarse and breaking off, that the outer part of her eyebrows have disappeared, and that her eyes are all puffy. Whichfollow-up question is best for the nurse to ask? (ANS- Have you noticed any changes in your fingernails? Rationale: The pattern of reported manifestations is suggestive of hypothyroidism After a third hospitalization 6 months ago, a client is admitted to the hospital withascites and malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up blood. What assessment finding warrants immediateintervention by the nurse? Capillary refill of 8 seconds Bruises on arms and legs Round and tight abdomen Pitting edema in lower legs (ANS- Capillary refill of 8 seconds After the nurse witnesses a preoperative client sign the surgical consent form, thenurse signs the form as a witness. What are the legal implications of the nurse's signature on the client's surgical consent form? (Select all that apply) (ANS- The client voluntarily grants permission for the procedure to be doneThe client is competent to sign the consent without impairment of judgmentThe client understands the risks and benefits associated with the procedure Following surgery, a male client with antisocial personality disorder frequentlyrequests that a specific nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the charge nurse implement? (ANS- Advise the client that assignments are not based on clients requests A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiationimplant in the bed. What action should the nurse take? (ANS- Place the implant in a lead container using long-handled forceps The client with which type of wound is most likely to need immediate interventionby the nurse? Laceration Abrasion Contusion Ulceration (ANS- Laceration Rationale: A laceration is a wound that is produced by the tearing of soft body tissue. This type of wound is often irregular and jagged. A laceration wound is often contaminated with bacteria and debris from whatever object caused the cut. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion inthis client's plan of care? (ANS- Monitor blood pressure frequently Rationale: A pheochromocytoma is a rare, catecholamine-secreting tumor that mayprecipitate life-threatening hypertension. The tumor is malignant in 10% of cases but may be cured completely by surgical removal. Although pheochromocytoma has classically been associated with 3 syndromes—von Hippel-Lindau (VHL) syndrome, multiple endocrine neoplasia type 2 (MEN 2), and neurofibromatosis type 1 (NF1)—there are now 10 genes that have been identified as sites of mutations leading to pheochromocytoma. When caring for a client who has acute respiratory distress syndrome (ARDS), thenurse elevates the head of the bed 30 degrees. What is the reason for this intervention? To reduce abdominal pressure on the diaphragm To promote retraction of the intercostal accessory muscle of respirationTo promote bronchodilation and effective airway clearance To decrease pressure on the medullary center which stimulates breathing (ANS- Toreduce abdominal pressure on the diaphragm Rationale: a semi-sitting position is the best position for matching ventilation andperfusion and for decreasing abdominal pressure on the diaphragm, so that the client can maximize breathing. When assessing a mildly obese 35-year-old female client, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral borderof the rectus abdominal muscle. What is the most likely explanation for failure tolocate the gallbladder by palpation? The client is too obese Palpating in the wrong abdominal quadrantDeeper palpation technique is needed The gallbladder is normal (ANS- The gallbladder is normal Rationale: a normal healthy gallbladder is not palpable A woman with an anxiety disorder calls her obstetrician's office and tells the nurseof increased anxiety since the normal vaginal delivery of her son three weeks ago.Since she is breastfeeding, she stopped taking her antianxiety medications, but thinks she may need to start taking them again because of her increased anxiety. What response is best for the nurse to provide this woman? Describe the transmission of drugs to the infant through breast milk Encourage her to use stress relieving alternatives, such as deep breathing exercisesInform her that some antianxiety medications are safe to take while breastfeeding Explain that anxiety is a normal response for the mother of a 3-week-old. (ANS- Inform her that some antianxiety medications are safe to take while breastfeeding Rationale: there are several antianxiety medications that are not contraindicated forbreastfeeding mothers. An older male client with a history of type 1 diabetes has not felt well the past fewdays and arrives at the clinic with abdominal cramping and vomiting. He is lethargic, moderately, confused, and cannot remember when he took his last dose of insulin or ate last. What action should the nurse implement first? Start an intravenous (IV) infusion of normal salineObtain a serum potassium level Administer the client's usual dose of insulin Assess pupillary response to light (ANS- Start an intravenous (IV) infusion ofnormal saline Rationale: the nurse should first start an intravenous infusion of normal saline toreplace the fluids and electrolytes because the client has been vomiting, and it is unclear when he last ate or took insulin. The symptoms of confusion, lethargy, vomiting, and abdominal cramping are all suggestive of hyperglycemia, which alsocontributes to diuresis and fluid electrolyte imbalance. A client who received multiple antihypertensive medications experiences syncopedue to a drop in blood pressure to 70/40. What is the rationale for the nurse's decision to