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HESI MILESTONE #2 LATEST 2023-2024 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |AGRADE ANSWERS WITH RATIONALE 100% ACCURACY The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regardi...

HESI MILESTONE #2 LATEST 2023-2024 QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) |AGRADE ANSWERS WITH RATIONALE 100% ACCURACY The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? 1. Listening to lung sounds 2. Palpating for organomegaly 3. Assessing for jugular vein distention 4. Assessing for peripheral and sacral edema - CORRECT ANSWER - Listening to lung sounds. The client with heart failure may present with different symptoms, depending on whether the right or the left side of the heart is failing. Peripheral and sacral edema, jugular vein distention, and organomegaly all are manifestations of problems with right-sided heart function. Lung sounds constitute an accurate indicator of left- sided heart function. The registered nurse (RN) is educating a new RN about the use of oxygen for clients with angina pectoris. Which statement by the new nurse indicates that the teaching has been effective? 1. "Oxygen has a calming effect." 2. "Oxygen will prevent the development of any thrombus." 3. "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." 4. "Oxygen dilates the blood vessels so that they can supply more nutrients to the heart muscle." - CORRECT ANSWER - "The pain of angina pectoris occurs because of a decreased oxygen supply to heart cells." The pain associated with angina results from ischemia of myocardial cells. The pain often is precipitated by activity that places more oxygen demand on heart muscle. Supplemental oxygen will help meet the added demands on the heart muscle. Oxygen does not dilate blood vessels or prevent thrombus formation and does not directly calm the client. The nurse has provided dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions? 1. "I'll need to become a strict vegetarian." 2. "I should use polyunsaturated oils in my diet." 3. "I need to substitute eggs and whole milk for meat." 4. "I should eliminate all cholesterol and fat from my diet." - CORRECT ANSWER - "I should use polyunsaturated oils in my diet." The client with coronary artery disease needs to avoid foods high in saturated fat and cholesterol such as eggs, whole milk, and red meat. These foods contribute to increases in low-density lipoproteins. The use of polyunsaturated oils is recommended to control hypercholesterolemia. It is not necessary to eliminate all cholesterol and fat from the diet. It is not necessary to become a strict vegetarian. The home care nurse has taught a client with heart failure and a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? 1. "I will try to exercise vigorously to strengthen my heart muscle." 2. "I will eat enough daily fiber to prevent straining during bowel movement." 3. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." 4. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels." - CORRECT ANSWER - "I will eat enough daily fiber to prevent straining during bowel movement." Standard home care instructions for a client with this problem include, among others, lifestyle changes such as avoiding alcohol intake, avoiding activities that increase the demands on the heart, instituting a bowel regimen to prevent straining and constipation, and maintaining fluid and electrolyte balance. Consuming 3000 to 3500 mL of fluid and exercising vigorously will increase the cardiac workload. A client with heart failure has been experiencing difficulty with completion of daily activities, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem? 1. Ambulates 10 feet (3 meters) farther each day 2. Verbalizes the benefits of increasing activity 3. Chooses a healthy diet that meets caloric needs 4. Sleeps without awakening throughout the night - CORRECT ANSWER - Chooses a healthy diet that meets caloric needs Each of the options indicates a positive outcome on the part of the client. Both option 2 and the correct one relate to the client problem of difficulty with completion of daily activities. However, the question asks about progress. The correct option is more action-oriented and therefore is the better choice. Option 3 would most likely indicate progress if the client had a problem of inadequate nutritional intake. Option 4 would be a satisfactory outcome for a client experiencing difficulty sleeping. A client with coronary artery disease is scheduled to have a diagnostic exercise stress test. Which instruction would the nurse plan to provide to the client about this procedure? 1. Eat breakfast just before the procedure. 2. Wear firm, rigid shoes, such as work boots. 3. Wear loose clothing with a shirt that buttons in front. 