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- Following discharge teaching, a male client with a duodenal ulcer tells the nurse he 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?
Review with the client the need to avoid foods that are rich in milk and cream. Dairy products, while initially soothing, stimulate acid production, which can exacerbate duodenal ulcers.
- 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 take?
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows. Pillows can pose a suffocation risk during a seizure. Soft blankets provide padding while minimizing this risk.
- A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
Stroke secondary to hemorrhage. Uncontrolled hypertension weakens blood vessel walls, increasing the risk of rupture and hemorrhagic stroke.
- An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?
Describes life without purpose. This statement indicates potential suicidal ideation and requires immediate assessment and intervention.
- 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?
Further evaluation involving surgery may be needed. Pap smears primarily screen for cervical cancer, not ovarian cancer. Given the family history and abdominal mass, further investigation, potentially including surgery, is warranted.
- A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?
Teach tracheal suctioning techniques. Maintaining a patent airway is paramount for a client with a tracheostomy, and the client/caregiver must be proficient in suctioning.
- 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's respiratory rate is 14 breaths / minute. What action should the nurse implement?
Document the assessment data. The reservoir bag not deflating completely during inspiration, with a normal respiratory rate, indicates that the oxygen flow rate is adequate to meet the client's inspiratory needs. No immediate intervention is required.
- During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
Respiratory apnea of 30 seconds. Apnea represents an immediate threat to life and requires immediate intervention.
- During a home visit, the nurse observed an elderly client with diabetes slip and fall. What is the priority action?
Check the client for lacerations or fractures. Ensuring the client's physical safety and assessing for injuries is the priority after a fall.
- 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 she wanted to avoid getting a headache. Which action should the nurse take first?
Inform the anesthesia care provider. The client's recent oral intake is crucial information for the anesthesia provider to assess aspiration risk during surgery.
- The mother of a child with phenylketonuria (PKU) is selecting foods for her child. Which of the following should she avoid?
Foods sweetened with aspartame should be avoided by individuals with PKU. Aspartame contains phenylalanine, which individuals with PKU cannot properly metabolize, leading to a buildup of phenylalanine in the blood and potential neurological damage.
- Before the first surgical case of the day, a part-time scrub nurse asks if a 3-minute surgical hand scrub is adequate. What is the circulating nurse's best response?
client is taking digoxin and has electrolyte imbalances or renal impairment. Knowing the medications will help determine if digoxin is a possible cause.
- The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?
Auscultate the client's bowel sounds. Hydromorphone is an opioid analgesic that can cause constipation. Assessing bowel sounds helps determine if the client is experiencing decreased bowel motility.
- A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What is the appropriate nursing action?
Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour. This will effectively dilute the feeding to half strength while maintaining the prescribed infusion rate.
- A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
Place the implant in a lead container using long-handled forceps. This is crucial to minimize radiation exposure to the nurse and others. Reinserting the implant without proper handling could cause injury. Double gloves are not sufficient protection. Disposal is not the immediate concern; securing the implant safely is.
- The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?
Monitor blood pressure frequently. Pheochromocytoma is a tumor of the adrenal gland that causes excessive release of catecholamines (epinephrine and norepinephrine), leading to severe hypertension. Frequent monitoring is essential to detect and manage hypertensive crises.
- When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention?
To reduce abdominal pressure on the diaphragm. Elevating the head of the bed reduces pressure from the abdominal contents on the diaphragm, improving lung expansion and ventilation. It does not directly promote bronchodilation or affect the medullary center.
- An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. What action should the nurse implement first?
Start an intravenous (IV) infusion of normal saline. Given the client's history of diabetes, vomiting, and abdominal cramping, dehydration and electrolyte imbalance are likely. Starting an IV infusion of normal saline will help to rehydrate the client and restore fluid balance. While assessing potassium and pupillary response are important, addressing dehydration is the priority.
- A client who received multiple antihypertensive medications experiences syncope due 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?
The additive effect of multiple medications has caused the blood pressure to drop too low. Antihypertensive medications work to lower blood pressure. When multiple medications are used, their effects can be additive or synergistic, leading to an excessive drop in blood pressure, resulting in hypotension and syncope.
- Which client is at the greatest risk for developing delirium?
An adult client who cannot sleep due to constant pain. Sleep deprivation and uncontrolled pain are significant risk factors for delirium, especially in hospitalized patients. The other options present less direct and immediate risks.
- Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?
Reduce risks factors for infection. Clients with COPD are at increased risk for respiratory infections, which can exacerbate their condition. Reducing exposure to irritants, promoting vaccination, and teaching proper hygiene are crucial for long-term management.
- 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. Abrupt cessation of corticosteroids can lead to adrenal insufficiency, which can manifest as fatigue, weakness, hypotension, and electrolyte imbalances. Monitoring vital signs is crucial to assess for these complications.
- A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab is important for the nurse to review before contacting the health care provider?