hold the client's scheduled antihypertensive medication? Increased urinary clearance of the multiple medications has produced diuresis andlowered the blood pressure. The antagonistic interaction among the various blood pressure medications hasreduced their effectiveness. The additive effect of multiple medications has caused the blood pressure to droptoo low. The synergistic effect of the multiple medications has resulted in drug toxicity andresulting hypotension. (ANS- The additive effect of multiple medications has caused the blood pressure to drop too low Which client is at the greatest risk for developing delirium?An adult client who cannot sleep due to constant pain. An older client who attempted 1 month ago A young adult who takes antipsychotic medications twice a day A middle-aged woman who uses a tank for supplemental oxygen (ANS- An adultclient who cannot sleep due to constant pain. Which intervention should the nurse include in a long-term plan of care for a clientwith Chronic Obstructive Pulmonary Disease (COPD)? Reduce risks factors for infection Administer high flow oxygen during sleepLimit fluid intake to reduce secretions Use diaphragmatic breathing to achieve better exhalation (ANS- Reduce risksfactors for infection Which location should the nurse choose as the best for beginning a screeningprogram for hypothyroidism? A business and professional women's group. An African-American senior citizens center A daycare center in a Hispanic neighborhood An after-school center for Native-American teens (ANS- A business andprofessional women's group. A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling"very tired". Which nursing intervention is most important for the nurse to implement? Measure vital signs Auscultate breath sounds Palpate the abdomen Observe the skin for bruising (ANS- Measure vital signs A male client reports the onset of numbness and tingling in his fingers and aroundhis mouth. Which lab is important for the nurse to review before contacting the health care provider? Capillary glucose Urine specific gravitySerum calcium White blood cell count (ANS- Serum calcium What explanation is best for the nurse to provide a client who asks the purpose ofusing the logrolling technique for turning? Working together can decrease the risk for back injury The technique is intended to maintain straight spinal alignment.Using two or three people increases client safety. Turning instead of pulling reduces the likelihood of skin damage (ANS- Thetechnique is intended to maintain straight spinal alignment. A client receiving chemotherapy has severe neutropenia. Which snack is best forthe nurse to recommend to the client? (ANS- Baked apples topped with dried raisins Which action should the school nurse take first when conducting a screening forscoliosis? (ANSInspect for symmetrical shoulder height. An unlicensed assistive personnel (UAP) assigned to obtain client vital signs reports to the charge nurse that a client has a weak pulse with a rate of 44 beat/minutes. What action should the charge nurse implement? (ANS- Assign a practical nurse (LPN) to determine if an apical radial deficit is present After a sudden loss of consciousness, a female client is taken to the ED and initial assessment indicate that her blood glucose level is critically low. Once her glucoselevel is stabilized, the client reports that was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan? (ANSEncourage a low- carbohydrate and high-protein diet A client with a peripherally inserted central catheter (PICC) line has a fever. Whatclient assessment is most important for the nurse to perform? (ANS- Observe the antecubital fossa for inflammation. The nurse administers an antibiotic to a client with respiratory tract infection. Toevaluate the medication's effectiveness, which laboratory values should the nursemonitor? Select all that apply (ANS- White blood cell (WBC) count Sputum culture and sensitivity A client is admitted to isolation with the diagnosis of active tuberculosis. Which infection control measures should the nurse implement? Negative pressure environment Contact precautions Droplet precautions Protective environment (ANS- Negative pressure environment A school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In what position should the nurse place the child? (ANS- Sitting up andleaning forward A young adult who is hit with a baseball bat on the temporal area of the left skull isconscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma? (ANS- Altered consciousness within the first 24 hours after injury. A female client with breast cancer who completed her first chemotherapy treatmenttoday at an out-patient center is preparing for discharge. Which behavior indicates that the client understands her care needs (ANS- Rented movies and borrowed books to use while passing time at home Which instruction should the nurse provide a pregnant client who is complainingof heartburn? (ANS- Eat small meal throughout the day to avoid a full stomach. A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitorclosely? Hypokalemia Ketonuria. Peripheral edema Elevated blood pressure (ANS- Hypokalemia Rationale: pituitary tumors that suppress antidiuretic hormone (ADH) result indiabetes insipidus, which causes massive polyuria and serum electrolyte imbalances, including hypokalemia, which can lead to lethal arrhythmias. A female client reports she has not had a bowel movement for 3 days, but now isdefecating frequent small amount of liquid stool. Which action should the nurse implement? (ANS- Digitally check the client for a fecal impaction After changing to a new brand of laundry detergent, an adult male reports