4. Avoid cigarettes for 30 minutes before the procedure. - CORRECT ANSWER - Wear loose clothing with a shirt that buttons in front. The client needs to wear loose, comfortable clothing for the procedure. Electrocardiogram (ECG) lead placement is enhanced if the client wears a shirt that buttons in the front. The client needs to receive nothing by mouth after bedtime or for a minimum of 2 hours before the test. The client would wear rubber-soled, supportive shoes, such as athletic training shoes. The client needs to avoid smoking, alcohol, and caffeine on the day of the test. Inadequate or incorrect preparation can interfere with the test, with the potential for a false-positive result. A client recovering from pulmonary edema is preparing for discharge. What would the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? 1. Weigh self on a daily basis. 2. Sleep with the head of the bed flat. 3. Take a double dose of the diuretic if peripheral edema is noted. 4. Withhold prescribed digoxin if slight respiratory distress occurs. - CORRECT ANSWER - Weigh self on a daily basis. The client can best determine fluid status at home by weighing himself or herself on a daily basis. Increases of 2 to 3 lb (0.9 to 1.4 kg) in a short period are reported to the primary health care provider (PHCP). The client needs to sleep with the head of the bed elevated. During recumbent sleep, fluid (which has seeped into the interstitium with the assistance of the effects of gravity) is rapidly reabsorbed into the systemic circulation. Sleeping with the head of the bed flat is therefore avoided. The client does not modify medication dosages without consulting the PHCP. The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data would alert the nurse to this occurrence? 1. Inability to pass flatus 2. Loss of anal sphincter control 3. Severe, constant pain with rapid onset 4. Firm, nontender mass palpable at the lower right costal margin - CORRECT ANSWER - Inability to pass flatus An inflammatory reaction such as acute pancreatitis can cause paralytic ileus, the most common form of nonmechanical obstruction. Inability to pass flatus is a clinical manifestation of paralytic ileus. Loss of sphincter control is not a sign of paralytic ileus. Pain is associated with paralytic ileus, but the pain usually manifests as a more constant generalized discomfort. Option 4 is the description of the physical finding of liver enlargement. The liver may be enlarged in cases of cirrhosis or hepatitis. Although this client may have an enlarged liver, an enlarged liver is not a sign of paralytic ileus or intestinal obstruction. The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The primary health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube? 1. Checking for normal serum electrolyte levels 2. Checking for normal pH of the gastric aspirate 3. Checking for proper nasogastric tube placement 4. Checking for the presence of bowel sounds in all four quadrants - CORRECT ANSWER - Checking for the presence of bowel sounds in all four quadrants Distention, vomiting, and abdominal pain are a few of the symptoms associated with intestinal obstruction. Nasogastric tubes may be used to remove gas and fluid from the stomach, relieving distention and vomiting. Bowel sounds return to normal as the obstruction is resolved and normal bowel function is restored. Discontinuing the nasogastric tube before normal bowel function may result in a return of the symptoms, necessitating reinsertion of the nasogastric tube. Serum electrolyte levels, pH of the gastric aspirate, and tube placement are important assessments for the client with a nasogastric tube in place but would not assist in determining the readiness for removing the nasogastric tube. The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities - CORRECT ANSWER - Encouraging active range-of-motion exercises Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat would not be applied without a primary health care provider's prescription. The nurse is caring for a teenage client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis? 1. Leukopenia with a shift to the left 2. Leukocytosis with a shift to the left 3. Leukopenia with a shift to the right 4. Leukocytosis with a shift to the right - CORRECT ANSWER - Leukocytosis with a shift to the left Laboratory findings do not establish the diagnosis of appendicitis, but there is often an elevation of the white blood cell count (leukocytosis) with a shift to the left (an increased number of immature white blood cells). Options 1, 3, and 4 are incorrect because they are not associated findings in acute appendicitis. A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse would document that these findings identify which type of ulcer? 1. A stage 1 ulcer 2. A vascular ulcer 3. An arterial ulcer 4. A venous stasis ulcer - CORRECT ANSWER - An arterial ulcer Arterial ulcers have a pale deep base and are surrounded by tissue that is cool with trophic changes such as dry skin and loss of hair. Arterial ulcers are caused by tissue ischemia from inadequate arterial supply of oxygen and nutrients. A stage 1 ulcer indicates a reddened area with an intact skin surface. A venous stasis ulcer (vascular) has a dark red base and is surrounded by brown skin with local edema. This type of ulcer is caused by the accumulation of waste products of metabolism that are not cleared, as a result of venous congestion. A client calls the nurse at the clinic and reports experiencing a sensation as though the affected leg is falling asleep ever since the vein ligation and stripping procedure was performed. The nurse would make which response to the client? 