Serum calcium. Numbness and tingling around the mouth and in the fingers (paresthesia) are classic symptoms of hypocalcemia. Reviewing the serum calcium level is essential to confirm this suspicion and guide further management.
c) Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills. This client is most likely experiencing a post- operative infection, which can rapidly lead to sepsis and requires immediate intervention.
- What is the most important nursing intervention in the first 24 hours after gastric bypass surgery?
Measure hourly urinary output. Monitoring urinary output is crucial to assess kidney function and fluid balance, especially after major surgery and anesthesia.
- A client hospitalized for adrenal crisis expresses anxiety about discharge. What is the most appropriate nursing intervention?
Schedule an appointment for an out-patient psychosocial assessment. Addressing the client's anxiety and concerns about managing their condition at home is essential for a successful transition.
- An adult female client discloses fear of her abusive boyfriend. What is the nurse's FIRST action?
Explore client's readiness to discuss the situation. Assessing the client's willingness to talk about the abuse is the initial step in providing support and resources.
- A client with Cushing's syndrome is being monitored. Which serum laboratory value is MOST important to monitor?
Glucose. Cushing's syndrome is characterized by excess cortisol, which leads to insulin resistance and hyperglycemia.
- An adolescent female is prescribed azithromycin for pneumonia and recurrent chlamydia. What information is most important for the nurse to provide?
Use two forms of contraception while taking this drug. Azithromycin can interact with hormonal contraceptives, reducing their effectiveness. Additionally, it's crucial to prevent pregnancy while treating a sexually transmitted infection.
- A client in the emergency department exhibits rapid speech, flight of ideas, and reports only 3 hours of sleep in the past 48 hours. Which medication's laboratory value is most important to review?
Divalproex. The client's symptoms suggest mania, often treated with mood stabilizers like divalproex. Monitoring divalproex levels is crucial to ensure therapeutic range and prevent toxicity.
- A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet?
The nurse should instruct the client to eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent. This is because vitamin K affects the efficacy of warfarin.
- A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention?
The most important intervention is to maintain contact transmission precautions. This will help prevent the spread of MRSA to other patients and healthcare workers.
- A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours 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. Which intervention is most appropriate if the client is showing signs of respiratory depression?
Administer Naloxone IV. Naloxone is an opioid antagonist that reverses the effects of morphine, including respiratory depression.
- Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis?
Place the client on fall precautions. Osteoporosis increases the risk of fractures, so preventing falls is crucial.
- 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 is most important for the nurse to report to the healthcare provider?
A serum potassium level of 3.1 mEq/L or mmol/L (SI). This indicates hypokalemia, which can be exacerbated by NG suction and requires prompt intervention.
- Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?
Eosinophils are the leukocytes primarily involved in allergic responses and the destruction of parasitic worms. They release substances that are toxic to parasites and contribute to inflammation in allergic reactions.
- Several months after a foot injury, an adult woman is diagnosed with neuropathic pain. 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?
- A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?
Skills of staff and client acuity. Matching staff skills to the acuity level of the patients ensures that patients receive the appropriate level of care while optimizing resource allocation.
- When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?
Explain that the client may be placed in five positions. Postural drainage involves using different positions to help drain secretions from different lung segments. The client needs to understand the process.
- 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 facial muscles. What symptoms suggest that the client has most likely experienced Bell's palsy rather than a stroke?
Inability to close the affected eye, raise brow, or smile. Bell's palsy typically affects the entire side of the face, including the forehead, whereas a stroke often spares the forehead due to dual innervation.
- The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicates that the client understood the teaching?
Keeps the irrigating container less than 18 inches above the stoma. Maintaining the correct height of the irrigating container ensures the proper flow rate and prevents injury to the stoma.
- The nurse should teach the client to observe which precaution while taking dronedarone?
Avoid grapefruits and its juice. Grapefruit juice can interact with dronedarone, increasing its levels in the blood and potentially leading to adverse effects.
- A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse includes 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?
Confusion and papilledema. Confusion indicates altered mental status due to pressure on the brain, and papilledema (swelling of the optic disc) is a direct sign of increased pressure within the skull.
- 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?
Confirm the necessity for continued use of the CVC. Removing unnecessary CVCs is a key component of infection prevention bundles, as it reduces the risk of catheter-related bloodstream infections (CRBSIs).
- During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl. Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?
Repeated fasting blood sugar (FBS) is 132 mg/dl. Consistent elevation of fasting blood sugar above the normal range (typically >126 mg/dL) on multiple occasions is a key diagnostic criterion for diabetes mellitus.
- A client is in skeletal traction while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan of care?
Ensure proper alignment of the leg in traction. Maintaining proper alignment is crucial to ensure the effectiveness of the traction, prevent complications such as nerve damage or circulatory impairment, and reduce pain. While assessing the skin under the traction moleskin is important for skin integrity, and a pillow might provide comfort, proper alignment directly addresses the therapeutic goal of the 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 nurse take in response to this finding?