that hehas a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse? (ANSBilateral Wheezing. The nurse should teach the parents of a 6 year-old recently diagnosed with asthmathat the symptom of acute episode of asthma are due to which physiological response? (ANSInflammation of the mucous membrane & bronchospasm A 10 year old who has terminal brain cancer asks the nurse, "What will happen to my body when I die?" How should the nurse respond? (ANS- "The heart will stopbeating & you will stop breathing." The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. Thischild should be medicated for pain based on which findings? Select all that apply: Restlessness Clenched Fist Increased pulse rate Increased respiratory rate. Increased temperature Peripheral pallor of the skin (ANS- Restlessness Clenched Fist Increased pulse rate Increased respiratory rate. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping and, aspiration pneumonia. What is the prioritynursing assessment that should be done before administering this medication? (ANS- Determine which side of the body is weak. The nurse who is working on a surgical unit receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires themost immediate attention by the nurse? Gunshot wound three hours ago with dark drainage of 2 cm noted on the dressing.Mastectomy 2 days ago with 50 ml bloody drainage noted in the Jackson-pratt drain. Collapsed lung after a fall 8h ago with 100 ml blood in the chest tube collectioncontainer Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. (ANS- Abdominal-perineal resection 2 days ago with no drainageon dressing who has fever and chills. Rationale: the client with an abdominal- perineal resection is at risk for peritonitisand needs to be immediately assessed for other signs and symptoms for sepsis. The nurse is caring for a client who had gastric bypass surgery yesterday. Whichintervention is most important for the nurse to implement during the first 24 postoperative hours? (ANSMeasure hourly urinary output. Rationale: a serious early complications of gastric bypass surgery is ananastomoses leak, often resulting in death. When preparing to discharge a male client who has been hospitalized for an adrenal crisis, the client expresses concern about having another crisis. He tells thenurse that he wants to stay in the hospital a few more days. Which intervention should the nurse implement? (ANS- Schedule an appointment for an out-patient psychosocial assessment. An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first? (ANS- Explore client's readiness to discuss thesituation. In caring for a client with Cushing syndrome, which serum laboratory value ismost important for the nurse to monitor? Lactate Glucose Hemoglobin Creatinine (ANS- Glucose Azithromycin is prescribed for an adolescent female who has lower lobe pneumonia and recurrent chlamydia. What information is most important for the nurse to provide to this client? (ANS- Use two forms of contraception while takingthis drug. A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48h. Based on these finding, it ismost important for the nurse to review the laboratory value for which medication?(ANS- Divalproex. Rationale: divalproex is the first line of treatment for bipolar disorder BPD becauseit has a high therapeutic index, few side effects, and a rapid onset in controlling symptoms and preventing recurrent episodes of mania and depression. The serum value of divalproex should be determined since the client is exhibiting symptoms of mania, which may indicate noncompliance with the medication regimen. A male client who is admitted to the mental health unit for treatment of bipolardisorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? (ANS- Serum lithium level of 1.6 mEq/L or mmol/l (SI) Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/L or mmol/l(SI). Slurred speech and ataxia are sign of lithium toxicity. A client was admitted to the cardiac observation unit 2 hours ago complaining of chest pain. On admission, the client's EKG showed bradycardia, ST depression, butno ventricular ectopy. The client suddenly reports a sharp increase in pain, telling the nurse, "I feel like an elephant just stepped on my chest" The EKG now shows Q waves and ST segment elevations in the anterior leads. What intervention shouldthe nurse perform? (ANSAdminister prescribed morphine sulfate IV and provide oxygen at 2 L/min per nasal cannula. The nurse is developing a teaching program for the community. What populationcharacteristic is most influential when choosing strategies for implementing a teaching plan? (ANS- Literacy level A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet? (ANS- Eat approximated the same amount of leafy green vegetables daily so the amount ofvitamin K consumed is consistent. A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but isreadmitted today because of diarrhea and dehydration. It is most important for thenurse to implement which intervention. (ANSMaintain contact transmission precaution A postoperative female client has a prescription for morphine sulfate 10 mg IV q3hours for pain. One dose of morphine was administered when the client was admitted to the post anesthesia care unit (PACU) and 3 hours later, the client is again complaining of pain. Her current respiratory rate is 8 breaths/minute. What action should the nurse take? (ANS- Administer Naxolone IV Which intervention is most important for the nurse to include in the plan of care foran older woman with osteoporosis? (ANS- Place the client on fall precautions Based on the information provided in this client's medical record during labor, which should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to viewall information contained in the client's medical record.) (ANS- Continue to monitor the progress of labor. An unlicensed assistive personnel UAP leaves the unit without notifying the staff.In what order should the unit manager implement this intervention to address the UAPs behavior? (Place the action in order from first on top to last on bottom.) (ANS- 1. Note date and time of the behavior. 