1. "Apply warm packs to the leg." 2. "Keep the leg elevated as much as possible." 3. "Your primary health care provider needs to be contacted to report this problem." 4. "This normally occurs after surgery and will subside when the edema goes down." - CORRECT ANSWER - "Your primary health care provider needs to be contacted to report this problem." A sensation of pins and needles or feeling as though the surgical limb is falling asleep may indicate temporary or permanent nerve damage after surgery. The saphenous vein and the saphenous nerve run close together, and damage to the nerve will produce paresthesias. The remaining options are inaccurate responses. An alternative to surgery is endovenous ablation of the saphenous vein. Ablation involves the insertion of a catheter that emits energy. This causes collapse and sclerosis of the vein. Potential complications include bruising, tightness along the vein, recanalization (reopening of the vein), and paresthesia. Endovenous ablation also may be done in combination with saphenofemoral ligation or phlebectomy. Transilluminated powdered phlebectomy involves the use of a powdered resector to destroy the varices and then removes the pieces via aspiration. The nurse has completed an educational course about first-degree heart block. Which statement by the nurse indicates that teaching has been effective? 1. "Presence of Q waves indicates first-degree heart block." 2. "Tall, peaked T waves indicate first-degree heart block." 3. "Widened QRS complexes indicate first-degree heart block." 4. "Prolonged, equal PR intervals indicate first-degree heart block." - CORRECT ANSWER - "Prolonged, equal PR intervals indicate first-degree heart block." Prolonged and equal PR intervals indicate first-degree heart block. The development of Q waves indicates myocardial necrosis. Tall, peaked T waves may indicate hyperkalemia. A widened QRS complex indicates a delay in intraventricular conduction, such as bundle branch block. An electrocardiogram (ECG) taken during a pain episode is intended to capture ischemic changes, which also include ST segment elevation or depression. The ambulatory care nurse is working with a client who has been diagnosed with Prinzmetal's (variant) angina. What would the nurse plan to teach the client about this type of angina? 1. It is most effectively managed by beta-blocking agents. 2. It has the same risk factors as stable and unstable angina. 3. It can be controlled with a low-sodium, high-potassium diet. 4. Generally it is treated with calcium channel-blocking agents. - CORRECT ANSWER - Generally it is treated with calcium channel-blocking agents. Prinzmetal's angina results from spasm of the coronary vessels and is treated with calcium channel blockers. Beta blockers are contraindicated because they may actually worsen the spasm. The risk factors are unknown, and this type of angina is relatively unresponsive to nitrates. Diet therapy is not specifically indicated. A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level would the nurse encourage for the client immediately after transfer? 1. Ad lib activities as tolerated 2. Strict bed rest for 24 hours after transfer 3. Bathroom privileges and self-care activities 4. Unsupervised hallway ambulation for distances up to 200 feet (60 meters) - CORRECT ANSWER - Bathroom privileges and self-care activities On transfer from CCU to an intermediate care or general medical unit, the client is allowed self-care activities and bathroom privileges. Activities ad lib as tolerated is premature at this time and potentially harmful for this client. It is unnecessary and possibly harmful to limit the client to bed rest. The client would ambulate with supervision in the hall for brief distances, with the distances being gradually increased to 50, 100, and 200 feet (15, 30, and 60 meters). A client with no history of heart disease has experienced acute myocardial infarction and has been given thrombolytic therapy with tissue plasminogen activator. What assessment finding would the nurse identify as an indicator that the client is experiencing complications of this therapy? 1. Tarry stools 2. Nausea and vomiting 3. Orange-colored urine 4. Decreased urine output - CORRECT ANSWER - Tarry stools Thrombolytic agents are used to dissolve existing thrombi, and the nurse would monitor the client for obvious or occult signs of bleeding. This includes assessment for obvious bleeding within the gastrointestinal (GI) tract, urinary system, and skin. It also includes Hematest testing of secretions for occult blood. The correct option is the only one that indicates the presence of blood. A client has experienced an episode of pulmonary edema. The nurse determines that the client's respiratory status is improving after this episode if which breath sounds are noted? 