HESI EXAM Study Guide PDF

**[HESI EXAM STUDY GUIDE ]** **[TRANSMISSION-BASED PRECAUTIONS (TIER TWO) FOR USE WITH SPECIFIC TYPES OF PATIENTS]** Category Disease Barrier Protection +-----------------------+-----------------------+-----------------------+ | Airborne Precautions | Measles, chickenpox | Private room; | | (Droplets \5 μm; | adenovirus, group A | cohort patients; mask | | being within 3 feet | streptococcus, | or respirator (refer | | of the patient) | Neisseria | to agency policy) | | | meningitides, | | | | pertussis, | | | | rhinovirus, | | | | mycoplasma | | | | pneumoniae, | | | | pertussis, | | | | diphtheria, pneumonic | | | | plague, rubella, | | | | mumps, respiratory | | | | syncytial virus | | +-----------------------+-----------------------+-----------------------+ | Contact Precautions | Colonization or | Private room or | | (Direct patient or | infection with | cohort patients (see | | environmental | multidrug-resistant | agency policy); | | contact) | organisms, such as | gloves, gowns | | | VRE and MRSA, | | | | Clostridium | Protective | | | difficile, shigella | environment | | | and other enteric | Allogeneic | | | pathogens, major | hematopoietic stem | | | wound infections, | cell transplants | | | herpes simplex, | | | | scabies, varicella | Private room; | | | zoster | positive airflow with | | | (disseminated), | ≥12 air exchanges per | | | respiratory syncytial | hour; HEPA filtration | | | virus | for incoming air; | | | | mask, gloves, gowns | +-----------------------+-----------------------+-----------------------+ **[TRICKS TO REMEMBER]** **[ABC S&D---look at what the question is asking for in this order---pick the best answer based on the ABC S&D]** **Airway** **Breathing** **Circulation** **Safety** **Discomfort** **[ADPIE---Remember this order and answer the question based on the template below]** **Assess** **Diagnose** **Planning** **Implementation** **Evaluation** **[REMEMBER, SAFETY OF THE PATIENT IS ALWAYS IMPORTANT]** **[LAB VALUES]** Potassium---(Banana) 3.5 -- 5.0 Magnesium---(Mag Wheels) 1.3 -- 2.1 Calcium---(Boone) 9.0 -- 10.5 Chloride---(Pool temperature) 97 -- 107 Phosphate---(Fossil) 3.0 -- 4.5 Sodium---(Age decrease sodium intake) 135 -- 145 **[Electrolyte Imbalances]** *Hypercalcemia*---bone pain, muscle weakness, excessive thirst, lethargy, nausea *Hypercalcemia*---numbness, tingling in digits, muscle cramps, wheezing, fatigue *Hyperkalemia*---heart arrythmias, numbness and tingling, breathing problems *Hypokalemia*---Muscle weakness, fatigue, heart arrythmias *Hypermagnesemia*---diminished deep tendon reflexes, flushing, headache, nausea, drowsiness. *Hypomagnesemia*---muscle weakness, twitches, tremors, irritability, insomnia, drowsiness *Hyperchloremia*---diarrhea, vomiting *Hypochloremia*---diarrhea, vomiting *Hyperphosphatemia*---Osteoporosis, cardiovascular disease *Hypophosphatemia*\--changes in mental state, bone pain, fragility, fatigue, weight loss, weakness *Hypernatremia*---lethargy, myoclonic jerks, confusion, nystagmus, tachycardia *Hyponatremi*a---nausea, vomiting, lethargy, seizure, neurological deficits **[24 hour urine sample]** In the morning, after waking up and emptying your bladder for the first time, urinate into the toilet and note the exact time. This is the start time of your collection. Collect every drop of urine in a special container for the next 24 hours. This includes urine passed with a bowel movement, but try not to include feces. On the second day, urinate into the container within 10 minutes before or after the same time as the first morning void on the first day. Store the container in the refrigerator or a cool place. Label the container with your name, the date, and the time of completion. Return the container to the lab as soon as possible. A 24-hour urine test measures the amount of protein or other substances in your urine to check how well your kidneys are working. Your healthcare provider may give you instructions on how and where to take the sample. You should check with your clinician before starting the collection if you have any questions or if you are taking any medications. **[When to use a facemask vs. respirator mask]** **N95 Respirators** An **N95 respirator** is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. Note that the edges of the respirator are designed to form a seal around the nose and mouth. Surgical N95 Respirators are commonly used in healthcare settings and are a subset of N95 Filtering Facepiece Respirators (FFRs), often referred to as N95s. **Face Masks** A face mask is a product that covers the wearer\'s nose and mouth. Face masks are for use as [source control](https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/face-masks-including-surgical-masks-and-respirators-covid-19#using) by the general public and health care personnel (HCP) in accordance with [CDC recommendations](https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html), and are not personal protective equipment. Face masks may or may not meet any fluid barrier or filtration efficiency levels; therefore, they are not a substitute for N95 respirators or other Filtering Facepiece Respirators (FFRs), which provide respiratory protection to the wearer, or for surgical masks, which provide fluid barrier protection to the wearer. **[Correct order of removing PPE]** The correct order for removing PPE after patient care **Gloves** **Gown** **Goggles** **Mask** Doff (off) the gloves FIRST, followed by the gown, then the face shield or goggles, and lastly, doff the mask or respirator. Types of Wound Drainage **Serous:** Clear, watery plasma wound drainage shows light colored circular spot. **Purulent:** Thick, yellow, green, tan, or brown wound drainage shows thick, yellow, green, tan, or brown stain. **Serosanguineous:** Pale, pink, watery; mixture of clear and red fluid wound drainage shows pale red and pink fluid completely staining the gauze. **Sanguineous**: Bright red; indicates active bleeding wound drainage shows bright red spot surrounded by light red stain. **[WOUND DRESSINGS]** Purposes of dressings. A dressing serves several purposes: Protects a wound from microorganism contamination Aids in hemostasis Promotes healing by maintaining wound moisture Promotes healing by absorbing drainage and debriding a wound Supports or splints a wound site Promotes thermal insulation of a wound surface **[DRESSINGS FOR WOUND CARE]** Pressure Pressure Expected Injury Stage Injury Status. Dressing Comments. 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A patient entering into hospice care is in the terminal phase of illness, and the patient, family, and health care provider agree that no further treatment will reverse the disease process. Hospice care is provided in a setting that best meets the needs of each patient and family, such as in a patient's home or in nursing homes, assisted-living facilities, freestanding hospices, and hospitals. The focus of hospice care is supportive care, not curative treatment (see Chapter 36). Hospice benefits families and patients in the terminal phase of any disease, such as cardiomyopathy, multiple sclerosis, acquired immunodeficiency syndrome (AIDS), and cancer. Hospice team members are available 24 hours a day, 7 days a week to answer questions or visit anytime the need for support arises. Team members collaborate to provide care that ensures death with dignity. Services continue without interruption even if a patient's care setting changes. **[HESI PRACTICE EXAM]**Top of Form ***A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?*** a. Assist the ambulating client back to the bed. b. Encourage the client to ambulate to resolve pneumonia. c. Obtain a prescription for portable oxygen while ambulating. d. Move the oximetry probe from the finger to the earlobe. Bottom of Form Rationale **An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client\'s activity at this time is depleting oxygen saturation of the blood. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation, but first the client should return to bed to rest.** Top of Form ***After completing an assessment and determining that a client has a problem, which action should the nurse perform next?*** a\. Determine the etiology of the problem. b\. Prioritize nursing care interventions. c\. Plan appropriate interventions. d\. Collaborate with the client to set goals. Bottom of Form Rationale **Before planning care, the nurse should determine the etiology, or cause, of the problem, because this will help determine goals, plan of care and priorities of interventions.\ ** Top of Form ***A client receives a prescription for azithromycin (Zithromax) 500 mg PO x 3 days. Azithromycin is available as 250 mg scored tablets. How many tablets should the nurse administer per dose? (Enter the numerical value only.). 2*** Bottom of Form Rationale **Using the formula, D/H** **500 mg/250 mg = 2 tablets** Top of Form ***Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?*** a. Reassure the client that he will become accustomed to the stoma appearance in time. b. Instruct the client that the stoma will become smaller when the initial swelling diminishes. c. Offer to contact a member of the local ostomy support group to help him with his concerns. d. Encourage the client to handle the stoma equipment to gain confidence with the procedure. Bottom of Form Rationale **Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. This will help reduce the client\'s anxiety and promote acceptance of the colostomy.