2. Discuss the issue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluate the UAP for signs of improvement. A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated ringer's at 100 ml/H. which finding ismost important for the nurse to report to the healthcare provider? (ANS- Serumpotassium level of 3.1 mEq/L or mmol/L (SI) Rationale: The normal potassium level in the blood is 3.5-5.0 milliEquivalents perliter (mEq/L). Which type of Leukocyte is involved with allergic responses and the destruction ofparasitic worms? Neutrophils Lymphocytes Eosinophils Monocytes (ANS- Eosinophils Rationale: Eosinophils are involved in allergic responses and the destruction ofparasitic worms. The healthcare provider prescribes the antibiotic cephradine 500mg PO every 6hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat? (ANS- Yogurt and/or buttermilk. Several months after a foot injury, and adult woman is diagnosed with neuropathicpain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will "finally go away." How should the nurse respond? (ANS- Assist the client in developing a goal ofmanaging the pain One day following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nursedetermines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk? (ANSNeurovascular and circulation compromiserelated to compartment syndrome. The nurse is completing a head to be assessment for a client admitted forobservation after falling out of a tree. Which finding warrants immediate intervention by the nurse? (ANS- Clear fluid leaking from the nose. A client with multiple sclerosis (MS) has decreased motor function after taking ahot bath (Uhthoff's sign). Which pathophysiological mechanism supports this response? (ANSTemporary vasodilation While assessing a radial artery catheter, the client complains of numbness and paindistal to the insertion site. What interventions should the nurse implement? (ANS- Promptly remove the arterial catheter from the radial artery. A client is admitted with an epidural hematoma that resulted from a skateboardingaccident. To differentiate the vascular source of the intracranial bleeding, which finding should the nurse monitor? (ANS- Rapid onset of decreased level of consciousness. The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? (ANS- Positiona firm wedge to support pelvis and thorax at 30 degree tilt. When preparing a client for discharge from the hospital following a cystectomy and a urinary diversion to treat bladder cancer, which instruction is most importantfor the nurse to include in the client's discharge teaching plan? (ANS- Report any signs of cloudy urine output. For the past 24 hours, an antidiarrheal agent, diphenoxylate, has been administeredto a bedridden, older client with infectious gastroenteritis. Which finding requires the nurse to take further action? (ANS- Tented skin turgor. After repositioning an immobile client, the nurse observes an area of hyperemia.To assess for blanching, what action should the nurse take? (ANS- Apply light pressure over the area. The nurse enters a client's room and observes the client's wrist restraint secured asseen in the picture. What action should the nurse take? (ANS- Reposition the restraint tie onto the bedframe. A female client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while she is on as assist-control ventilator using 50% FIO2.Which assessment finding warrants immediate intervention by the nurse? (ANS- Diminished left lower lobe sounds Rationale: Diminished lobe sounds indicate collapsed alveoli or tension pneumothorax, which required immediate chest tube insertion to re-inflate thelung. The development of atherosclerosis is a process of sequential events. Arrange the pathophysiological events in orders of occurrence. (Place the first event on top andthe last on the bottom) (ANS- 1. Arterial endothelium injury causes inflammation 2. Macrophages consume low density lipoprotein (LDL), creating foam cells 3. Foam cells release growth factors for smooth muscle cells 4. Smooth muscle grows over fatty streaks creating fibrous plaques 5. Vessel narrowing results in ischemia Following a motor vehicle collision, an adult female with a ruptured spleen and a blood pressure of 70/44, had an emergency splenectomy. Twelve hours after the surgery, her urine output is 25 ml/hour for the last two hours. What pathophysiological reason supports the nurse's decision to report this finding to thehealthcare provider? (ANS- Oliguria signals tubular necrosis related to hypoperfusion A nurse-manager is preparing the curricula for a class for charge nurses. A staffingformula based on what data ensures quality client care and is most cost-effective? (ANS- Skills of staff and client acuity When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? (ANS- Explainthat the client may be placed in five positions A client presents in the emergency room with right-sided facial asymmetry. The nurse asks the client to perform a series of movements that require use of the facialmuscles. What symptoms suggest that the client has most likely experience a Bell'spalsy rather than a stroke? (ANSInability to close the affected eye, raise brow, or smile The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicated that the client