1. Ronchi 2. Wheezes 3. Crackles in the bases 4. Crackles throughout the lung fields - CORRECT ANSWER - Crackles in the base Pulmonary edema is characterized by extreme breathlessness, dyspnea, air hunger, and the production of frothy, pink-tinged sputum. As the client's condition improves, the amount of fluid in the alveoli decreases, which may be detected by crackles in the bases. (Clear lung sounds indicate full resolution of the episode.) Rhonchi and wheezes are not associated with pulmonary edema. Auscultation of the lungs reveals crackles throughout the lung fields. A hospitalized client has been diagnosed with heart failure as a complication of hypertension. In explaining the disease process to the client, the nurse identifies which chamber of the heart as primarily responsible for the symptoms? 1. Left atrium 2. Right atrium 3. Left ventricle 4. Right ventricle - CORRECT ANSWER - Left ventricle Hypertension increases the workload of the left ventricle because the ventricle has to pump the stroke volume against increased resistance (afterload) in the major blood vessels. Over time this causes the left ventricle to fail, leading to signs and symptoms of heart failure. The remaining options are not the chambers that are primarily responsible for this disease process, although these chambers may be affected as the disease becomes more chronic. The registered nurse (RN) is educating a new nurse on mitral stenosis. Which statement by the new nurse indicates that the teaching has been effective? 1. "Left ventricle to aorta narrowing will impede flow of blood." 2. "Left atrium to left ventricle narrowing will impede flow of blood." 3. "Right atrium to right ventricle narrowing will impede flow of blood." 4. "Right ventricle to pulmonary artery narrowing will impede flow of blood." - CORRECT ANSWER - "Left atrium to left ventricle narrowing will impede flow of blood." The mitral valve separates the left atrium from the left ventricle. The remaining options describe impeded flow due to aortic, tricuspid, and pulmonic stenosis, respectively. The registered nurse (RN) is educating a new nurse about aortic regurgitation. Which statement by the new nurse indicates that the teaching has been effective? 1. "Failure of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricle." 2. "Failure of the aortic valve to close completely allows blood to flow retrograde through the left ventricle to the left atrium." 3. "Failure of the aortic valve to close completely allows blood to flow retrograde through the right ventricle to the right atrium." 4. "Failure of the aortic valve to close completely allows blood to flow retrograde through the pulmonary artery to the right ventricle." - CORRECT ANSWER - "Failure of the aortic valve to close completely allows blood to flow retrograde through the aorta to the left ventricle." The aortic valve separates the aorta from the left ventricle. The statements in the remaining options are inaccurate. Levothyroxine is prescribed for a client diagnosed with hypothyroidism. Upon review of the client's record, the nurse notes that the client is taking warfarin. Which modification to the plan of care would the nurse review with the client's primary health care provider? 1. A decreased dosage of levothyroxine 2. An increased dosage of levothyroxine 3. A decreased dosage of warfarin sodium 4. An increased dosage of warfarin sodium - CORRECT ANSWER - A decreased dosage of warfarin sodium Levothyroxine accelerates the degradation of vitamin K-dependent clotting factors. As a result, the effects of warfarin are enhanced. If thyroid hormone replacement therapy is instituted in a client who has been taking warfarin, the dosage of warfarin would be reduced A client received 20 units of Humulin N insulin subcutaneously at 08:00. At what time would the nurse plan to assess the client for a hypoglycemic reaction? 1. 10:00 2. 11:00 3. 17:00 4. 24:00 - CORRECT ANSWER - 17:00 Humulin N is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and the duration of action is 16 to 24 hours. Hypoglycemic reactions most likely occur during peak time. The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching? 1. "I would keep the insulin in the cabinet during the day only." 2. "I know I have to keep my insulin in the refrigerator at all times." 3. "I can store the open insulin bottle in the kitchen cabinet for 1 month." 4. "The best place for my insulin is on the windowsill, but in the cupboard is just as good." - CORRECT ANSWER - "I can store the open insulin bottle in the kitchen cabinet for 1 month." An insulin vial in current use can be kept at room temperature for 1 month without significant loss of activity. Direct sunlight and heat must be avoided. Therefore, options 1, 2, and 4 are incorrect. The new registered nurse (RN) is orienting on the cardiac unit. Which statement by the new RN indicates an understanding of an early indication of fluid volume deficit due to blood loss? 1. "Pulse rate will increase." 