** *Top of Form* ***Which assessment data provides the most accurate determination of proper placement of a nasogastric tube?*** a. Aspirating gastric contents to assure a pH value of 4 or less. b. Hearing air pass in the stomach after injecting air into the tubing. c. Examining a chest x-ray obtained after the tubing was inserted. d. Checking the remaining length of tubing to ensure that the correct length was inserted. Bottom of Form Rationale **Assessing the pH of gastric contents and listening for air in the stomach are both methods used to determine proper placement of the nasogatric tube. However, the best indicator that the tube is properly placed is confirming with a chest x-ray.** Top of Form ***A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?*** a. Sexual activity patterns. b. Nutritional history. c. Leisure activities. d. Financial stressors. Bottom of Form Rationale **Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first.** *Top of Form* ***The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?*** a. Avoid any types of sprays, powders, and perfumes. b. Wearing a mask while cleaning will not help to avoid allergens. c. Purchase any type of clothing, but be sure it is washed before wearing it. d. Pollen count is related to hay fever, not to allergens. Bottom of Form Rationale **The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes. The client should be encouraged to wear a mask when working around dust or pollen. Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics. Pollen count is related to allergens, and the client should be instructed to stay indoors when the pollen count is high.** Top of Form ***A client with multiple sclerosis is prescribed Dantrolene (Dantrium) 0.1 grams PO bid for spasticity. Dantrolene is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.)*** Bottom of Form Rationale **Using the conversion of 1 gram = 1000 mg:** **0.1 gram = 100 mg** **100 mg = 1 capsule** Top of Form ***During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?*** a. Adequate venous blood flow to the lower extremities. b. Estimated amount of body fat by an underarm skinfold. c. Degree of flexion and extension of the client\'s knee joint. d. Change in the circumference of the joint in centimeters. Bottom of Form Rationale **The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor. On the other hand, a doppler is used to measure blood flow; calipers are used to measure body fat; and a tape measure is used to measure circumference of body parts.** Top of Form ***A client\'s daily PO prescription for aripiprazole (Abilify) is increased from 15 mg to 30 mg. The medication is available in 15 mg tablets, and the client already received one tablet today. How many additional tablets should the nurse administer so the client receives the total newly prescribed dose for the day? (Enter numeric value only.)*** Bottom of Form Rationale **30 mg (total dose) - 15 mg (dose already administered) = 15 mg that still needs to be administered.** **Using the Desired/Have formula:** **15 mg/15 mg = 1 tablet** *Top of Form* ***The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?*** a. Immediately after exhalation. b. During the inhalation. c. At the end of three inhalations. d. Immediately after inhalation. Bottom of Form Rationale **The client should be instructed to deliver medication through a metered inhaler during the last part of inhalation. After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and hold the breath for several seconds to allow for distribution of the medication.** Top of Form ***A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?*** a. Record the coughing incident. No further action is required at this time. b. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. c. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. d. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling Bottom of Form Rationale **Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action. The auscultating method has been found to be unreliable for small-bore feeding tubes.** Top of Form ***At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client\'s silence?*** a. \"It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel.\" b. \"Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery.\" c. \"It is OK if you don\'t want to talk about your surgery. I will be available when you are ready.\" d. \"I will ask a woman who has had a mastectomy to come by and share her experiences with you.\" Bottom of Form Rationale **When a client is reluctant to look at a surgical wound or refuses to talk about the surgery, the nurse should reflect that these feelings are OK and that the nurse is available when the client is ready. Such a response displays sensitivity and understanding without judging the client. On the other hand, telling a client how she should feel is judgmental and insensitive.** Top of Form ***A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is available as 5 mg/5 ml. A measuring device marked in teaspoons is being used. How many teaspoons should the nurse administer? 2*** Bottom of Form Rationale **First, using the formula, Desired dose/dose on Hand x Quantity of volume on hand (D/H x Q),** **10 mg / 5 mg x 5ml = 10 ml** **Next using the known conversion of 5 ml = 1 tsp:** **5 ml : 1 tsp :: 10 ml : X** **5 / 10 : 1 / X** **5X = 10** **X = 2** Top of Form b\. Fowler\'s. c\. Sims\'. d\. Supine. Bottom of Form Rationale **A gastrostomy tube (GT), known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. The unresponsive client should be positioned in a semi-sitting (Fowler\'s) position during feeding through a gastrostomy tube to decrease the occurrence of aspiration. In prone or Sims\' positions, the client is placed on the abdomen, an unsafe position for feeding. Placing the client in supine position increases the risk of aspiration.** *Top of Form* ***During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client\'s primary health problem?*** a. Restatement of responses. b. Open-ended questions. c. Closed-ended questions. d. Problem-seeking responses. Bottom of Form Rationale **Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions that focus on common signs and symptoms about a client's health problem.Other question types are used when therapeutically interacting and should be used after specific information is obtained from the client.** Top of Form ***The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO.* *Zaroxolyn is available in 5 mg tablets. How many tablets should the nurse plan to administer?*** a. 1/2 tablet. b. 1 tablet. c. 1 1/2 tablets. d. 2 tablets. Bottom of Form Rationale **D/H X Q = 7.5/5 X 1 tablet = 1 1/2 tablets**Top of Form ***An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with \"miseries.\" Based on this statement, which focused assessment should the nurse conduct?\ *** a. Inquire about the source and type of pain. b. Examine the nose for congestion and discharge. c. Take vital signs for temperature elevation. d. Explore the abdominal area for distension. Bottom of Form Rationale **Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as \"the miseries. \" Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain.** *Top of Form* ***When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?*** a. Loosen the right wrist restraint. b. Apply a pulse oximeter to the right hand. c. Compare hand color bilaterally. d. Palpate the right radial pulse. Bottom of Form Rationale **The nurse has observed that a client\'s fingers are blue distal to a wrist restraint. The priority nursing action is to restore circulation by loosening the restraint, because blue fingers (cyanosis) indicates decreased circulation. Assessing the depth of color change and the radial pulse are also important nursing interventions, but do not have the priority of removing the restraint. Pulse oximetry measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints).** *Top of Form* ***The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?*** a. Observe the appearance of the skin under the ice pack. b. Instruct the client regarding the need for the covering. c. Reapply the covering after filling with fresh ice. d. Ask the client how long the ice was applied to the skin. Bottom of Form Rationale **The client has been using an ice pack without the protective covering. The first action the nurse should take is to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can then explain the need for a cover and reapply the ice pack with the cover in place.** *Top of Form* ***An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client\'s nursing care?*** a. Massage any reddened areas for at least five minutes. b. Encourage active range of motion exercises on extremities. c. Position the client laterally, prone, and dorsally in sequence. d. Gently lift the client when moving into a desired position. Bottom of Form Rationale **To avoid shearing forces when repositioning, the client should be lifted gently across a surface. Reddened areas should not be massaged since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg.** *Top of Form* ***The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions?*** a. Thalamus. b. Hypothalamus. c. Frontal lobe. d. Parietal lobe. Bottom of Form Rationale **The frontal lobe of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. On the other hand, the thalamus is an afferent relay center in the brain that directs impulses to the cerebral cortex. The hypothalamus regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. The parietal lobe is the location of sensory and motor functions.