Nursing Care Procedures and Client Safety, Exams of Nursing

Download Nursing Care Procedures and Client Safety and more Exams Nursing in PDF only on Docsity! HESI COMPREHENSIVE RN EXAM 2024 NEW VERSION|ACCURATE ANSWERS|VERIFIED ANSWERS|GUARANTEED PASS| LATEST UPDATE. . A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take? A. Review the plan and the steps in performing the procedure with another nurse. B. Look up the specific procedure in a medical-surgical nursing text on the unit. C. Discuss the client's prescribed procedure with an available health care provider. D. Consult the agency's policies and procedures manual and follow the guidelines. - Ans - D Rationale: The agency's policies and procedures manual should be consulted to verify the agency's approved protocol for the client's procedure, which is adapted to follow current standards of care. Options A and B may be resources, but client care should be implemented according to the agency's published policies and procedures. Option C is not practical. The nurse is correct in withholding an older adult client's dose of nifedipine if which assessment finding is obtained? A. Blood pressure of 90/56 mm Hg B. Apical pulse rate of 68 beats/min C. Potassium level of 3.3 mEq/L D. Urine output of 200 mL in 4 hours - Ans - A Rationale: Nifedipine is a calcium channel blocker that causes a decrease in blood pressure. It should be withheld if the blood pressure is lowered, and 90/56 mm Hg is a low blood pressure for an adult male. A pulse rate <60 beats/min is an indication to withhold the drug. A potassium level of 3.3 mEq/L is low (normal, 3.5 to 5.0 mEq/L), but this finding does not affect the administration of Procardia. Urine output of more than 30 mL/hr, or 120 mL in 4 hours, is normal. Although a 200-mL output in 4 hours is slightly less than normal and warrants follow-up, it is not an indication to withhold a nifedipine (Procardia) dose. A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? A. Oral hygiene should be performed before the medication. B. Antifungal medications are available in tablet, suppository, and liquid forms. C. Candida albicans is the organism that causes the white lesions in the mouth. D. The dietary intake of dairy and spicy foods should be limited. - Ans - A Rationale: HIV infection causes depression of cell-mediated immunity that allows an overgrowth of C. albicans (oral moniliasis), which appears as white, cheesy plaque or lesions that resemble milk curds. To ensure effective contact of the medication with the oral lesions, oral liquids should be consumed and oral hygiene performed before swishing the liquid Nystatin. Options B and C provide the client with additional information about the pathogenesis and treatment of opportunistic infections, but option A allows the client to participate in self-care of the oral infection. Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but restriction of dairy products is not indicated. Which actions should the nurse include in the plan of care for a client with bipolar disorder in the manic phase? (Select all that apply.) A. Report lithium level of 2.0 mEq/L to the primary health care provider. B. Encourage competitive physical activities as part of the client's therapy. C. Provide an environment with increased stimuli to engage the client. D. Maintain consistent salt levels in the diet when client is taking lithium. E. Assess the client's nutritional and hydration status. - Ans - A, D, E Rationale:A therapeutic level for serum lithium is 0.5 to 1.5 mEq/L, and the client with 2.0 mEq/L is experiencing toxicity (A). Consistent salt levels are important when taking lithium to maintain a therapeutic level (D). Because of the client's manic state, the client is at risk for impaired nutrition and dehydration; therefore, they should be assessed (E). Noncompetitive physical activities should be encouraged because of the risk for agitation (B), and decreased environmental stimuli are therapeutic for the manic phase (C). The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. What is the priority nursing action? A. Examine for clamp closures. B. Assign the UAP to complete the assessment while the nurse checks for the advanced directive. C. Check the medical record for the advanced directive and then complete the client assessment. D. Call for the charge nurse to check the advanced directive while continuing to assess the client. - Ans - D Rationale: Because the client's condition is worsening, the nurse should remain with the client and continue the assessment while calling for help from the charge nurse to determine the client's resuscitative status. Options A and B are tasks that must be completed by a nurse and cannot be delegated to the UAP. Option C is contraindicated. An 84-year-old client is scheduled for transfer from the hospital to skilled care to rehabilitate after a hip repair. What disciplines will the nurse coordinate in the sending and receiving of this client? (Select all that apply.) A. Medical care B. Palliative care C. Nursing care D. Physical therapy E. Social work F. Respiratory therapy - Ans - A, C, D, E Rationale:Multiple disciplines need to be involved to rehabilitate this client. There is no mention of any level of cognitive decline, so it cannot be assumed in the elderly. Medical, nursing care and social work, as well as physical therapy are all