2. "Blood pressure will decrease." 3. "Edema will be present in the legs." 4. "Crackles in the lungs will be present." - CORRECT ANSWER - "Pulse rate will increase." The cardiac output is determined by the volume of the circulating blood, the pumping action of the heart, and the tone of the vascular bed. Early decreases in fluid volume are compensated for by an increase in the pulse rate. Although the blood pressure will decrease, it is not the earliest indicator. Edema and crackles in the lungs indicate an increase in fluid volume. A nursing student who is researching a medication at the nurses' station asks the registered nurse (RN) what the function of an alpha-adrenergic receptor is, and where the receptors are primarily found. The RN educates the nursing student. Which statement by the nursing student indicates that teaching has been effective? 1. "The peripheral arteries and veins; when stimulated they cause vasoconstriction." 2. "Arterial and bronchial walls; when stimulated they cause vasodilation and bronchodilation." 3. "The heart; when stimulated it causes an increase in heart rate, atrioventricular node conduction, and contractility." 4. "Several tissues; when stimulated they cause contraction of smooth muscle, inhibition of lipolysis, and promotion of platelet aggregation." - CORRECT ANSWER - "The peripheral arteries and veins; when stimulated they cause vasoconstriction." Found in the peripheral arteries and veins, alpha-adrenergic receptors cause a powerful vasoconstriction when stimulated. The remaining options are incorrect statements. The client who has begun an exercise program asks the nurse why the heart "feels like it's pounding" when exercising vigorously. The nurse provides education to the client about increased cardiac response based on which physiological concept? 1. Pulse rate is not a reflection of cardiac response. 2. Cardiac index is the mechanism that allows blood to flow better. 3. Cardiac output is the body's attempt to meet metabolic demands. 4. Stroke volume is an artificial number used to determine the adequacy of cardiac output. - CORRECT ANSWER - Cardiac output is the body's attempt to meet metabolic demands. The client's symptoms are the direct result of the body's attempt to meet the metabolic demands generated during exercise. An adequate cardiac output is needed to maintain perfusion to the vital organs of the body. With exercise, these demands increase, and the heart must beat faster (increased heart rate) and harder (increased stroke volume) to meet them. Cardiac index is an artificial number used to determine the adequacy of the cardiac output for a given individual. It is calculated by adjusting the cardiac output for body surface area. The nurse is listening to a cardiologist explain the results of a cardiac catheterization to a client and family. The cardiologist tells the client that a blockage is present in the large blood vessel that supplies the anterior wall of the left ventricle. The nurse determines that the blockage is located in which area? 1. Circumflex coronary artery 2. Right coronary artery (RCA) 3. Posterior descending coronary artery (PDA) 4. Left anterior descending coronary artery (LAD) - CORRECT ANSWER - Left anterior descending coronary artery (LAD) The LAD bifurcates from the left main coronary artery to supply the anterior wall of the left ventricle and a few other structures. The circumflex coronary artery bifurcates from the left coronary artery and supplies the left atrium and the lateral wall of the left ventricle. The RCA supplies the right side of the heart, including the right atrium and right ventricle. The PDA supplies the posterior wall of the heart. The new registered nurse (RN) is reviewing cardiac rhythms with a mentor. Which statement by the new RN indicates that teaching about ventricular fibrillation has been effective? 1. "Ventricular fibrillation appears as irregular beats within a rhythm." 2. "Ventricular fibrillation does not have P waves or QRS complexes." 3. "Ventricular fibrillation is a regular pattern of wide QRS complexes." 4. "Ventricular fibrillation has recognizable P waves, QRS complexes, and T waves." - CORRECT ANSWER - "Ventricular fibrillation does not have P waves or QRS complexes." Ventricular fibrillation is characterized by the absence of P waves and QRS complexes. The rhythm is instantly recognizable by the presence of coarse or fine fibrillatory waves on the cardiac monitoring screen. Premature ventricular contractions (PVCs) appear as irregular beats within a rhythm. Ventricular tachycardia is a regular pattern of wide QRS complexes. Sinus tachycardia has a recognizable P wave, QRS complex, and T wave. Each of the incorrect options has a recognizable complex that appears on the monitoring screen. The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse anticipate the physician to most likely prescribe? Select all that apply. 