** Top of Form ***During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?*** a. additional coffee on the client\'s breakfast tray. b. Exchange the client\'s grape juice for cranberry juice. c. Bring the client additional fruit at mid-morning. d. Encourage additional oral intake of juices and water. Bottom of Form Rationale **Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C).** **[FLUID BALANCE]** **Meet the Client: Donna KingDonna King is an 80-year-old female with coronary artery disease and hypertension. Her daughter brought her to the Emergency Department because she has become increasingly weak and confused and was found by a neighbor wandering her neighborhood unable to locate her home. Donna\'s daughter tells the nurse that her mother takes a \"water pill\" for her blood pressure 2 or 3 times a day. The label on the medication bottle that she brought to the hospital states, \"hydrochlorothiazide (HydroDIURIL). Take 1 tablet daily.\" Donna is admitted with fluid volume deficit.** *Top of Form* *Top of Form* *Since Donna has a fluid volume deficit, the nurse anticipates a decrease in which vital sign when Donna changes position?* Respiratory rate. Blood pressure. Temperature. Pulse rate. *Top of Form* *The nurse plans to assess Donna for orthostatic vital sign changes. Which action will the nurse take first?* Assist Donna to a standing position. Position Donna in a supine position. Elevate the head of Donna\'s bed. Dangle Donna\'s feet at the bedside. Top of Form *The nurse takes the first blood pressure measurement. After recording the first blood pressure measurement, what action will the nurse take?* Count the client\'s radial pulse rate. Remove the blood pressure cuff. Help the client change positions. Assess for an auscultatory gap. Bottom of Form *Top of Form* *For ongoing evaluation of Donna\'s fluid volume status, it is most important to obtain which assessment data?* Urine color. Capillary refill. Body weight. Skin turgor. Top of Form *Top of Form* *What action should the nurse implement?* Confirm this finding by pinching the skin on her hand. Notify the healthcare provider that the client is now retaining fluid. Advise Donna that the fluid deficit seems to be worsening. Document the presence of inelastic skin turgor. **Donna\'s daughter reports that her mother usually weighs about 137 lbs. and is 5 feet, 3 inches in height. The nurse weighs Donna and obtains a measurement of 60 kg.** Bottom of Form *Bottom of Form* *Top of Form* *The nurse explains to Donna\'s daughter that Donna has lost approximately how many pounds?* 3. 5. 60 kg × 2.2 = 132 lbs. 137 lbs. - 132 lbs. = 5 lbs. This represents an approximate weight loss of 5 pounds. 4. 7. Top of Form **Age-related Risk Factors** **The nurse discusses factors that contributed to Donna\'s fluid volume deficit with Donna and her daughter.** *Which problem often occurs in the elderly and may have contributed to the fluid volume deficit Donna is experiencing?* Decreased hepatic blood flow. Decreased drug absorption. Decreased drug half-life. Decreased GI acidity. Bottom of Form *Top of Form* *Which lab test will the nurse monitor to determine if this may be a factor contributing to Donna\'s problem?* Serum creatinine. Serum protein. AST. BUN. **Intravenous Fluids** **The nurse starts an intravenous line to administer fluids. The prescription states, \"3% Normal Saline to infuse at 100 mL/hour.\" The client\'s most recent serum sodium level is 135 mEq/L.** **Medication Errors** **A short while later, a prescription for 0.9% Normal Saline at 100 mL/hour is received. Donna\'s primary nurse is at lunch, so another nurse hangs the solution. When checking Donna upon returning from lunch, the primary nurse observes that a solution of 5% Dextrose and 0.9% Normal Saline is infusing at 125 mL/hour.** Bottom of FormTop of Form *What action should the primary nurse implement?* Hang 0.9% Normal Saline at 100 mL/hour.Bottom of Form Begin infusing the solution at a keep-open rate. Start the intravenous solution as prescribed. Obtain appropriate IV fluid prescription. **Legal Consideration: Treatment Error** **After hanging the correct IV solution at the correct rate of infusion, the nurse discusses the error with the nurse who hung the first IV solution. Together, the nurses complete a variance (incident)** *Top of Form* *What additional action should the primary nurse take?* Discuss the consequences of the error with the hospital legal counsel. Notify the healthcare provider of the error in treatment that occurred. Report to the hospital pharmacist that a variance report was written. Notify the hospital educator of the need for staff training about IV fluids. Bottom of Form *Top of Form* *How should the primary nurse respond?* \"The variance report will show that this is your first medication error.\" \"As long as you understand your error, we can disregard this report.\" \"Since no harm was done to the client, the variance report will not matter.\" \"Variance reports are used to find ways to prevent further errors.\" **Local IV Site Complications** **Later that day, Donna\'s IV pump alarm sounds. The nurse notes that the IV is not infusing in the right antecubital area, and the alarm indicates an obstruction is present. The nurse determines that all the clamps are open and there are no kinks in the tubing.** *Bottom of Form* *Top of Form* *Which intervention should the nurse take next?* Apply light pressure above the site. Lower the IV solution below the site. Straighten the joint above the site. Change the IV site dressing. *Bottom of Form* *Top of Form* *Which action should the nurse take?* Continue the IV with the arm elevated on a pillow. Remove the IV and restart it in a different location. Notify the healthcare provider that the IV site appears inflamed. Complete a variance report regarding the IV site. Bottom of Form *Top of Form* *When assessing the IV site, what step of the nursing process did the nurse use?* Analyze the data. Plan interventions. Determine the problem. Establish a goal. Bottom of Form *Top of Form* *Which problem did the nurse identify as most pertinent in that situation?* Risk for impaired skin integrity. Risk for injury (thrombus formation). Fluid volume deficit. Infection. **Intake and Output Measurement** **Donna continues to receive 0.9% Normal Saline at a rate of 100 ml/hour. She is stronger and has started taking oral food and fluids well. She receives a regular no-added-salt diet. Her breakfast includes one cup of scrambled eggs, one bowl of oatmeal, a fresh orange, apple juice, and a carton of milk.** Bottom of FormTop of Form *Which items should be measured as fluid intake?* *Select all that apply* Scrambled eggs. Bowl of oatmeal. Fresh orange. Milk. Apple juice. Top of Form Top of Form *Now that Donna is taking oral fluids well, what action should the nurse implement?* Notify the healthcare provider that a prescription to continue intake and output measurement is needed. Continue the measurement of the client\'s fluid intake and output. Stop measuring the client\'s fluid intake and output as long as she takes oral fluids. Measure the client\'s fluid output, but discontinue measuring fluid intake. **Fluid Volume Excess** **Donna\'s intake and output measurements indicate her intake is greater than her output. The nurse is concerned that Donna may develop fluid volume excess.** Bottom of Form *Top of Form* *Which assessment is important for the nurse to perform?* Auscultate the client\'s breath sounds. Measure the client\'s tympanic temperature. Compare the client\'s muscle strength bilaterally. Ask the client if she is experiencing any syncope. **The nurse also observes that Donna\'s feet and ankles are swollen. When the nurse presses a finger over the client\'s ankle (bony prominence), an 8 mm indentation appears.** A close-up of a hand pointing at a person\'s body Description automatically generatedTop of Form *How will the nurse document this finding?* Gross edema in the lower extremities. 4+ pitting edema present around ankles and feet. Blanching and induration present bilaterally. Neither blanching nor induration are indicated by this assessment. ![A diagram of a person lying down Description automatically generated](media/image2.png)Bottom of Form *Top of Form* *Which change in Donna\'s pulse will the nurse anticipate?* Increase in rate and volume. Decrease in rate and volume. Increase in rate, but no change in the volume. Decrease in rate, but no change in the volume. Bottom of Form *Top of Form* *The nurse reviews the client's laboratory results. Which laboratory result is critical and should be reported to the healthcare provider?* Sodium 140. Chloride 105. Albumin 4. Potassium 3.Bottom of Form Top of Form *The nurse reports the findings to the healthcare provider and receives several prescriptions. Which prescription should the nurse question?* Furosemide (Lasix) 40 mg IV push now. Potassium chloride 40 mEq PO. Decrease the Normal Saline to KVO. Administer oxygen per nasal cannula at 2 L/minute. **Pharmacology: Diuretics** **Donna\'s fluid volume excess improves and the prescription for hydrochlorothiazide (HydroDIURIL) 12.5 mg PO daily is restarted.** *Bottom of Form* *Top of Form* *Which lab values are most important for the nurse to monitor? (Select all that apply).