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HESI Health Assessment Exam 3 2024
A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? - A multiparous client who is dilated 5 cm and 50% effaced A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? - Oral hygiene should be performed before the medication. A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? - Sitting upright and forward with both arms supported on an over the bed table A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide (HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? - The client's renal function has affected his potassium level. A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? - Sending medical records to health care providers via the Internet Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is elevated. B.Higher doses of opioids are required when cerebral blood flow is reduced by an elevated ICP. C.Dysphoria from opioids contributes to altered levels of consciousness with an elevated ICP. D.Opioids suppress respirations, which increases Pco2 and contributes to an elevated ICP. - D The greatest risk associated with opioids such as morphine (D) is respiratory depression that causes an increase in Pco2, which increases ICP and masks the early signs of intracranial bleeding in head injury. (A, B, and C) do not support the risks associated with opioid use in a client with increased ICP. The charge nurse of a medical surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A.Prepare to evacuate the unit, starting with the bedridden clients. B.UAPs should report to the emergency center to handle transports. C.The licensed staff should begin counting wheelchairs and IV poles on the unit. D.Continue with current assignments until more instructions are received. - D
When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received (D). Evacuation is typically a response of last resort that begins with clients who are most able to ambulate (A). (B) is premature and is likely to increase the chaos if incoming casualties are anticipated. (C) is poor utilization of personnel. The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? A.Ask the UAP to check for the advanced directive while the nurse completes the assessment. B.Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C.Check the medical record for the advanced directive and then complete the client assessment. D.Call for the charge nurse to check the advanced directive while continuing to assess the client. - D Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status (D). (A and B) are tasks that must be completed by a nurse and cannot be delegated to the UAP. (C) is contraindicated. The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP? A.Remove the client's nail polish and dentures. B.Assist the client to the restroom to void. C.Obtain the client's height and weight. D.Offer the client emotional support. - D By using therapeutic techniques to offer support (D), the nurse can determine any client concerns that need to be addressed. (A, B, and C) are all actions that can be performed by the UAP under the supervision of the nurse. Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP? A.An adolescent who was readmitted to the hospital because of a postoperative infection B.A woman with a new colostomy who requires discharge teaching C.A woman who had a hip replacement and may be transferred to the home care unit D.A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction - C The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs (A). The client is infected and an employee who works on an OB unit should be assigned to clean cases in case the employee is required to return to the OB unit (B). This requires the skills of a registered nurse (RN) to do discharge teaching and provide emotional support (D). This may require skills beyond the level of this UAP.
Syndrome of inappropriate antidiuretic hormone (SIADH) results from an abnormal production or sustained secretion of antidiuretic hormone, causing fluid retention, hyponatremia, and central nervous system (CNS) fluid shifts. The client's normalization of the serum sodium level (normal is 135 to 145 mEq/L) (D) is the most important outcome because sudden and severe hyponatremia caused by fluid overload can result in heart failure. Fluid retention of SIADH contributes to daily weight gain, which can predispose to peripheral edema (A), but the higher priority outcome is the effect on serum electrolyte levels. Although (B and C) are findings associated with resolving SIADH, they do not have the priority of (D). Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) A.Direct the client to sign a liability release form. B.Restrict the client's ability to leave the unit. C.Explain the benefits of remaining in the hospital. D.Instruct the client to take medications as prescribed. E.Provide the client with names of local support groups. F.Notify the health care provider of the client's intention. - CDF Correct responses are (C, D, and F). To maintain safety and to provide information, the nurse should explain the potential benefits of continuing treatment in the hospital (C) and the need to take prescribed medications (D). This client, who is very likely self-destructive, should remain on the unit and the health care provider should be notified (F). Signing a release form (A) before leaving the hospital does not contribute to safety. The nurse may ask the client not to leave the hospital (B), but pressuring clients is unethical behavior. (E) may be helpful at a later time in this client's treatment program. Which assessment finding indicates that nystatin (Mycostatin) swish and swallow, prescribed for a client with oral candidiasis, has been effective? A.The client denies dysphagia. B.The client is afebrile with warm and dry skin. C.The oral mucosa is pink and intact. D.There is no reflux following food intake. - C Mycostatin swish and swallow is prescribed for its local effect on the oral mucosa, reducing the white curdlike lesions in the mouth and larynx (C). The ability to swallow (A) does not indicate that the medication has been effective. (B and D) do not reflect effectiveness of the local medication. Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? A.A stage 3 sacral pressure ulcer, with colonized methicillin-resistant Staphylococcus aureus (MRSA) B.Pneumonia, with a sputum culture of gram-negative bacteria C.Urinary tract infection, with positive blood cultures
D.Culture of a diabetic foot ulcer shows gram-positive cocci - A The client with colonized MRSA (A) is the most stable client, because colonization does not cause symptomatic disease. The gram-negative organisms causing pneumonia are typically resistant to drug therapy (B), which makes recovery very difficult. Positive blood cultures (C) indicate a systemic infection. Poor circulation places the diabetic with an infected ulcer (D) at high risk for poor healing and bone infection. An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client? A.Turn off the client's television and speak very loudly. B.Communicate in writing whenever it is possible. C.Speak very slowly while exaggerating each word. D.Face the client and speak in a normal tone of voice. - D A hearing-impaired client frequently relies on lip reading and body language to determine what is being said, so (D) should be implemented. (A and C) may distort the sounds and facial expressions, which alters the client's ability to interpret the verbal message. Communicating in writing is another option that could be used if verbal or body language is ineffective (B). The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? A.Administer a nonsteroidal antiinflammatory drug (NSAID) to the child prior to getting the child out of bed in the morning. B.Apply ice packs to edematous or tender joints to reduce pain and swelling. C.Warm the child with an electric blanket prior to getting the child out of bed. D.Immobilize swollen joints during acute exacerbations until function returns. - C Early morning stiffness and pain are common symptoms of rheumatoid arthritis. Warming the child (C) in the morning helps reduce these symptoms. Although moist heat is best, an electric blanket could also be used to help relieve early morning discomfort. (A) on an empty stomach is likely to cause gastric discomfort. Warm (not cold) packs or baths are used to minimize joint inflammation and stiffness (B). (D) is contraindicated, because joints should be exercised, not immobilized. The health care provider prescribes 1000 mL of Ringer's lactate solution with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse should set the flow rate at how many gtt/min? A. B. C. D.250 - B Use the following calculation (B): 20 gtt/mL × (1000 mL/4 hr) × (1 hr/60 min) = 83 gtt/min
to participate while turning in the bed, during transfers in and out of bed, or performing upper arm exercises. The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A."What makes you think we did anything to your baby?" B."Are you or any of your blood relatives of Asian descent?" C."Those are stork bites and will go away in about 2 years." D."Those are Mongolian spots and will gradually fade in 1 or 2 years." - D Mongolian spots (D) are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African decent or dark-skinned babies. (A) is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African decent, (B) does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites (C), appear reddish-purple or red and are usually on the face or head and neck area. The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program? A.Parents of children with spina bifida B.High school girls in a health class C.Individuals interested in having children D.Postpartum women attending a baby care class - C Folic acid is needed early in pregnancy to prevent neural tube defects; the group most likely to be considering pregnancy is (C). Parents with children who already have a neural tube defect such as spina bifida (A) are not as invested in the content as (C). High school age students (B) may have interest in the topic but as a group are less likely to anticipate the likelihood that problems could occur in their lives than (C). (D) may be interested if planning future pregnancies, but have higher learning priorities during the postpartum period. A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? A."I will avoid coughing, sneezing, and forceful nose blowing." B."Swimming can begin on the tenth postoperative day." C."Any mild discomfort can be managed with acetaminophen." D."Drainage from my ears is expected after the surgery." - B The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims (B) or allows water to enter the external ear. (A, C, and D) reflect correct responses. A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? A.Help the client dangle his legs.