1. Strict bed rest 2. Elevation of the right leg 3. Administration of acetaminophen 4. Application of moist heat to the right leg 5. Monitoring for signs of pulmonary embolism - CORRECT ANSWER - Elevation of right leg, Administration of acetaminophen, Application of moist heat to the right leg, Monitoring for signs of pulmonary embolism Standard management for the client with DVT includes maintaining the activity level as prescribed by the physician; limb elevation; relief of discomfort with warm, moist heat; and analgesics as needed. Strict bed rest is not likely to be prescribed; recent research is showing that ambulation does not cause pulmonary embolism and does not cause the existing DVT to worsen. Additionally, bed rest can cause complications such as skin integrity problems, weakness due to immobility, and respiratory problems. The nurse is teaching a pregnant client with diabetes about nutrition and insulin needs during pregnancy. The nurse would provide the client with which information? 1. Glucose crosses the placenta. 2. Insulin crosses the placenta. 3. Increased caloric intake is needed. 4. Decreased caloric intake is required. - CORRECT ANSWER - Glucose crosses the placenta. Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the pregnant client's demand for insulin and is referred to as the diabetogenic effect of pregnancy. Caloric requirements are not affected by diabetes. A client had a colectomy 2 days earlier to remove a bowel tumor and had a new colostomy created. The client is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client would not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation. - CORRECT ANSWER - This is a normal, expected event. As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client would begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations. The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin." 2. "I need to increase my fluid intake." 3. "I need to monitor my blood glucose every 3 to 4 hours." 4. "I need to call the primary health care provider (PHCP) because of these symptoms." - CORRECT ANSWER - "I need to stop my insulin." When a client with diabetes mellitus is unable to eat normally because of illness, the client still needs to take the prescribed insulin or oral medication. The client would consume additional fluids and needs to notify the PHCP. The client needs to monitor the blood glucose level every 3 to 4 hours. The client would also monitor the urine for ketones during illness. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions would be included in the plan of care? Select all that apply. 1. Avoid stimulation. 2. Decrease fluid intake. 3. Expose all of the newborn's skin. 4. Monitor skin temperature closely. 5. Reposition the newborn every 2 hours. 6. Cover the newborn's eyes with eye shields or patches. - CORRECT ANSWER - Monitor skin temperature closely, Reposition the newborn every 2 hours, Cover the newborn's eyes with eye shields or patches Phototherapy (bili-light or bili-blanket) is the use of intense fluorescent light to reduce serum bilirubin levels in the newborn. Adverse effects from treatment, such as eye damage, dehydration, or sensory deprivation, can occur. Interventions include exposing as much of the newborn's skin as possible; however, the genital area is covered. The newborn's eyes are also covered with eye shields or patches, ensuring that the eyelids are closed when shields or patches are applied. The shields or patches are removed at least once per shift to inspect the eyes for infection or irritation and to allow eye contact. The nurse measures the lamp energy output to ensure efficacy of the treatment (done with a special device known as a photometer), monitors skin temperature closely, and increases fluids to compensate for water loss. The newborn may have loose green stools and green- colored urine. The newborn's skin color is monitored with the fluorescent light turned off every 4 to 8 hours and is monitored for bronze baby syndrome, a grayish brown discoloration of the skin. The newborn is repositioned every 2 hours, and stimulation is provided. After treatment, the newborn is monitored for signs of hyperbilirubinemia because rebound elevations can occur after therapy is discontinued. The nurse is monitoring for adverse effects in a client who is taking digoxin. Which findings are characteristic of digoxin toxicity? Select all that apply. 1. Tremors 2. Diarrhea 3. Irritability 4. Blurred vision 5. Nausea and vomiting - CORRECT ANSWER - Diarrhea, Blurred vision, Nausea and vomiting Digoxin is a cardiac glycoside. The risk of toxicity can occur with the use of this medication. Toxicity can lead to life-threatening events, and the nurse needs to monitor the client closely for signs of toxicity. Early signs of toxicity include gastrointestinal manifestations such as anorexia, nausea, vomiting, and diarrhea. Subsequent manifestations include headache; visual disturbances such as diplopia, blurred vision, yellow-green halos, and photophobia; drowsiness; fatigue; and weakness. Cardiac rhythm abnormalities can also occur. The nurse also monitors the digoxin level. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding would the nurse expect to note if this condition is present? 