* *Select all that apply* Hemoglobin. White blood cell count. Serum potassium. Magnesium. Bottom of Form *Top of Form* *The nurse will emphasize the importance of taking this medication only once a day, on what schedule?* Before eating breakfast. With breakfast. After lunch. At bedtime. Top of Form *Since Donna is receiving a diuretic that contributes to the loss of potassium, the nurse must provide dietary teaching. Which foods selected by the client indicate an understanding of potassium-rich foods?* *Select all that apply* Baked potato. Green beans. Chicken breast. Apple. Grapefruit juice. Bottom of Form **Medication Administration: Oral Tablets** **In preparing to administer the hydrochlorothiazide, the nurse notes that the prescribed dose is 12.5 mg, and the tablet available is 25 mg.** *Top of Form* *Which action should the nurse take?* Observe the tablet to see if it is scored. Notify the pharmacist of the error. Hold the medication until the right dose is available. Document the change in dose on the medication record. Top of Form *What is the best response by the nurse?* \"It is hospital policy to always check client identification.\" is probably correct, it is more beneficial to explain the rationale for the action to the client. \"Your healthcare provider has asked that we always perform this check.\" \"Wearing an identification band is important for all clients.\" \"This is a double-check to ensure that no errors occur.\" Top of Form *Which identifiers are acceptable for the nurse to use when verifying the right client prior to medication or treatment administration?* *Select all that apply* Client full name. Date of birth. Current photograph. Room number. Physical location. Bottom of Form *Top of Form* *The nurse is preparing discharge instructions for Donna. Which signs and symptoms of fluid volume deficit should the nurse include when educating the client and her daughter prior to discharge?* *Select all that apply* Changes in mental status. Change in urine output. Tenting on arm when checking skin turgor. Presence of tachycardia. Longitudinal furrows on the tongue. **A older client is discharged from the hospital to rehab after suffering a cerebral vascular accident (CVA) often referred to as a stroke. The client lives with her spouse who is in good health. The rehab nurse enters the room to assess the client.** *Top of Form* *Of the client problems addressed on the nursing plan of care, which is the **highest **priority problem?* Aspiration. Skin breakdown.. Altered nutrition. Self-care deficit. Top of Form *After establishing priorities, the nurse should take which action next in preventing the client from aspirating?* Obtain a prescription for placement of enteral feeding tube. Elevate the head of bed to 45 degrees. Ensure client participates with PT and OT exercises for strengthening. Ensure the client\'s meals are pureed. **The nurse visits with the client\'s spouse then observes as the unlicensed assistive personnel (UAP) assists the client with a meal. The UAP gives the client a glass of iced tea to drink and the client begins to cough. The nurse recognizes that the client\'s dysphagia may impact her fluid and nutritional status.** *Top of Form* *The nurse should obtain an order from which member of the interprofessional team?* Case manager. Speech therapist. Registered dietician. Geriatric nurse practitioner. Bottom of Form *Top of Form* *With which member of the interprofessional team should the nurse consult regarding this problem?* Clinical nutritionist. Occupational therapist. Rehabilitation counselor. Physical therapist.Top of Form **The speech therapist is consulted to evaluate the client. The therapist determines that dysphagia precautions are needed and writes a prescription for pureed diet and honey-thickened liquids. The nurse and the unlicensed assistive personnel (UAP) enter the client\'s room shortly after the therapist\'s evaluation is completed. The UAP prepares to assist client with the noon meal and with personal care.** *Which instruction should the nurse provide to the UAP?* Keep the client in a Sim\'s position while bathing and also while assisting with her meal. Help feed the client first and then allow the client to rest with the head of the bed lowered for 1 hour before bathing. Provide assistance with the meal then lower the head of the bed to bathe the client and change the bed linens. Bathe the client first and then place the client in a high Fowler\'s position during and after the meal. Bottom of Form *Top of Form* *Considering the need for dysphagia precautions, what action should the nurse implement to intervene?* Remind the UAP to keep track of the fluid intake and output. Advise the UAP to provide all fluids at room temperature. Instruct the UAP to add a thickening agent to all liquids per orders. Establish a fluid restriction for the client. **Three days later, the nurse assesses the client\'s nutritional status.** Top of Form *Which data indicate the need for the nurse to evaluate the client further for altered nutrition? (Select all that apply.)* Pale conjunctivae. Smooth, thick finger and toe nails. Rough, dry, scaly, and pale skin. Flat abdomen, painful to palpate. The lips are dry and cracked. Top of Form *Which information is **best** to use for assessment of the client\'s functional ability related to nutrition?* The client\'s food preferences. Types of food the client has eaten within the last 24 hours. The client\'s ability to feed herself with her left hand. The spouse\'s schedule for preparing meals. Bottom of Form *Top of Form* *To ensure the client receives adequate nutrition, which intervention should the nurse implement?* Obtain and record a weekly weight. Obtain an order for a weekly complete blood count. Measure and record her abdominal girth every day. Perform capillary glucose measurements before every meal. **A week later, the nurse notes a change in the client\'s weight. The nurse consults with the nutritionist, who helps complete a 24-hour calorie count. The nutritionist reports back to the nurse that the client weighs 110 lbs (50 kg), is 67 in (170.2 cm) tall, and is consuming 700 calories per day.** Top of Form *Top of Form* *How should the nurse explain the results of the calorie count to the client and the spouse?* Client is taking in more calories than needed and may gain weight. Client is consuming an adequate number of calories for her height. Calorie consumption is insufficient and will result in weight loss. Since activity is limited, caloric intake is sufficient to meet needs. Bottom of Form *Bottom of Form* *Top of Form* *Before notifying the healthcare provider of the data reported by the nutritionist, what information is **most** important for the nurse to obtain?* Type of vitamin supplement the client is taking. Percent of diet composed of carbohydrates. Client\'s calculated body mass index. Daily fat gram intake by the client. Bottom of Form *Top of Form* *Which statement **best **describes the value of obtaining laboratory values?* To definitively diagnose the severity of the malnutrition. To rule out the cause of the malnutrition. To aid in supplements needed to correct the malnutrition. To use as objective measures in the diagnosis of malnutrition. **The healthcare provider prescribes an appetite stimulant and asks the nutritionist to consult with the client and client\'s family regarding dietary needs. The nutritionist develops a plan of care to improve the client\'s nutritional status. The nurse reinforces the plan with the client and her spouse to include foods that are high in protein and provides them with sample menus.** Top of Form *Which breakfast selection(s) are good sources of protein? (Select all that apply.)* *Select all that apply* Oatmeal with a sliced banana. Pancakes with maple syrup. Hash browns and an English muffin. Scrambled eggs and sausage. Cheese and bacon omelet. *Bottom of Form* *Top of Form* *The spouse states that the client loves applesauce and asks if this is a good snack choice. Which response by the nurse is **best**?* Do not offer her applesauce because it does not provide very many calories. Processed foods such as applesauce are often very high in sodium. Offer applesauce since that is what the client likes, along with higher calorie snacks. Applesauce is an excellent source of nutrients and calories. **The client has a new prescription for an appetite stimulant.** *Top of Form* *Which information about the drug should the nurse obtain prior to reinforcing the education provided to the client regarding the time the medication should be administered?* Onset of action. Peak action. Duration of action. Plateau. Top of Form *How should the nurse respond?* \"You shouldn\'t worry about the cost of medications right now. You should purchase whatever your spouse needs to get well.\" \"Brand-name medications are generally more effective than generic drugs, so they are worth the additional cost.\" \"Brand-name drugs and generic drugs are bioequivalent, so the client can safely take either form of the medication.\" \"Your pharmacist and healthcare provider can determine if there is a generic drug that is a safe alternative to the brand-name drug.\" **The client gradually weakens and is admitted to the medical unit. The healthcare provider (HCP) recommends the insertion of a feeding tube by means of a percutaneous esophageal gastrostomy (PEG). The client signs the consent form, and the procedure is scheduled for the next day. That evening, the nurse notes that the client\'s medical record contains an advance directive requesting no resuscitation (DNR) in the event of a cardiopulmonary arrest, which is confirmed in the prescriptions written by the HCP. While the nurse is conversing with the client and spouse, they both confirm that no heroic measures are to be implemented.