needed. Medicine to prescribe the care needed. Nursing to implement and coordinate care. Physical therapy for strengthening. Social work to work with the rehabilitation facility and medicare. There is no indication that palliative care, or care for life-limiting diseases. There is no mention of respiratory compromise, so respiratory care is not indicated. The nurse is working on an inpatient mental health unit and is providing care to a client newly admitted with a major depressive disorder. Which assessments place the nurse on alert that the client is considering suicide? (Select all that apply.)A. Reports feelings of sadness B. Mood changes from depressed to happy C. Begins giving away possessions D. Becomes compliant with medication regimen E. Independently joins a support group - Ans - B, C Rationale: Feelings of elation and giving away possessions are common characteristics of those who have made a plan to commit suicide. Feelings of sadness are signs of depression but not impending suicide. Options D and E are not typically indicative of impending suicide. A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse take first? A. Teach the client testicular self-examination (TSE). B. Assess for the presence of blood in the urine. C. Ask about scrotal pain or blood in the semen. D. Inquire about a history of kidney stones. - Ans - C Rationale: Orchitis is an acute testicular inflammation resulting from recurrent urinary tract infection, recurrent sexually transmitted disease (STD), or an indwelling urethral urinary catheter causing pain on ejaculation, scrotal pain, blood in the semen, and penile discharge, so the nurse should determine the presence of other symptoms. Although all men should practice TSE, the client's symptoms are suggestive of an inflammatory syndrome rather than testicular cancer. Although hematuria is associated with renal disease or calculi, the client's pain is associated with ejaculate, not urine. Which assessment finding for a client with peritoneal dialysis requires an immediate action by the nurse? A. The color of the dialysate outflow is opaque yellow. B. The dialysate outflow is greater than the inflow. C. The inflow dialysate feels warm to the touch. D. The inflow dialysate contains potassium chloride. - Ans - A Rationale: Opaque or cloudy dialysate outflow is an early sign of peritonitis. The nurse should obtain a specimen for culture, assess the client, and notify the health care provider. Options B and C are desired. Option D is commonly done to prevent hypokalemia. Which assessment finding indicates to the nurse that the nystatin swish and swallow, prescribed for a client with oral candidiasis, has been effective? A. The client denies dysphagia. B. The client is afebrile with warm and dry skin. C. The oral mucosa is pink and intact. D. There is no reflux following food intake. - Ans - C Rationale: Nystatin swish and swallow is prescribed for its local effect on the oral mucosa, reducing the white curdlike lesions in the mouth and larynx. The ability to swallow does not indicate that the medication has been effective. Options B and D do not reflect effectiveness of the local medication. A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. What is the best nursing action for this client? A. Request a prescription for a bed board to provide increased back support. B. Reposition the client so that both feet are supported by the bed board. C. Move the trapeze bar to allow the client to pull with the upper extremities. D. Place trochanter rolls on the lateral aspects of the client's thighs. - Ans - D Rationale: Trochanter rolls should be placed on the lateral aspects of the thighs to prevent external rotation of the hips when the client is in a supine position. Although options A, B, and C are supportive equipment used to maintain proper positioning of the client who is immobile, it is most important to maintain the lower extremities in the aligned anatomical position. A bed board provides increased back support, especially with a soft mattress. The footboard maintains the feet in dorsiflexion and prevents foot drop. The trapeze bar allows the client to participate while turning in the bed, during transfers in and out of bed, or performing upper arm exercises. The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? A. "What makes you think we did anything to your baby?" B. "Are you or any of your blood relatives of Asian descent?" C. "Those are stork bites and will go away in about 2 years." D. "Those are Mongolian spots and will gradually fade in 1 or 2 years." - Ans - D Rationale:Mongolian spots are areas of bluish-black or gray-blue pigmentation seen primarily on the dorsal area and buttocks of infants of Asian or African descent or dark- skinned babies. Option A is a defensive answer. Although Mongolian spots occur more frequently in those of Asian and African descent, option B does not respond to the father's concern. Telangiectatic nevi, frequently referred to as stork bites, appear reddish-purple or red and are usually on the face or head and neck area. Confusion B. Peripheral edema C. Crackles in the lungs D. Dyspnea E. Distended neck veins - Ans - A, C, D Rationale: Left-sided heart failure results in pulmonary congestion caused by the left ventricle's inability to pump blood to the periphery. Confusion, crackles in the lungs, and dyspnea are all signs of pulmonary