B.Apply compression stockings. C.Assist with passive leg exercises. D.Ambulate three times a day. - A The client who has arterial PVD may benefit from dependent positioning, and this can be achieved with bedside dangling (A), which will promote gravitation of blood to the feet, improve blood flow, and relieve pain. (B) is indicated for venous insufficiency (C) and indicated for bed rest. Ambulation (D) is indicated to facilitate collateral circulation and may improve long-term complaints of pain. Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A.Clients' names are not used while they are in a public waiting room. B.Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C.Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D.Old medical records are kept in a locked file cabinet in the department. - D Past medical records must be "secured" and "reasonably protected" from inadvertent viewing (D). A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without their diagnosis or treatment) is not considered confidential or PHI (A). Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous (B), but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions (C). Prior to administering an oral suspension, which intervention is most important for the nurse to implement? A.Assess the client's ability to swallow liquids. B.Obtain applesauce in which to mix the medication. C.Determine the client's food likes and dislikes. D.Auscultate the client's breath sounds. - A An oral suspension is a liquid, so the nurse needs to assess the client's ability to swallow liquids (A) to ensure that the client will not choke. If the client has difficulty swallowing liquids, a thickening substance may be used (B). If a food product is used to thicken the liquid, (C) would be beneficial. (D) may also be warranted, but only if the client is at risk for aspiration, determined by (A). A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond? A."Let's play some dominoes for a few minutes." B."I don't think the violence means the world is ending." C."The news makes you have upsetting thoughts." D."Listening to the news seems to be frightening you." - D A client's delusional statements are best addressed by identifying the feeling associated with the delusion (D). Distraction (A) may be helpful but ignores the feelings that the client is experiencing. Delusional clients often argue with statements that contradict their belief
A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? A.This feeling occurs during feeding with a breast infection. B.This sensation occurs as breast milk moves to the nipple. C.The baby does not have good latch-on. D.The infant is not positioned correctly. - B When the mother's milk comes in, usually 2 to 3 days after delivery, women often report they feel a tingling sensation in their nipples (B) when let-down occurs. (A, C, and D) provide inaccurate information. A comatose client is admitted to the critical care unit and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? A.Pain scale B.Vital signs C.Breath sounds D.Level of consciousness - C Before administering IV fluids through a central line, the nurse must first ensure that the catheter did not puncture the vessel or lungs. A chest radiograph should be obtained STAT, and the nurse should auscultate the client's breath sounds (C). (A, B, and D) are important assessment data but are not specifically related to insertion of a central venous catheter. The nurse is correct in withholding an older adult client's dose of nifedipine (Procardia) if which assessment finding is obtained? A.Blood pressure of 90/56 mm Hg B.Apical pulse rate of 68 beats/min C.Potassium level of 3.3 mEq/L D.Urine output of 200 mL in 4 hours - A Nifedipine (Procardia) is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male (A). A pulse rate less than 60 beats/min is an indication to withhold the drug (B). A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia (C). Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200- mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose (D). A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting? A.Hyperexcitability of reflexes B.Hyperextension of the head and back C.Inability to flex the chin to the chest D.Lateral facial paralysis - C Nuchal rigidity (neck stiffness) is a characteristic of meningeal irritation and is elicited by attempting to flex the neck and place the chin to the chest (C). Although (A, B, and D) may
occur in meningitis, (A) describes exaggerated spinal nerve reflex responses, (B) describes opisthotonus, and (D) may be related to cranial nerve pathology of the trigeminal nerve. An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of Clostridium difficile. While planning care, which nursing goal should the nurse establish as the priority? A.Fluid and electrolyte balance is maintained. B.Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C.Abdominal pain is relieved and perianal skin integrity is maintained. D.Normal bowel patterns are reestablished. - B A priority goal for the client with infectious diarrhea caused by Clostridium difficile is infection control precautions and the prevention of health care-associated infection (HAI) transmission (B). (A and C) are goals dependent on the return of the client's normal bowel pattern (D). When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? A.Keep the residual limb elevated during positioning. B.Instruct the client to grasp the overhead trapeze bar. C.Maintain alignment with an abduction pillow. D.Use pillow support to prevent turning to a prone position. - B The client will gain upper body strength and independence by using the overhead trapeze bar for positioning (B). Elevation of the residual limb is controversial (A) because a flexion contracture of the hip may result, so it is not necessary to maintain elevation during positioning. (C) is used for alignment following some hip surgeries. A prone position (D) should be encouraged to stretch the flexor muscles and prevent flexion contracture of the hip. The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) A.Confusion B.Peripheral edema C.Crackles in the lungs D.Dyspnea E.Distended neck veins - ACD Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion (A, C, and D). (B and E) are associated with right-sided heart failure. A child is having a generalized tonic-clonic seizure. Which action should the nurse take? A.Move objects out of the child's immediate area. B.Quickly slip soft restraints on the child's wrists. C.Insert a padded tongue blade between the teeth. D.Place in the recovery position before going for help. - A The first priority during a seizure is to provide a safe environment, so the nurse should clear the area (A) to reduce the risk of trauma. The child should not be restrained (B) because this
unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? - Team 1: RN team leader, PN; team 2, PN team leader, UAP The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement? - Rest in bed with the head of the bed elevated 20 degrees and flex the knees. The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? - Increased oxygen saturation A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? - Allow the client to sit on the side of the bed for a few minutes before transferring. When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement? - Speak privately with the nurse. A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? - Check the client's blood pressure. A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time?