** Top of Form *What action should the nurse take to ensure the client\'s DNR status?* Meet privately with client\'s spouse to discuss that a feeding tube can be considered a heroic means of keeping a client alive. Inform the client that the instructions in the advance directive can specify decisions regarding resuscitation, which can include nutrition. Ask the client why she wants to have a feeding tube inserted since she has an advance directive requesting no heroic measures. Advise the client that the healthcare provider will document in the medical record the do not resuscitate decision and any exceptions. Bottom of Form *Top of Form* *Which action should the nurse implement regarding cancellation of the procedure?* Provide the couple with privacy to discuss the decision. Continue to prepare the client for the scheduled procedure. Remind the client that the consent form is already signed. Ask the client\'s spouse if the procedure should be cancelled. Top of Form **The couple discusses the decision together, and the client decides to have the procedure as scheduled. The client is taken to the procedure room, where a PEG tube is inserted. The client returns to her room following the insertion of the PEG tube. An IV of lactated Ringer\'s solution is infusing at 50 mL/hour. No feeding solution is attached to the PEG tube.** *Which initial actions should the nurse implement?* Connect the lactated Ringer\'s solution to the PEG tube at the prescribed rate. Immediately check the PEG placement upon arrival to the room. Call the dietary department and request immediate delivery of the feeding solution. Continue to monitor the client without infusing any solution through the PEG tube. Bottom of Form *Top of Form* *Which action should the nurse implement?* Apply a pressure dressing over the initial dressing. Circle the amount of drainage on the initial dressing. Remove the dressing and apply a new sterile dressing. Notify the HCP of the finding immediately. **The next day, the nurse initiates the feeding prescribed by the HCP. The prescription is for the formula to infuse at 30 mL/hour. The physician has ordered it to be \"half-strength\" (50/50 water and formula). The formula is available in 8-ounce cans. The nurse is preparing enough formula for 12 hours.** Top of Form HowHow *How many cans of formula will the nurse need? (Enter numeric value only. If rounding is necessary, round to the whole number.) 1* Calculate Total Volume Needed for 12 hours: 12 hours × 30 mL/hour = 360 mL\ Calculate Half Strength Volume: 360 mL/2 = 180 mL of formula and 180 mL of water\ Calculate Ounces to mL: 8 ounces per can × 30 mL/ounce = 240 mL\ Calculate Number of Cans: 180 mL formula/240 mL per can = 0.75 of a can (3/4ths of a can), therefore, only 1 can of formula is needed when rounding to a whole number. *Top of Form* *Which action should the nurse implement?* Decrease the rate of the formula to 20 mL/hour. Maintain the rate of the formula at 30 mL/hour. Increase the rate of the formula to 40 mL/hour. Increase the rate of the formula to 75 mL/hour. **Over time, the continuous feeding is increased to 80 mL/hour. The nurse plans to reinforce the education provided to the client\'s spouse on how to manage the continuous feeding once discharged.** *Top of Form* *What information is **most** important for the nurse to collect prior to providing discharge instructions on how to manage the continuous feedings*? Ask about the couple\'s financial resources. Learn the client\'s anticipated discharge date. Determine if the client and her husband feel ready to learn the skill. Obtain information about the couple\'s educational level. Top of Form *Which action should the nurse implement?* Continue with the demonstration of the equipment while allowing the spouse time to control his emotions. Reassure the spouse that management of the feeding equipment can be easily mastered with some practice. Stop the demonstration and leave the room until the spouse states he is ready to continue with the session. Acknowledge the stressful nature of the situation and ask the spouse if he is ready to continue. **The feedings are changed to bolus feeding 3 times a day. After receiving instruction, the client\'s spouse demonstrates correct ability to perform the skill and states that he feels he can handle this responsibility. The client is discharged home and home healthcare services are initiated. During a home visit, the nurse observes the client\'s spouse administering a bolus feeding to the client, who is sitting upright in the bed. After checking the residual volume, the spouse pours the feeding into the syringe attached to the feeding tube. The spouse then holds the syringe upright while the feeding enters the stomach.** Top of Form *In observing this procedure, which action should the nurse take?* Tell the spouse to lower the syringe to increase the speed of the feeding. Lower the head of the bed until the feeding has all drained from the syringe. Remind the spouse to check for residual again after the feeding has entered the stomach. Ensure that he flushes the tubing with water after the syringe is empty of feeding. *What is the sequence of nursing actions? (Place in numerical order from first action through last action.)* - 1. Tell the spouse to hold the remaining feeding. - 2. Auscultate for the presence of bowel sounds. - 3. Assess the elasticity of the client\'s skin. - 4. Notify the HCP of the diarrhea. **[ABDONMINAL ASSESSMENT]** **The client is a female, mature adult who was admitted to the medical/surgical unit with complaints of right upper quadarant abdominal pain, nausea and vomiting for the last 3 hours. Client rates her pain 5/10. Vital signs include heart rate 92 beats/minute, respirations 20 breaths/minute, and blood pressure 132/70 mmHg. The client is accompanied by her spouse.** *Top of Form* *Which assessment should the nurse complete **first**?* Check the pulse. Listen to bowel sounds. Observe the color of the emesis. Obtain a STAT blood pressure. Top of Form *The nurse assesses the patient\'s vomitus. Which finding would the nurse be the **most **concerned about?* Green vomit with particles of food. Thick dark brown vomit White foamy vomit Yellow clear vomit Bottom of Form *Top of Form* *The nurse is documenting the client\'s vomitus. Which documentation should be included in the client\'s medical record? (Select all that apply.)* Client vomited green with undigested food particles. Vomit without odor. Vomit is soft in consistency. Approximately 250ml of vomit was noted. Client vomited x 1 lasting approximately 2 minutes. **The client vomits 200 milliliters of yellow-green liquid. The client continues to feel nauseated. The nurse administers a PRN dose of a prescribed antiemetic. Shortly after the nurse administers the antiemetic, the client states she feels better. The nurse offers to provide oral care with a mint-flavored foam swab and cool water.** *Top of Form* *Which assessment takes priority while the nurse provides oral care?* Assess for presence of dentures. Observe the condition of the mucus membranes. Evaluate the color of the gums Check for the presence of cavities. **Management of Care\ Fifteen minutes after receiving the antiemetic, the client stops vomiting, appears relaxed, and denies further nausea. She states that she is comfortable enough for the nurse to begin the admission assessment.** **The nurse questions the client about what brought her to the hospital. The client states she had right upper quadrant abdominal pain, nausea and vomiting right after she ate lunch. Pain remains at 5/10. The client states her last bowel movement was yesterday.** Bottom of Form *Top of Form* *For the nurse to learn about the client\'s bowel patterns, which questions are **most** important to ask the client? (Select all that apply.)* Have you had any recent onset of heartburn? Do you take any prescription or over-the-counter medications? Have you had any changes in your bowel movements? What is the color and consistency of your bowel movements? How often do you have a bowel movement? Top of Form *What questions should the nurse ask next? (Select all that apply.)* Can you identify which spicy foods cause a problem? How often do you eat spicy foods? What happens when you eat spicy foods? Does anyone in your family have problems with spicy food? Why do you think spicy foods are a problem?Bottom of Form Top of Form *What additional focused interview questions will be important for the nurse to ask the client?* *Select all that apply* Do you have a history of any abdominal conditions or surgeries? Have you experienced any weight gain or weight loss? Are you have any difficulty with urination? Are you experiencing any shortness of breath? Do you have any difficulty swallowing your food? Bottom of Form *Top of Form* *The nurse prepares the client for the physical assessment of the abdomen. What actions should the nurse take prior to initiating the assessment? (Select all that apply.)* Encourage the client to empty her bladder. Place a pillow under the client\'s knees. Inquire where the client is experiencing pain.\ Instruct the client to place her hands over her head. Discuss the sequence of steps performed during the abdominal assessment. Bottom of Form *To ensure the **most** accurate assessment of the abdomen, what actions should the nurse take? (Place in order from first action through last action.)