congestion. Options B and E are associated with right-sided heart failure. A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? A. Ask the client to describe the symptoms of the vaginal infection. B. Assess if the client has been sexually active recently. C. Tell the client to reschedule the examination in 1 week. D. Inform the client that the scheduled Pap test cannot be done today. - Ans - D Rationale: The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular sample, alters cytology analysis, and masks bacterial or sexually transmitted disease infections, so the Pap test should be postponed. Although options A, B, and C are indicated, the client needs further teaching for the return visit to perform the Pap smear test. The admission nurse is preparing a client for surgery. Which statements indicate to the nurse the client is well informed and has participated in the informed consent process? (Select all that apply.) A. "I didn't want the surgeon to tell me about the surgery for fear it would make me vomit." B. "I signed the consent form in the office a week ago. But, I have a few questions now." C. "Because I was in so much pain, I took two hydrocodone pills an hour before I signed the consent." D. "The surgeon is going to make incisions in my tummy and belly button for this laparoscopic surgery." E. "The surgeon addressed all of my concerns and then I signed the consent form 2 days ago." - Ans - D, E Rationale: Describing the procedure and having no questions indicate to the nurse that the client is knowledgeable and informed. Fears about surgery are common, but the client must have a rudimentary understanding of the procedure, risks, and alternatives. The surgeon must address all questions as the client has the right to refuse consent at any time in the pre-operative process. The client must not sign an informed consent after ingesting sedating medication. That is not considered an informed consent. The charge nurse is making assignments for the day. On the unit are 2 RNs, 1 LPN/LVN and 2 UAPs. Which client will the charge nurse assign to the LPN/LVN? A. Newly admitted client with respiratory distress B. Post-op day 2 after an open appendectomy C. Transfer from the ICU 2 hours ago after a valve replacement D. Transfer from the ER with severe pelvic pain and hyperemesis - Ans - B Rationale: The post-op client is the most stable client. The remaining clients need the assessment skills of the RNs on the unit. To decrease the incidence of urinary tract infections, the hospital mandated that no nursing students may insert a urinary catheter. What is the next step for the nursing management staff? A. Assess for any changes in the rate of infection in 6 months. B. Tell the area nursing school program director to take catheter placement out of the curriculum. C. Work with the obstetricians to remove the standing order for an indwelling catheter with epidural placement. D. Tell the nursing staff that students may not be present when a urinary catheter is placed. - Ans - A Rationale: Assessment is necessary to determine if the nursing students are the root cause of the rate of infection. The nursing curriculum is not hospital dependent. Placing multiple variables in the assessment will not help determine the root cause. Students can learn from observation. The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? A. A client who is 2 days postoperative with a right total knee replacement B. A client who is scheduled for a sigmoid colostomy surgery today C. A client who has a surgical abdominal wound with dehiscence D. A client who is 1 day postoperative following a right-sided mastectomy - Ans - A Rationale: Option A is the least critical client and should be assigned to the RN with the least experience. A client with a knee replacement is probably ambulating and able to perform self-care, and a physical therapist is likely to be assisting with the client's care. Option B will require a high level of nursing care when returned from surgery. Option C means that there is a separation or rupture of the wound, which requires an experienced nurse to provide care. Option D requires extensive teaching and should be assigned to a more experienced nurse. Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. What is the best nursing action based on these results? A. Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B. Assess the client for pain and administer pain medication as prescribed. C. Encourage the client to take short shallow breaths for 5 minutes. D. Prepare to administer sodium bicarbonate IV over 30 minutes. - Ans - B Rationale: These ABGs reveal respiratory alkalosis, and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A PaO2 of 96 mm Hg does not indicate the need for an increase in oxygen administration. The PaCO2 indicates mild hyperventilation, so option C is not indicated. In addition, it is very difficult to change one's breathing pattern. The use of sodium bicarbonate is indicated for the treatment of metabolic acidosis, not respiratory alkalosis. The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN? A. Assess skeletal pins for infection. B. Assist the client with toileting. C. Establish thrombus prevention care. D. Evaluate pain management plan. - Ans - B Rationale: The PN can implement nursing care, such as option B. The PN assists the RN in the development of a teaching