- Hypotension A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? - "Did your daughter also start her menstrual period at 12 years of age?" The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. A. "Mr. Jones is experiencing pain of a 7 on a scale of 1 to 10. Vital signs are B/P 150/88, HR 90, and RR 26, with an O2 sat of 95%." B. "This is Mary Smith, RN, calling about Mr. Jones in room 325 at Memorial Hospital." C. "Mr. Jones had an open cholecystectomy yesterday and reports inadequate pain control with his current medication regimen since the surgery." D. "Would you like to make a change in his pharmacologic regimen?" - B, C, A, D SBAR: S = Situation and includes introduction of the nurse and client/setting (B). B = Background and includes the presenting complaint and relevant history (C). A = Assessment and includes current vital signs and other information (A).
R = Recommendations and includes an explanation of why you are calling or a suggestion about which action should be taken (D). A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? - Blood urea nitrogen >25 mg/dL What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.) A.Use lanolin to moisturize the tops and bottoms of the feet. B.Soak the feet in warm water for at least 1 hour daily. C.Wash feet daily and dry well, particularly between the toes. D.Use over-the-counter products to remove corns and calluses. E.Wear leather shoes that fit properly. - - Use lanolin to moisturize the tops and bottoms of the feet.
- Wash feet daily and dry well, particularly between the toes.
- Wear leather shoes that fit properly. The nurse recognizes which behavior(s) in a client as warning sign(s) of an impending suicide attempt? (Select all that apply.) - - Mood changes from depressed to happy
- Begins giving away possessions The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members? - Assign the UAPs to take vital signs and obtain daily weights. The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment? - .Immunization history Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treatments for dehydration in a 36-month-old child? (Select all that apply.) - - Record wet diapers.
- Examine skin turgor.
- Observe mucous membranes. The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image? - The spouse has never seen the client naked. Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) - - Shave the area where the TENS will be placed.
- Place the TENS unit directly over or near the site of pain.
- Describe the use of TENS for postoperative procedures such as dressing changes.
After administration of an 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? - Ensure that the client receives breakfast within 30 minutes. A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement? - Ask about scrotal pain or blood in the semen. Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? - The color of the dialysate outflow is opaque yellow. The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of Regular and NPH insulin. Which statement indicates that the client needs further instruction? - "When I give myself an injection, I should aspirate to make sure that I am not in a blood vessel." The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which action should the nurse perform? - Examine for clamp closures. A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization? - Encourage as much independence in decision making as possible. According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults? - A 75-year-old woman who wishes her friends were still alive so she could change some of the choices she made over the years The antigout medication allopurinol (Zyloprim) is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? - "I take aspirin for my pain." A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain? - The client's usual sleeping pattern A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? - The ventilator setting for respiratory rate and the client-initiated respirations A client has been receiving levofloxacin (Levaquin), 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? - Obtain a stool specimen for culture and sensitivity. The nurse is preparing to administer dalteparin (Fragmin) subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? - Guaiac-positive stool The nurse administers levothyroxine (Synthroid) to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.) - - Increase in T3 and T
- Decrease in periorbital edema The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? - Leave the room and discuss the incident privately with the staff member. A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation? - Offer to develop an alternate solution so that the residents can continue to watch television. When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? - Encourage the client to ambulate every 3 hours. Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; Paco2, 30 mm Hg; HCO3, 25 mEq/L; Pao2, 96 mm Hg. Which intervention should the nurse implement based on these results? - Assess the client for pain and administer pain medication as prescribed. Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? - Pain scale measurement A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? - Inform the client that the scheduled Pap test cannot be done today. A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? - Save the next urine sample. The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP?
- Position the client who has vomited on his side and obtain vital signs. A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? - "Tell me more about how you're feeling." Which instruction should the nurse provide to a client whose vision is being tested with a Snellen chart? - Cover one eye while reading the chart with the other. The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.) A.Monitor maternal vital signs for hemorrhage. B.Instruct the woman to report any contractions.