* - 1. Inspection. - 2. Auscultation. - 3. Percussion. - 4. Palpation. *Top of Form* *The nurse is completing an inspection of the abdomen. Which findings would cue the nurse of the need for action?* *Select all that apply* The presence of striae on the right and left lower quadrants. A protruberant shaped abdomen. A midline, inverted umbilicus. A large amount of pigmented nevi scattered accross the abdomen. Marked visible peristalsis. **While inspecting the client\'s abdomen, the nurse notes the following: Abdomen is rounded and symmetrical. No bulges or masses seen. Umbilicus is inverted and midline. No rashes noted. Silvery white striae noted on the lower abdomen. A four centimeter scar is noted on the right lower quadrant of the abdomen. No visible pulsations or perstalsis noted. No hair noted.** Bottom of Form *Top of Form* *What statements from the client\'s focused interview correlate to the abnormal inspection findings? (Select all that apply.)* Daily bowel movements Past surgical history of an appendectomy. Nausea and vomiting. Food intolerance to spicy foods. Change in body mass index (BMI). Bottom of Form *Top of Form* *Where should the nurse begin abdominal auscultation?* They can begin anywhere. Right upper quadrant (RUQ). Right lower quadrant (RLQ) Left upper quadrant (LUQ) **The nurse auscultates the client\'s abdomen. The nurse notes eight high-pitched gurgling sounds occurring at irregular intervals in the right lower abdomen over 15 seconds.** *Bottom of Form* *Top of Form* *What action should the nurse take **next**?* Move to the right upper quadrant (RUQ) to hear the sounds more distinctly. Continue to auscultate for bowel sounds in the right lower quadrant\ Change to the bell of the stethoscope to listen. Listen for 5 minutes before documenting the activity of the bowel sounds. *Bottom of Form* *Top of Form* *When continuing to assess the abdominal area, the nurse hears a swishing sound. In what area would this sound be heard?* Femoral artery. Epigastric area. Umbilical area. Right quadrants. **The nurse listens in all areas and hears gurgling sounds at each location between 8 to 20 sounds per minute. After auscultating the client's bowel sounds, the nurse also listens for abdominal vascular sounds, which are soft, low-pitched, and continuous. The nurse does not hear any venous sounds.** Top of Form *What action should the nurse take in response to this finding?* Stop the assessment and notify the healthcare provider (HCP) immediately of the assessment finding. Take the client\'s blood pressure and heart rate after the assessment. Call another nurse to verify the finding. Document this normal finding on the client's assessment record. Bottom of Form *Top of Form* *A dull sound is heard when the nurse percusses over the suprapubic area. What action should the nurse take in response to this finding?* Reposition the client to her right side. Observe the area for bladder distention. Determine if the client feels bloated or gaseous. Assist the client to a sitting position immediately. **While percussing the abdomen, the nurse hears tympany over most of the abdomen but notes a duller sound when percussing at the right costal margin.** Top of Form *Which is the **most** appropriate follow up action the nurse should implement? (Select all that apply.)* Note this location as the border of the liver. Ask the client if she is constipated. Document the presence of splenic dullness. Document the finding as normal. Make a note to notify the HCP of the findings. Bottom of Form *Top of Form* *The nurse is assessing for costo-vertebral angle (CVA) tenderness. Which statements **best** describe this percussion assessment? (Select all that apply.)* It is normal for a client to feel pain with this percussion assessment. Percussion is completed over the 12th rib in the back bilaterally. Place one hand over the flank area and hit the hand with the ulnar side of the fist. Client will need to take a deep breath prior to completion of the percussion technique. Technique is used to assess for inflammation of the kidney. *Bottom of Form* *Top of Form* *The nurse's goal in palpating the client's abdomen is to screen for any masses or tenderness. To achieve this goal, what action should the nurse take **first**?* Deeply palpate each abdominal organ. Carefully palpate areas of tenderness. Lightly palpate the abdominal surface. Gently palpate the edges of the liver. **When beginning palpation of the client\'s abdomen, the nurse uses a circular finger motion to depress the client\'s skin about a half centimeter. While palpating, the client\'s superficial abdominal muscles become tense and the client states she is very ticklish.** Bottom of Form *Top of Form* *What action should the nurse take?* Use the client\'s own hand to assist with palpation. Switch to using the heel of the hand to palpate. Obtain an order for a muscle relaxant. Stop any further palpation immediately. **Three hours later, the client\'s husband calls the nurse, stating that she is reporting increased abdominal pain. The nurse asks the client where she is experiencing pain and she points to her right upper abdomen.** Top of Form *When completing the pain assessment, how should the nurse assess for rebound tenderness?* Position the client on her right side. Lightly palpate over the painful area. Ask the client to describe the pain. Push down on the left side of the abdomen. *Bottom of Form* *Top of Form* *After observing the presence of rebound tenderness, the nurse notes the onset of involuntary rigidity of the client's abdomen. Which action should the nurse implement?* Notify the HCP of the findings. Assist the client to a semi-Fowler's position. Administer a pain medication. Place a warm moist pack on the client's abdomen. Bottom of Form *Top of Form* *Based on the client\'s assessment, what condition would the nurse suspect?* Appendicitis Liver failure Cholecystitis Ureteral colic Bottom of Form *Top of Form* *What further assessment technique would the nurse consider to confirm a problem with the gallbladder?* Murphy\'s sign Illiopsoas test Obturator test The Alvarado score **After the nurse reports the findings to the HCP, the client is scheduled for immediate removal of her gallbladder. Following surgery, the client returns to her room. During the nursing assessment on the first postoperative day, the client seems anxious and tells the nurse that she is in a lot of pain.** Bottom of Form *Top of Form* *In response to the client's statement that she is in a lot of pain, what action should the nurse take **first**?* Explain to the client that post-operative pain is normal. Ask the client to describe her pain location and intensity. Ask the client if she has passed gas since surgery. Assess the client's heart rate and blood pressure. Bottom of Form Top of Form Fill in the blank *Pharmacological and Parenteral TherapiesAfter completing the pain assessment, the nurse prepares to administer a prescribed opioid analgesic: Morphine Sulfate 6 mg by intravenous push every 6 hours. Morphine is available in 10 mg/1 mL vials. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the tenth.) * ***Desired dose divided by Dose on hand = Dose to give\ 6mg/10 mg /1 ml = 0.6 mL*** Bottom of Form *Top of Form* *Thirty minutes later, the nurse returns to assess the client\'s response to the medication. Which findings provide the **best** data about the effectiveness of the medication? (Select all that apply.)* The client's vital signs are within normal limits. The client is holding a pillow over her abdomen. The client's facial expression is calm and relaxed. The client states a lessening of her pain. The spouse reports that the client looks like her pain has improved. Bottom of Form *Top of Form* *To learn about the intensity of the client's pain, what pain scale is **most** appropriate to use to assess the client\'s pain?* FLACC behavioral pain scale Numeric pain scale Faces Pain scale Non-verbal cues **[HEART AND NECK ASSESSMENT]** **Client is a 58-year-old male. He is admitted directly to the cardiac telemetry unit from his healthcare provider\'s (HCP) office with a history of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort.** *Top of Form* *Based on client's report of increasingly frequent periods of dyspnea, dizziness, and minor chest discomfort, what assessment should the nurse perform **next**?* Ask the client to stand and then recheck the blood pressure. Place the client in a supine position and observe for orthopnea. Measure the apical and radial pulse rates at the same time. Determine if the client is currently experiencing any angina. *Top of Form* *Client denies any angina. After palpating an irregular pulse rhythm at the left radial pulse site, what action should the nurse take to confirm the client's heart rate?* Palpate both radial pulses simultaneously. Auscultate the apical pulse for 1 minute. Compare the ulnar pulse to the radial pulse. pulse is often difficult to palpate and is not the best site to use to assess cardiac rate and rhythm. **Health Promotion and Maintenance\ The client\'s apical rate is 92 and irregular, consistent with the radial pulse. The nurse implements cardiac telemetry monitoring, obtains oxygen for PRN use, and begins treatment for client\'s irregular heart rhythm as prescribed. After gathering the initial priority data, the nurse interviews him to gather subjective data related to his cardiac function.