plan and reinforces information to the client Ask another nurse to trade assignments. - Ans - C Rationale: The nurse must realize limitations, but can provide post-operative care. Letting the charge nurse know of the limitations allows the charge to reassign the client, or to maintain the client assignment and find the necessary assistance for the nurse. Refusing to take an assignment is uncooperative. Trading assignments does not involve the charge nurse who has the knowledge of the needs of the entire unit. At which point should the nurse encourage a laboring client to begin pushing? A. When the cervix is completely effaced B. When the client describes the need to have a bowel movement C. When the cervix is completely dilated D. When the anterior or posterior lip of the cervix is palpable - Ans - C Rationale: Pushing begins with the second stage of labor, when the cervix is completely dilated at 10 cm. If pushing begins before the cervix is completely dilated, the cervix can become edematous and may never dilate completely, necessitating an operative delivery. The most effective pushing occurs when the cervix is completely dilated and the woman feels the urge to push (Ferguson reflex). A client says angrily to the nurse, "Get out of my room! I do not like you or the care you are giving me." The nurse reports the client's refusal of care to the nurse manager. What is the nurse manager's best response? A. "What did YOU do to anger the client?" B. "I'm sure the client did not mean to say that." C. "How has the client been behaving before this?" D. "I'll get another nurse to care for this client." - Ans - C Rationale: The nurse manager must assess the baseline for this client before intervening. Asking about the client's behavior before refusing the nurse's care helps establish that baseline and does not place the nurse on the defensive. Do not offer false reassurance. Prior to reassigning the client, the manager must determine the root cause for the dismissal. It may have nothing to do with the nurse. Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? A. Clients' names are not used while they are in a public waiting room. B. Nurses should not recommend any community self-help groups by specific name, such as Alcoholics Anonymous. C. Clients must pick up their filled prescriptions from a pharmacy in person with a photo identification card. D. Old medical records are kept in a locked file cabinet in the department. - Ans - D Rationale: Past medical records must be "secured" and "reasonably protected" from inadvertent viewing. A locked room or file cabinet can serve this purpose, and when any protected health information (PHI) is discarded, it must be shredded. A person's name only (without his or her diagnosis or treatment) is not considered confidential or PHI. Nurses may suggest categories of community resources, with examples, such as Alcoholics Anonymous, but cannot market a specific program in which they have a financial interest. Others can pick up a client's filled prescriptions. A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? - Ans - B Rationale: Rhabdomyolysis is characterized by destruction of muscles that release myoglobin, causing myoglobinuria, which places the client at risk for acute renal failure, so an increased blood urea nitrogen (BUN) level indicates a decrease in renal function. Blood in the urine from the accompanying breakdown of red blood cells contributes to proteinuria, an expected finding. Metabolic acidosis is the potential complication, not alkalosis. During the diuretic phase of acute renal failure, there can be a normal output volume (≈2000 mL/day), which can result from IV fluid hydration. A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? A. High Fowler position without a pillow behind the head B. Semi-Fowler position with a single pillow behind the head C. Right side-lying position with the head of the bed elevated 45 degrees D. Sitting upright and forward with both arms supported on an over the bed table - Ans - D Rationale: Adequate lung expansion is dependent on deep breaths that allow the respiratory muscles to increase the longitudinal and anterior-posterior size of the thoracic cage. Sitting upright and leaning forward with the arms supported on an over the bed table allows the thoracic cage to expand in all four directions and reduces dyspnea. A high Fowler position does not allow maximum expansion of the posterior lobes of the lungs. A semi-Fowler position restricts the expansion of the anterior- posterior diameter of the thoracic cage. Positioning a client on the right side with the head of the bed elevated does not facilitate lung expansion. The charge nurse of a medical-surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? A. Prepare to evacuate the unit, starting with the bedridden clients. B. UAPs should report to the emergency center to handle transports. C. The licensed staff should begin counting wheelchairs and IV poles on the unit. D. Continue with current assignments until more instructions are received. - Ans - D Rationale: When faced with an impending disaster, hospital personnel may be alerted but should continue with current client care assignments until further instructions are received. Evacuation is typically a response of last resort that begins with clients who are most able to ambulate. Option B is premature and is