Document the ongoing wound healing. Bright red tissue in a wound bed indicates granulation tissue, which is a sign of healthy healing. While irrigation might be part of routine wound care, and a pressure dressing might be used in some cases, the priority is to recognize and document the positive progress of 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 the priority nursing diagnosis for this client?
Anxiety. The client's statement and emotional response indicate a high level of anxiety related to the anticipated pain. While knowledge deficit might be a contributing factor, the immediate priority is to address the client's emotional distress and anxiety, which can significantly impact their perception of pain and coping abilities.
- The nurse notes a visible prolapse of the umbilical cord after a client experiences spontaneous rupture of the membranes during labor. What is the priority nursing intervention?
67 Questions on hesi-exit-exam-799-
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Following discharge teaching, a male client with a duodenal ulcer tells the nurse he 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?
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 take?
A male client with hypertension, who received new antihypertensive prescriptions at his last visit, returns to the clinic two weeks later to evaluate his blood pressure (BP). In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?
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?
A client who recently underwent a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan?
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's respiratory rate is 14 breaths / minute. What action should the nurse implement?
During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?
During a home visit, the nurse observed an elderly client with diabetes slip and fall. What is the priority action?
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 she wanted to avoid getting a headache. Which action should the nurse take first?
The mother of a child with phenylketonuria (PKU) is selecting foods for her child. Which of the following should she avoid?
Before the first surgical case of the day, a part-time scrub nurse asks if a 3-minute surgical hand scrub is adequate. What is the circulating nurse's best response?
Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?
A charge nurse is informed of understaffing in the critical care unit. Which client should receive the most care hours by a registered nurse (RN)?
A 6-year-old child steps on a rusty nail. The nail pierced the shoe and the bottom of the foot. What is the initial nursing action?
A mother reports that her adolescent son has athlete's foot and she has been applying triple antibiotic ointment for two days with no improvement. What instruction should the nurse provide?
A client with a simple goiter is prescribed levothyroxine sodium (Synthroid). Which symptoms indicate that the prescribed dosage is too high?
A client with a history of heart failure presents with nausea, vomiting, yellow vision, and palpitations. Which finding is most important for the nurse to assess?
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed diarrhea. The client has a new prescription to change the feeding to half strength. What is the appropriate nursing action?
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care, the nurse finds the radiation implant in the bed. What action should the nurse take?
The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention?
An older male client with a history of type 1 diabetes has not felt well the past few days and arrives at the clinic with abdominal cramping and vomiting. What action should the nurse implement first?
A client who received multiple antihypertensive medications experiences syncope due to a drop in blood pressure to 70/40. What is
An adolescent female is prescribed azithromycin for pneumonia and recurrent chlamydia. What information is most important for the nurse to provide?
A client in the emergency department exhibits rapid speech, flight of ideas, and reports only 3 hours of sleep in the past 48 hours. Which medication's laboratory value is most important to review?
A client is being discharged with a prescription for warfarin (Coumadin). What instruction should the nurse provide this client regarding diet?
A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention?
A postoperative female client has a prescription for morphine sulfate 10 mg IV q3 hours 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. Which intervention is most appropriate if the client is showing signs of respiratory depression?
Which intervention is most important for the nurse to include in the plan of care for an older woman with osteoporosis?
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 is most important for the nurse to report to the healthcare provider?
Which type of Leukocyte is involved with allergic responses and the destruction of parasitic worms?
Several months after a foot injury, an adult woman is diagnosed with neuropathic pain. 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?
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 nurse determines the client's left pedal pulses are diminished. Based on these finding, what is the client's greatest risk?
The nurse is completing a head to toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?
A client with multiple sclerosis (MS) has decreased motor function after taking a hot bath (Uhthoff's sign). Which pathophysiological mechanism supports this response?
A client with acute respiratory distress syndrome (ARDS) is chemically paralyzed and sedated while on an assist-control ventilator with 50% FIO2. Which assessment finding warrants immediate intervention by the nurse?
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 the healthcare provider?
A nurse-manager is preparing the curricula for a class for charge nurses. A staffing formula based on what data ensures quality client care and is most cost-effective?
When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?
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 facial muscles. What symptoms suggest that the client has most likely experienced Bell's palsy rather than a stroke?
The nurse is teaching a client how to perform colostomy irrigations. When observing the client's return demonstration, which action indicates that the client understood the teaching?
The nurse should teach the client to observe which precaution while taking dronedarone?
A client who sustained a head injury following an automobile collision is admitted to the hospital. The nurse includes 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?
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?
During an annual physical examination, an older woman's fasting blood sugar (FBS) is determined to be 140 mg/dl. Which additional finding obtained during a follow-up visit 2 weeks later is most indicative that the client has diabetes mellitus (DM)?
A client is in skeletal traction while waiting for surgery. Which intervention is most important for the nurse to include in this client's plan of care?
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