understood the teaching? (ANSKeeps the irrigating container less than 18 inchesabove the stoma The nurse should teach the client to observe which precaution while takingdronedarone? (ANSAvoid grapefruits and its juice A client who sustained a head injury following an automobile collision is admittedto the hospital. The nurse include the client's risk for developing increased intracranial pressure (ICP) in the plan of care. Which signs indicate to the nurse that ICP has increased? Increased Glasgow coma scale score. Nuchal rigidity and papilledema. Confusion and papilledema Periorbital ecchymosis. (ANS- Confusion and papilledema Rationale: papilledema is always an indicator of increased ICP, and confusion isusually the first sign of increased ICP. Other options do not necessarily reflect increased ICP. The nurse is caring for a client receiving continuous IV fluids through a single lumen central venous catheter (CVC). Based on the CVC care bundle, which action should be completed daily to reduce the risk for infection? (ANS- Confirmthe necessity for continued use of the CVC. During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl or 7.8 mmol/L (SI). Which additional findingobtained during a follow-up visit 2 weeks later is most indicative that the client hasdiabetes mellitus (DM)? (ANSRepeated fasting blood sugar (FBS) is 132 mg/dl or 7.4 mmol/L (SI). A new mother tells the nurse that she is unsure if she will be able to transition intoparenthood. What action should the nurse take? (ANS- Determine if she can ask for support from family, friend, or the baby's father. A client who was admitted yesterday with severe dehydration is complaining of pain a 24 gauge IV with normal saline is infusing at a rate of 150 ml/hour. Whichintervention should the nurse implement first? (ANS- Stop the normal saline infusion. An elderly female is admitted because of a change in her level of sensorium. During the evening shift, the client attempts to get out bed and falls, breaking herleft hip. Buck's skin traction is applied to the left leg while waiting for surgery. Which intervention is most important for the nurse to include in this client's plancare? (ANSEnsure proper alignment of the leg in traction. An Unna boot is applied to a client with a venous stasis ulcer. One week later, when the Unna boot is removed during a follow-up appointment, the nurse observes that the ulcer site contains bright red tissue. What action should the nursetake in response to this finding? (ANS- Document the ongoing wound healing. At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." What is thepriority nursing diagnosis for this client? (ANS- Anxiety The nurse note a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What intervention should thenurse implement immediately? (ANS- Elevate the presenting part off the cord. A client who had a right hip replacement 3 day ago is pale has diminished breath sound over the left lower lung fields, a temperature of 100.2 F, and an oxygen saturation rate of 90%. The client is scheduled to be transferred to a skilled nursingfacility (SNF) tomorrow for rehabilitative critical pathway. Based on the client's symptoms, what recommendation should the nurse give the healthcare provider? (ANS- Reassess readiness for SNF transfer. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all thatapply.) (ANS- Recognize signs and symptoms of hypoglycemia. Report persist polyuria to the healthcare provider. Take Glucophage with the morning and evening meal. The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure thatthe educational materials include which characteristics? Select all that apply Written at a twelfth-grade reading level Contains a list with definitions of unfamiliar termsUses common words with few Syllables Printed using a 12 point type font Uses pictures to help illustrate complex ideas (ANS- Contains a list withdefinitions of unfamiliar terms Uses common words with few Syllables Uses pictures to help illustrate complex ideas Rationale: During the aging process older clients often experience sensory or cognitive changes, such as decreased vision or hearing acuity, slower thought orreasoning processes, and shorter attention span. Materials for this age group should include at least of terms, such as medical terminology that incline may not know and use common words that expresses information clearly and simply. Simple, attractive pictures help hold the learner'sattention. The reading level of material should be at the 4th to 5th grade level. Materials should be printed using large font (18-point or higher), not the standard12-point font. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI) (Click the chosen location.To change, click on a new location) (ANS- #117 An older male adult resident of long-term care facility is hospitalized for a cardiac catheterization that occurred yesterday. Since the procedure was conducted, the client has become increasingly disoriented. The night shift nurse reports that he attempted to remove the sandbag from his femoral artery multiple times during thenight. What actions should the nurse take? (Select all that apply.) (ANS- Notify thehealthcare provider of the client's change in mental status. Include q2 hour's reorientation in the client's plan of care. An older male comes to the clinic with a family member. When the nurse attemptsto take the client's health history, he does not respond to questions in a clear manner. What action should the nurse implement first? (ANS- Assess the surroundings for noise and distractions. The nurse caring for a client with acute renal fluid (ARF) has noted that the clienthas voided 800 ml of urine in 4 hours. Based