likely to increase the chaos if incoming casualties are anticipated. Option C is poor utilization of personnel. A client newly admitted to hospice care with end-stage bladder cancer is being discharged from the hospital to home with a list of medications. Which medication will the nurse need to confirm with the prescribing health care provider? A. Morphine sulfate oral solution 10 mg per 5 mL q 4 hours prn. B. Atorvastatin 20 mg po daily C. Acetaminophen 650 mg suppositories prn every 6 hours. D. Lorazepam oral solution 1 mg per 1 mL, 1 mL every 2 hours as needed. - Ans - B Rationale: Atorvastatin treats high cholesterol. In the terminal phases of life, this medication is no longer necessary. Morphine is for the pain associated with end-stage cancer. Acetaminophen is for the fever than can accompany the dying process. Lorazepam can treat the restlessness or anxiety often seen in dying clients. An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of C. difficile. While planning care, which nursing goal should the nurse establish as the priority? A. Fluid and electrolyte balance is maintained. B. Health care-associated infection (HAI) transmission of infectious diarrhea is prevented. C. Abdominal pain is relieved and perianal skin integrity is maintained. D. Normal bowel patterns are reestablished. - Ans - B Rationale: A priority goal for the client with infectious diarrhea caused by C. difficile is infection control precautions and the prevention of health care-associated infection the verbal message. Communicating in writing is another option that could be used if verbal or body language is ineffective. A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? A. Save the next urine sample. B. Restrict oral fluid intake. C. Strain all voided urine. D. Reduce physical activity. - Ans - A Rationale:The nurse should instruct the client to save the next urine sample for observation of its appearance and for possible urinalysis. The client is reporting symptoms that may indicate the onset of a urinary tract infection. Increased fluid intake should be encouraged, unless contraindicated. Option C is only necessary if a calculus (stone) is suspected. Option D is not indicated by this client's symptoms. A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? A. "I will avoid coughing, sneezing, and forceful nose blowing." B. "Swimming can begin on the tenth postoperative day." C. "Any mild discomfort can be managed with acetaminophen." D. "Drainage from my ears is expected after the surgery." - Ans - B Rationale: The purpose of the ventilating tubes in the tympanic membrane is to equalize pressure and drain fluid collection from the middle ear. The tube's patency allows air and water to enter the middle ear, so the client should be reeducated if the client swims or allows water to enter the external ear. Options A, C, and D reflect correct responses. Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP? A. An adolescent who was readmitted to the hospital because of a postoperative infection B. A woman with a new colostomy who requires discharge teaching C. A woman who had a hip replacement and may be transferred to the home care unit D. A man who had a cholecystectomy and currently has a nasogastric tube set to intermittent suction - Ans - C Rationale: A hip replacement is considered a clean case, and transferring the client to another unit is likely to involve physically moving the client and her belongings. The charge nurse will be responsible for providing a report to the home care unit if the transfer occurs. The adolescent client is infected, and an employee who works on an OB unit should be assigned to clean cases in case the employee is required to return to the OB unit. This requires the skills of a registered nurse (RN) to do discharge teaching and provide emotional support. This may require skills beyond the level of this UAP. A nurse is providing care to four clients who are all requesting to be medicated for pain. Which client prescription is the nurse's priority? A. Four mg IV of morphine sulfate every 3 to 4 hours B. Two hydrocodone bitartrate 10/325 tablets every 6 hours C. One tramadol 50 mg tablet every 4 to 6 hours. D. Two 325 mg tablets of acetaminophen every 6 hours - Ans - A Rationale: Administer pain medication in the order of IV, IM, and po, from the most powerful to the least. Morphine IV has both the route and the strength according to this prioritization practice. A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? A. A primigravida who is 8 cm dilated after 14 hours of labor B. A client scheduled for a repeat cesarean birth at 38 weeks' gestation C. A client being induced for fetal demise at 20 weeks' gestation D. A multiparous client who is dilated 5 cm and 50% effaced - Ans - D Rationale: The new nurse should be assigned the least complicated client to gain experience and confidence, as well as protect client safety. Of the clients available for assignment, option D is progressing well and is the least complicated. Options A, B, and C have actual or potential complications and should be assigned to a more experienced nurse. A client is prescribed the amantadine HCl. Which action should the nurse take? A. Encourage foods high in vitamin B6, such as meat or liver. B. Teach client to change positions slowly. C. Instruct client to take at the same time as prescribed beta