** Top of Form To gather data about client's history of chest pain, how should the nurse begin? Encourage the client to describe his chest discomfort. Determine if the chest pain has radiated to other sites. Question the client about the frequency of his symptoms. Ask the client to rate his chest pain on a numeric scale. Top of Form **Reduction of Potential Risk\ Client reports feeling pressure on his chest sometimes, stating that it stops when he sits down and rests. He also tells the nurse that he feels tired a lot lately. He states, \"I guess that\'s part of growing older.\"** *To obtain information that will help distinguish whether the client's fatigue is cardiac in nature, what question should the nurse ask him?* \"Why do you feel your fatigue is related to your age?\" \"Can you describe the quality of your fatigue?\" \"What do you do when you feel tired?\" \"At what time of day do you feel most fatigued?\" Top of Form **Health Promotion and Maintenance: Inspection of the Precordium** *The nurse begins the physical assessment by inspecting the client\'s precordium. How should the nurse prepare the client for inspection of the precordium?* Assist the client to a left side-lying position with his chest and back exposed. Open the back of the client's gown while he sits on the side of the bed. Help the client to a supine position on the bed with his chest exposed. Loosen the client's gown and ask him to lean forward in the bedside chair. Top of Form *The nurse should observe the force of the impulse at what location?* Left midclavicular line, 2^nd^ intercostal space. Left sternal border, 4^th^ intercostal space. Right sternal border, 2^nd^ intercostal space. Left midclavicular line, 5^th^ intercostal space. **Palpation of the Precordium\ The nurse uses the palmar aspects of the fingers to palpate across the precordium.** Top of Form *To begin palpation at the base of the heart, where should the nurse palpate first?* Right sternal border, 2^nd^ intercostal space. Right sternal border, 4^th^ intercostal space. Left sternal border, 5^th^ intercostal space. Left midclavicular line, 5^th^ intercostal space. Top of Form *Before attempting to palpate again, the nurse should give the client what instruction?* Lift his left arm above his head. Turn onto his right side. Externally rotate his right shoulder. Roll half-way to his left side. Bottom of Form **Palpation of the Precordium\ The nurse is able to palpate the apical impulse after client turns midway to his left side. The nurse considers whether to percuss the client\'s precordium. Client\'s medical record contains the results of several diagnostic tests completed prior to his admission to the hospital.** *Top of Form* *Which test result can the nurse review to obtain the same information that might be obtained during precordial percussion? (Select all that apply. One, some, or all options may be correct.)* Creatine phosphokinase (CPK). Carotid ultrasound. Serum liver enzymes. Chest x-ray. Echocardiogram. **Auscultation of the Precordium\ The nurse uses a stethoscope for auscultation of the client\'s heart and plans to begin auscultation at the aortic area.** *Top of Form* *How should the nurse plan to continue auscultation from that site?* Move the stethoscope back and forth across the sternum. Slide the stethoscope over and up in an \"X\" pattern. Lift the stethoscope from one valve area to the next.. Inch the stethoscope across and down in a \"Z\" pattern. Inching the stethoscope across the chest and using a systematic pattern ensures that all sounds produced by the valves will be heard. Top of Form *In listening at this site, what should the nurse attempt to distinguish first?* S1 and S2 heart sounds. Diastolic heart murmur. S3 and S4 heart sounds. Systolic heart murmur. Bottom of Form **Auscultation of the Precordium\ During auscultation, the nurse has difficulty distinguishing S1 from S2 because of the client\'s irregular heart rhythm.** *Top of Form* *Bottom of Form* *Top of Form* *While continuing to listen at the aortic site, what action should the nurse take?* Observe the P wave on the telemetry monitor. Watch the client's inhalation and exhalation. Palpate the carotid artery pulse. Check for a pulse deficit.Top of Form **The nurse is able to distinguish the LUB-dup sequence of S1 and S2 and continues the assessment. After inching the diaphragm of the stethoscope to the left second intercostal space, the nurse hears a split S2 during the client\'s inspiration.** *What action should the nurse take in response to this finding?* Document this normal finding on the initial assessment record. Confirm the finding on the bedside cardiac telemetry monitor. Assess for a change in the client's oxygen saturation reading. Contact the healthcare provider (HCP) to report the assessment finding. Top of Form *How should the nurse identify this sound?* Diastolic murmur. Systolic murmur. S4 heart sound. S3 heart sound. Bottom of Form *Top of Form* *To determine the grade of the murmur, what action should the nurse take?* Listen in surrounding areas for the extent of radiation of the sound. Assess for a change in the murmur during a change in the client's position. Determine the location on the client's chest where the murmur is best heard. Note how easily the murmur is heard by gradually lifting the stethoscope. Top of Form *What action should the nurse take **next**?* Document the findings and report the murmur to the charge nurse. Repeat auscultation across the chest using the bell of the stethoscope. Continue assessment of heart sounds across the client's posterior thorax. Plan to repeat the assessment in 1 hour, after the client rests. Top of Form *What action will help the nurse confirm the presence of this sound?* Move the diaphragm of the stethoscope to the base of the heart. Use the bell of the stethoscope to continue listening at the apical site. Palpate the apical impulse while listening at the base of the heart. Place the bell of the stethoscope at the right sternal border at the third interspace. Top of Form **The nurse\'s further assessment confirms the finding of an S3 heart sound. After determining that the client has an S3 heart sound, the nurse reassesses the client.** *What assessment should the nurse include?* Check for jugular vein distention. Note the onset of nailbed clubbing. Check for diminished skin elasticity. Assess for orthostatic hypotension. Top of Form *To inspect for jugular vein distention, what actions should the nurse take? (Select all that apply. One, some, or all options may be correct.)* Place the client in a Fowler's position with his head straight. Lower the head of the bed while observing the neck veins. Remove the client's pillow and turn his head away slightly. Assist the client to lean forward at a 30 to 45° angle. Place the client in a Semi-Fowler\'s position. **The nurse observes a pulsation low and laterally on the neck at the area of the left internal jugular vein but is unable to palpate the pulsation.** Bottom of Form *Top of Form* *What action should the nurse take?* Use a stethoscope to auscultate the pulsation. Palpate the pulsation again, using less pressure. Reposition the client's head and attempt to palpate again. Document the level at which the pulsation is observed. Bottom of Form *Top of Form* *How should the nurse begin the carotid artery assessment?* Palpate one artery while listening to the other side with a stethoscope. Palpate one artery and then palpate the artery on the opposite side. Gently compress both arteries simultaneously to compare the volume Avoid palpation and only use a stethoscope to listen to each artery. **The nurse assesses the carotid artery pulse volume as +2. The nurse then listens for a carotid bruit by placing the bell of the stethoscope at the base of the neck on the right side.** Top of Form *The nurse does not hear a bruit. What should the nurse do **next**?* Listen at the base of the neck again, this time using the diaphragm of the stethoscope. The bell of the stethoscope is used to assess for a carotid bruit. Move the bell of the stethoscope up the right side of the neck to the mid-cervical area. Press the bell of the stethoscope more firmly against the base of the neck and listen again. **Top of FormNo carotid bruit is heard. After completing the assessment, the nurse reminds client to call if anything is needed and leaves the room. The nurse documents the findings and prepares to report the findings to the HCP.** *Which assessment data are important for the nurse to report to the client\'s HCP? (Select all that apply. One, some, or all options may be correct.)* Presence of S1 and S2 heart sounds. Onset of an S3 heart sound. Observed jugular vein distention. Noted absence of a carotid bruit. Client's subjective report of dyspnea. Top of Form *The nurse uses the SBAR method when communicating with the primary HCP. Which are components of the SBAR method? (Select all that apply. One, some, or all options may be correct.)* Assessment. Response. Recommendation. Action. Situation. **A client with paraplegia as the result of a spinal cord injury received in a motorcycle accident lives at home with their parents who assist with care. The client is attending college and has a strong social support system. The client visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on their sacrum.** *Top of Form* *In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? (Select all that apply. One, some, or all options may be correct.)