on this assessment, what should the nurse anticipate that client will need? (ANS- Large amounts of fluid and electrolyte replacement. Which intervention should the nurse include in the plan of care for a child withtetanus? (ANS- Minimize the amount of stimuli in the room Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client's room. Which intervention is most important forthe nurse to implement? (ANS- Remove cigarettes for the client's room A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Selectall that apply.) (ANS- A client must be willing to accept palliative care, not curative care. The healthcare provider must project that the client has 6 months or less to live. A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client's teaching plan? (ANS- Avoid useof nonsteroidal antinflammatory drugs (NSAID). A nurse with 10 years experience working in the emergency room is reassigned tothe perinatal unit to work an 8 hour shift. Which client is best to assign to this nurse? (ANS- A mother with an infected episiotomy An infant who is admitted for surgical repair of a ventricular septal defect (VSD) isirritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? (ANS- Digoxin. The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should thecharge nurse assign to the RN? (ANS- Supervise a newly hired graduate nurse during an admission assessment. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should thenurse take? (ANS- Ask the client what he is thinking about at his time. After several hours of non-productive coughing, a client presents to the emergencyroom complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. Whilecompleting the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.) (ANS- Administer PRN nebulizer treatment. Obtain 12 lead electrocardiogram. Monitor continuous oxygen saturation. The nurse caring for a 3-month-old boy one day after a pylorotomy notices that theinfant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take? (ANS- Administer a prescribed analgesiafor pain. A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy(CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child? (ANS- Use sunblock or protective clothing when outdoors. Two days after admission a male client remembers that he is allergic to eggs, andinforms the nurse of the allergy. Which actions should the nurse implement? (Select all that apply) (ANSNotify the food services department of the allergy. Enter the allergy information in the client's record. Add egg allergy to the client's allergy arm band. The rapid response team's detects return of spontaneous circulation (ROSC) after 2min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation.What action should the nurse implement? (ANS- Perform bilateral chest auscultation. After administering an antipyretic medication. Which intervention should the nurseimplement? (ANS- Encouraging liberal fluid intake A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment?(ANS- Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should thenurse implement first? (ANSDetermine client's pulse, blood pressure, and respirations The nurse is caring for a group of clients with the help of a licensed practical nurse(LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply) (ANS- Take postoperative vital signs for a client who has an epidual following knee arthroplasty Collect a sputum specimen for a client with a fever of unknown originAmbulate a client who had a femoral-popliteal bypass graft yesterday A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should thenurse implement? (ANS- Raise the head of the bed to a Fowler's position and support his arms with a pillow A client with a history of chronic pain requests a nonopioid analgesic. The client isalert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next? (ANS- Administer the analgesic as requested Rationale: Chronic pain may be difficult to describe but should be treated withanalgesics as indicated. A client with a chronic health problem has difficulty ambulating short distance dueto generalized weakness, but is able to bear weight on both legs. To assist with ambulation and provide the greatest stability, what assistive device is best for this client? Crutches with 2 point gait. Crutches with 3 point gait. Crutches with 4 point gait. A quad cane (ANS- Crutches with 4 point gait. The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hoursfluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.) (ANSAnswer: 12160 Rationale: 4ml x 67kg x 40 (bsa) =12,160 ml A client with leukemia undergoes a bone marrow biopsy. The client's laboratory values indicate the client has thrombocytopenia. Based on this data, which nursingassessment is most important following the procedure? Observe aspiration site. Assess body temperature Monitor skin elasticity Measure urinary output (ANS- Observe aspiration site. An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? (ANS- Reinforce theimportance of annual papanicolaou (Pap) smears. A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first? (ANS- Establish a structured routinefor the client to follow. A client with history of bilateral adrenalectomy is admitted with a week, irregularpulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? (ANSVentricular arrhythmias. Rationale: adrenal crisis, a potential complication of bilateral adrenalectomy, results in the loss of mineralocorticoids and sodium excretions that is characterizedby hyponatremia, hyperkalemia, dehydration, and hypotension. Ventricular arrhythmias are life threatening and required immediate intervention to correct critical potassium levels. The mother of a 7-month-old brings the infant to the clinic because the skin in thediaper area is excoriated and red, but there are no blisters or bleeding. The motherreports no evidence of watery stools. Which nursing intervention should the nurse implement? (ANS- Instruct the mother to change the child's diaper more often. A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when droppingutensils on the floor and then refuses to eat. What action should the nurse implement? (ANS- Encourage the client to eat finger foods. A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication?(ANS- Bowel patterns Rationale: the client should be assessed for a change in bowel patterns to evaluate the effectiveness of this medication because Mesalamine is used to treat ulcerative colitis (a condition which causes swelling and sores in the lining of the colon [largeintestine] and rectum) and also to maintain improvement of ulcerative colitis symptoms. Mesalamine is in a class of medications called anti-inflammatory agents. It works by stopping the body from producing a certain substance that may cause inflammation. While in the medical records department, the nurse observes several old medicalrecords with names visible in waste container. What action should the nurse implement? (ANS- Contact the medical records department supervisor. A 16-year-old adolescent with meningococcal meningitis is receiving a continuousIV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 millionunits/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) (ANSAnswer 83 Rationale: 1000 ml ---------12hr. Xml----------- 1hr. 1000/12 = 83.33 = 83. While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first? (ANS- Submit a referral for an evaluation by a physical therapist. A client has an intravenous fluid infusing in the right forearm. To determine the client's distal pulse rate most accurately, which action should the nurse implement?(ANS- Palpate at the radial pulse site with the pads of two or three fingers. A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should thenurse implement? (ANS- Reposition the client with the head of the bed elevated. based on what they reason. A tour of the unit allows the child to see the hospitalenvironment and reinforce explanation and conceptual thinking. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client's arm? (ANS- AssessIV site frequently for signs of extravasation When developing a teaching plan for a client newly diagnosed type 1 diabetes, thenurse should explain that increased thirst is an early sign of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occurs? Resume normal physical activity Drink electrolyte fluid replacement Give a dose of regular insulin per sliding scale Measure urinary output over 24 hours. (ANS- Give a dose of regular insulin persliding scale Rationale: As hyperglycemia persists, ketone body becomes a fuel source, and theclient manifests early signs of DKA that include excessive thirst, frequent urination, headache, nausea, and vomiting. Which results in dehydration and loss of electrolyte. The client should determine fingersticks glucose level and self- administer a dose of regular insulin per sliding scale. The nurse is teaching a group of clients with rheumatoid arthritis about the need tomodify daily activities. Which goal should the nurse emphasize? Protect joint function Improve circulation Control tremors Increase weight bearing (ANS- Protect joint function An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the childfrom the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should thenurse take? (ANS- Ask the older brother how he felt during the incident. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client beginscoughing, as if strangled. What intervention is most important for the nurse to implement? (ANS- Hold oral intake until swallow evaluation is done. The nurse is interacting with a female client who is diagnosed with postpartumdepression. Which finding should the nurse document as an objective signs of depression? (Select all that apply) (ANS- Interacts with a flat affect. Avoids eye contact. Has a disheveled appearance. A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement? (ANS-Transfer the client to the surgical floor. In caring for the body of a client who just died, which tasks can be delegate to theunlicensed assistive personnel (UAP)? (Select all that apply.) (ANS- Place personal religious artifacts on the body. Attach identifying name tags to the body. Follow cultural beliefs in preparing the body. An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse providethe client about future antibiotic prescriptions? (ANS- Be alert for possible cross-sensitivity to cephalosporin agents. A client with a prescription for "do not resuscitate" (DNR) begins to manifest signsof impending death. After notifying the family of the client's status, what priority action should the nurse implement? (ANS- The client's need for pain medication should be determined. A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all thatapply.) Monitor abdominal girth. Increase oral fluid intake to 1500 ml daily.Report serum albumin and globulin levels. Provide diet low in phosphorous. Note signs of swelling and edema. (ANS- Monitor abdominal girth. Report serum albumin and globulin levels.Note signs of swelling and edema. Rational: monitoring for increasing abdominal girth and generalized tissue edema and swelling are focused assessments that provide data about the progression of disease related complications. In advanced cirrhosis, liver function failure results in low serum albumin and serum protein levels, which caused third spacing that results in generalized fluid