1. Soft abdomen 2. Uterine tenderness 3. Absence of abdominal pain 4. Painless, bright red vaginal bleeding - CORRECT ANSWER - Uterine tenderness Abruptio placentae, or placental abruption, is the premature separation of the placenta from the uterine wall after the twentieth week of gestation and before the fetus is delivered. In abruptio placentae, acute abdominal pain is present. Uterine tenderness is present, especially with a central abruption and trapped blood behind the placenta. The abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. A soft abdomen and painless, bright red vaginal bleeding in the second or third trimester of pregnancy are signs of placenta previa. The nurse is caring for a client with a small bowel obstruction located in the proximal jejunum. The nurse would monitor the client for which acid-base imbalances associated with this condition? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis - CORRECT ANSWER - Metabolic alkalosis Bowel obstructions can occur in either the large or small bowel, and each has different clinical manifestations and complications. Large bowel obstruction is associated with an increased risk of metabolic acidosis. Small bowel obstruction in the proximal small bowel is associated with metabolic alkalosis due to the persistent vomiting associated with this condition. Since the client's obstruction is located in the proximal jejunum, which is in the proximal portion of the small intestines, the client is at increased risk for metabolic alkalosis. Eliminate option 1 because this is a complication of a large bowel obstruction. Next, eliminate options 3 and 4 because the acid-base imbalance of bowel obstruction is metabolic in nature. Therefore, option 2 is correct. The nurse is teaching the parent of a preschool child how to administer the child's insulin injection. The child will be receiving 2 units of Humulin R insulin and 12 units of Humulin N insulin every morning. How would the nurse instruct the parents to prepare the insulin? 1. Draw the insulin into separate syringes. 2. Draw the Humulin R insulin first and then the Humulin N insulin into the same syringe. 3. Draw the Humulin N insulin first and then the Humulin R insulin into the same syringe. 4. Check blood glucose first, and if the result is between 70 and 99 mg/dL (3.9 and 5.5 mmol/L), withhold the insulin injection. - CORRECT ANSWER - Draw the Humulin R insulin first and then the Humulin N insulin into the same syringe. When mixing types of insulin, always withdraw the clear, rapid-acting insulin into the syringe first and then the long-acting insulin. This procedure avoids contaminating the short-acting insulin with the longer-acting insulin. Therefore, the Humulin R insulin would be drawn into the syringe first, followed by the Humulin N insulin. When a child's insulin dosage requires the injection of both short- and intermediate-acting insulin at the same time, it is preferable to mix the two and use a single injection. Blood glucose results between 70 and 99 mg/dL (3.9 and 5.5 mmol/L) are considered to be euglycemic (normal), and the prescribed dose would be administered to maintain euglycemia. A client has been prescribed clozapine. The nurse reviews the result of which laboratory study to detect a serious adverse effect associated with this medication? 1. Platelet count 2. Liver function 3. Blood glucose level 4. White blood cell count - CORRECT ANSWER - Platelet count Clozapine is an antipsychotic medication. The client taking clozapine may experience agranulocytosis as an adverse effect, which is monitored by obtaining weekly white blood cell counts. Treatment is withheld if the level drops below 3000 mm3 (3 × 109/L). Agranulocytosis could be fatal if undetected and untreated. The other options are incorrect. The nurse is preparing a plan of care for an infant who will be returning from the recovery room following the surgical repair of a cleft lip located on the right side of the lip. On return from the recovery room, the nurse would plan to place the infant in which position? 1. Prone and flat 2. Supine and flat 3. On the left side 4. On the right side - CORRECT ANSWER - On the left side Following cleft lip repair, the infant would be positioned supine or on the side opposite the repair to prevent the suture line from contacting the bed linens. Immediately after surgery, it is best to place the infant on the left side rather than supine to prevent aspiration if the infant vomits. The nurse is reviewing the laboratory results of a client diagnosed with multiple myeloma. Which would the nurse expect to note specifically in this disorder? 1. Increased calcium level 2. Increased white blood cells 3. Decreased blood urea nitrogen level 4. Decreased number of plasma cells in the bone marrow - CORRECT ANSWER - Increased calcium level Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue, and an elevated blood urea nitrogen level. An increased white blood cell count may or may not be present and is not related specifically to multiple myeloma.