* *Select all that apply* Apply light pressure to the area with the fingertips. Measure the diameter of the redness. Obtain a wound culture. Gently lift a fold of skin. Observe for wound approximation. Top of Form *The sacral area has remained red for 2 hours and does not blanch when tested. Which is the **best **description for the nurse to document?* Excessive pallor. Unusual skin mottling. Dependent sacral rubor. Reactive hyperemia. *Top of Form* *Which areas are **most** important for the nurse to observe for additional pressure injuries (PI)?* Distal tips of the toes. Lower abdominal folds. Ischial tuberosities. Thighs and calves. *Top of Form* *What action should the nurse implement?* Apply heat to reduce the inflammation that has occurred at these sites. Notify the healthcare provider (HCP) that the client is retaining excess fluid. Reassure the client that no pressure damage is present at these sites. Identify these areas as sites where pressure damage has occurred. Bottom of Form *Top of Form* *Which etiology identified by the nurse is accurate?* Noncompliance with turning schedule. Poor nutritional intake. Impaired physical mobility. Impaired adjustment. Top of Form *Which goal should the nurses include in the client\'s plan of care?* The client\'s skin will remain intact without deterioration. The client\'s motor function will be restored. Client teaching will be provided. Impaired skin integrity will not occur. Top of Form *To provide pressure relief at night, the nurse teaches the client to sleep in which position?* Supine with the head of the bed elevated. Supine with a foam wedge between the knees. Thirty-degree lateral inclined position. Full side-lying position supported with pillows. Bottom of Form *Top of Form* *Upon learning that the client has a pressure-reducing gel chair cushion for their wheelchair, which action should the nurse take?* Encourage them to continue to use this device in their wheelchair at all times. Recommend that they replace the gel pad with a donut-shaped foam cushion. Advise them to avoid the use of any form of pressure cushion on their wheelchair. Teach them that regular use of skin moisturizer is more important than cushion use. Bottom of Form *Top of Form* *The nurse teaches the client to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 PI?* Transparent film dressing. Aherent film dressing. Gauze dressing. Hydrogel covered with a foam dressing. Bottom of Form *Top of Form* *How should the nurse describe the drainage in documenting the wound?* Infectious. Purulent. Serous. Sanguineous. Bottom of Form *Top of Form* *To reduce the effects of moisture on the client\'s skin, which intervention should be implemented?* Apply a moisture-repellent ointment to intact skin areas. Rinse ulcerated areas with an alcohol-based irrigating solution. Position a plastic-lined pad under the buttocks. Apply moist heat to the area following exposure to feces. Bottom of Form *Top of Form* *What action should the nurse take?* Provide verbal instructions about positioning to the UAP and document the instructions in the nurse\'s notes. Ask the charge nurse to assist with verbal communication to all of the staff involved in the client\'s care to ensure continuity of care. Advise the charge nurse that client confidentiality is secondary to continuity of care. Assure the charge nurse that written instructions in the client\'s room are effective and do not violate any client rights. Top of Form *After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client?* Standard precautions. Droplet precautions. Airborne precautions. Contact precautions. Bottom of Form *Top of Form* *Which equipment should the nurse utilize to assess the length of the tract?* Sterile gloves and lubricant. Sterile tape measure. Sterile cotton-tipped applicator. Sterile irrigation tray with syringe. *Top of Form* *Which irrigation technique is **best**?* Pour the saline directly onto the wound from the bottle. Moisten a sterile gauze pad and pat the gauze over the wound. Irrigate as gently as possible using a 60-mL bulb syringe. Apply steady pressure using a 35 mL syringe and 19-gauge needle. Bottom of Form *Top of Form* *What is the purpose of this type of dressing?* Mechanically debride the tissue. Facilitate tissue healing. Decrease risk of infection. Preserve granulation tissue. **Math**\ **The nurse plans to administer an ordered dose of linezolid, an antibiotic, which interferes with the production of proteins that bacteria need to multiply and divide. The order states, \"linezolid suspension 400 mg by mouth (PO) every 12 hours for 14 days.\" The medication is labeled, \"100 mg/5 mL.\"** Bottom of FormTop of Form *Fill in the blank How many mL of medication will the nurse administer? (Enter numerical value only. If rounding is necessary, round to the whole number.)* 400 mg/100 mg × 5 mL = 20 mL Bottom of Form *Top of Form* *Fill in the blank What is the total daily dosage (in mg) that the client will be receiving? (Enter numerical value only. If rounding is necessary, round to the whole number.)* 400 mg × 2 daily doses (every 12 hours) = 800 mg/24 hours. *Bottom of Form* *Top of Form* *Who is the **best** member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy?* HCP. Pharmacist. Client. Charge nurse. Bottom of Form *Top of Form* *Which technique should the nurse use to mix the linezolid?* Shake gently for 60 seconds. Mix according to directions. Shake vigorously until mixed. Stir medicine after pouring it into the medication measuring cups. Bottom of Form *Top of Form* *The nurse correctly uses which technique when pouring the suspension?* Hold the medication bottle up to eye level. Hold the medication cup up to eye level. Place the medication cup on a flat surface at eye level. Place the medication bottle on a flat surface at eye level. *Bottom of Form* *Top of Form* *The nurse explains to the client that this precaution reduces the risk for what potential problem?* Anaphylactic reaction. Idiosyncratic response. Synergistic effect. Drug incompatibility. Top of Form *Which class of medication should the nurse expect to administer?* A 5HT3 receptor antagonist, such as palonosetron. An adrenergic medication, such as epinephrine. A tocolytic medication, such as terbutaline. An antihistamine, such as diphenhydramine. *Top of Form* *Which diagnostic test should the nurse request an order for to determine if the client is developing drug toxicity?* Culture and sensitivity. Therapeutic index. Half life. Peak and trough. **Psychosocial Support**\ **No evidence of drug toxicity is found. The client\'s next BP is within normal limits, and experiences no further episodes of diarrhea. The wound eschar has been removed (debrided), and there is no further drainage. A hydrocolloid dressing is placed over the wound, and the client is discharged.\ \ The client will complete the 2-week antibiotic treatment at home. The home care nurse visits the client a week after discharge to assess the wound. The nurse reviews symptoms of pressure injuries as well as preventative measures, with the client, and when to call the HCP. The client yells at the nurse and says that they do not need a nurse to tell them that they will spend the rest of their life in and out of hospitals.** *Bottom of Form* *Top of Form* *What **initial** action should the nurse take?* Confront the client about their rude and unacceptable behavior and attitude. Offer the client the opportunity to discuss their feelings of anger. Ask the client\'s parents to calm the client so the nursing assessment can be completed. Reassure the client that they will not need to spend the rest of their life in and out of hospitals. Bottom of Form *Top of Form* *Which nursing response **best** promotes effective communication?* Clarify the difference between an infected pressure injury and a bed sore to the client. Explain to the client that they should not allow themself to become discouraged. Help the client identify the concerns he is trying to cope with at this time. Tell the client that he does not to worry about an infection that is almost resolved. Bottom of Form *Top of Form* *Considering the client\'s developmental stage at the age of 20, the nurse\'s plan of care emphasizes interaction with which group?* The clients parents, aunts, uncles, and cousins. A large group of the clients former high school classmates. A small group of the clients professors from the college. The clients girlfriend and his two best male friends from the college. Bottom of Form *Top of Form* *It is **most** important to include this group in which aspect of the client\'s overall care?* Reviewing class notes and studying for exams. Helping the client plan meals to promote wound healing. Purchasing wound care supplies for the client. Reminiscing about life when they were all younger. Top of Form *The nurse encourages the client to select which breakfast items to provide a good source of protein?* Whole wheat toast with butter. Bagels and cream cheese. Oatmeal and a banana. Eggs and orange juice. *Top of Form* *What teaching should the nurse provide?* Another round of antibiotic therapy will probably be needed. Hydrocolloid dressings should be continued over the ulcer. Debridement of the pressure ulcer must be restarted. The pressure ulcer should now be kept open to the air. Bottom of Form Bottom of Form Bottom of Form Bottom of Form Bottom of Form

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