retention and ascites. Other options are not indicated inend stage liver disease. During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? (ANS- Reportweight gain of 2 pounds (0.9kg) in 24 hours Which problem, noted in the client's history, is important for the nurse to be awareof prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)? (ANSAural migraine headaches. When implementing a disaster intervention plan, which intervention should thenurse implement first? Initiate the discharge of stable clients from hospital units Identify a command center where activities are coordinatedAssess community safety needs impacted by the disaster Instruct all essential off-duty personnel to report to the facility (ANS- Identify acommand center where activities are coordinated The nurse is evaluating a client's symptoms, and formulates the nursing diagnosis,"high risk for injury due to possible urinary tract infection." Which symptoms indicate the need for this diagnosis? (ANS- Fever and dysuria. A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurseimplement? (ANSMaintain both lower extremities elevated on pillows. A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). Toachieve maximum mobility and independence, which intervention is most important for the nurse to include in the client's plan of care? (ANS- Teach familyproper range of motion exercises. The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calciumsupplements daily. What information should the nurse include when teaching this client about osteoporosis prevention? (ANS- Postmenopausal women need an intake of at least 1,500 mg of calcium daily. When evaluating a client's rectal bleeding, which findings should the nursedocument? (ANSColor characteristics of each stool. The nurse is auscultating a client's lung sounds. Which description should the nurseuse to document this sound? High pitched or fine crackles. Rhonchi High pitched wheeze Stridor (ANS- High pitched or fine crackles. An adult male is admitted to the emergency department after falling from a ladder.While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? (ANS- Explain the reason for using only non-narcotics. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) (ANS- Weigh the client and report any weight gain. Report any client complaint of pain or discomfort. Note and report the client's food and liquid intake during meals and snacks. Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most importantfor the nurse to include in the client's plan of care? (ANS- Medicate as needed for pain and anxiety. An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a resultof this increases in glaucoma surgeries? (ANS- Decrease prevalence of glaucoma in the population. The nurse is caring for a client who is entering the second stage of labor. Whichaction should the nurse implement first? (ANS- Convey to the client that birth isimminent. To evaluate the effectiveness of male client's new prescription for ezetimibe, whichaction should the clinic nurse implement? (ANS- Remind the client to keep his appointments to have his cholesterol level checked. Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurseto include? (ANS- Fall prevention measures. A young adult client is admitted to the emergency room following a motor vehiclecollision. The client's head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as " Risk of injury" What term best expresses the "related to" portion of nursing diagnosis? Infection Increase intracranial pressure Shock Head Injury. (ANS- Shock An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? (ANS- Identify pills in the bag. A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to theclinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider? (ANS- New onset of purple skin lesions. In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement? (ANS- Ensure that no dependentloops are present in the tubing. The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mgPO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat? Yogurt and/or buttermilk. Avocados and cheese Green leafy vegetables Fresh fruits (ANS- Yogurt and/or buttermilk. The charge nurse is making an assignment on a psychiatric unit for a practical nurse (PN) and a newly licensed registered nurse (RN). Which client should beassigned to the RN? An adult female who has been depressed for the past several months and deniessuicidal ideations. A middle-aged male who is in a depressive phase on bipolar disease and isreceiving Lithium. A young male with schizophrenia who said voices is telling him to kill hispsychiatrist. An elderly male who tells the staff and other clients that he is superman and he canfly. (ANS- A young male with schizophrenia who said voices is telling him to kill his psychiatrist. Rationale: The RN should deal with the client with command hallucinations andthese can be very dangerous if the client acts on the commands, especially if thecommand is homicidal in nature. Other clients present low safety risks. A client at 30 week gestation is admitted due to preterm labor. A prescription of terbutaline sulfate 8.35 mg is gives subcutaneously. Based on which finding shouldthe nurse withhold the next dose of this drug? (ANS- Maternal pulse rate of 162 beats per min In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursingdiagnosis? (ANS- Anxiety related to fear of suffocation. A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletaltraction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client's a plan of care? (ANS- Provide daily care of tong insertion sites using saline and antibiotic ointment A client arrives on the surgical floor after major abdominal surg