blocker. D. Notify the client that the development of a rash is a common side effect. - Ans - B Rationale: Amantadine can cause postural hypotension, so sudden position changes should be avoided. Options A and C are contraindicated with this drug, and option D is a sign of a possible allergic reaction, not a common side effect. A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? A. Encourage staff to participate in online in-service education. B. Assign staff to make sure that all equipment is thoroughly cleaned. C. Ask which staff members would like to go home for the remainder of the day. D. Notify the supervisor that the staff needs additional assignments. - Ans - A Rationale: Online educational programs are available around the clock, so staff can engage in continuing education programs when the opportunity arises, such as during periods of low census. Option B is not the responsibility of the nursing staff. Option C is not the best use of staff and does not use the extra time provided by the low census. The charge nurse should use the time to improve the unit, and requesting additional assignments is not necessary. A family is at the bedside of 22-year-old who was severely injured in a motor vehicle accident. The health care providers report to the family the absence of EEG waves and that the brain is essentially dead. The family asks the nurse, "What should we do?" What is the nurse's best response? A. "That is a decision each of you have to make." B. "Unfortunately ethically, I am unable to offer my opinion." C. "What was the client like before the accident?" D. "Does anyone know what the client would have liked?" - Ans - B Rationale: All of the responses are adequate in helping make a decision. However, the best response takes the nurse's opinion out of the ethical decision-making process. By that statement, the family is clearly informed the nurse cannot be responsible for the decision that the family has to make. However, the nurse can help guide the family through the difficult decision-making process. The clinic nurse is conducting an intake interview. Which client statement indicates to the nurse the possibility of glomerulonephritis? A. The nurse is reviewing the chart of a 26-year-old client with type 1 diabetes mellitus. Which data may indicate that the client is experiencing chronic complications of diabetes? A. Blood pressure, 159/98 mm Hg B. Hemoglobin A1C (HbA1C), 6% C. Creatinine level, 1.0 mg/dL D. Chronic sciatica - Ans - A Rationale:A blood pressure of 159/98 mm Hg is hypertensive and increases the client's risk for acute coronary syndrome and/or stroke. Options B and C are within defined parameters, and Option D is not a recognized chronic complication of diabetes. The clinic nurse is performing an intake interview of a mother of the 5-year-old client. The mother reports a fever of 103 to 104°F/39.5 to 40°C for 3 days, muscle pain, fatigue, and a new break out of a red, flat rash along the child's hairline. What is the next nursing action? A. Ask if any siblings exhibit the same signs. B. Review the child's chart for immunizations. C. Ask where the child has been in the past 10 to 14 days. D. Take the child's weight. - Ans - B Rationale:The child is showing classic signs of measles. Checking for immunizations will confirm if the child received the MMR vaccine. Measles is highly contagious, and on the rise with the anti-vaccine movement. They were once thought to be eradicated. If this child was not vaccinated, then there is an increased chance that other siblings will not be immunized. However, the focus of the question is on the 5-year-old. Measles take 7 to 14 days to incubate after exposure. The child's weight may be down from lack of appetite, associated with the illness. However, determining the symptoms are possibly measles is the first step. Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? A. States having difficulty with color perception B. Presents with opacity of the lens upon assessment C. Complains of seeing a cobweb-type structure in the visual field D. Reports the need to use a magnifying glass to see small print - Ans - C Rationale:Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment. Distorted color perception, opacity of the lens, and gradual vision loss are expected signs and symptom of cataracts but do not need immediate attention. A client is being admitted to the step-down unit from the ICU. Which action will the nurse delegate to the aid who has worked on the unit for 12 years? A. Take the client's vital signs upon admission. B. Evaluate the client's ECG reading. C. Prepare the room with the routine supplies. D. Ask the client's spouse about how long they have been married. - Ans - C Rationale:Aides complete routine and predictable care, such as setting up a room in preparation for a client. Vital signs of a transfer client from the ICU may not be routine and the nurse will need to include them in the initial assessment. Assessment is the job of the RN and it includes assessment of the ECG. Asking the spouse about the duration of their marriage is a part of the psychosocial assessment. That does not mean that the aide cannot be friendly to the spouse. The nurse is speaking at a senior center about the physiologic changes that occur that can impact driving. Which factors will the nurse include in the teaching plan? (Select all that apply.) A. Muscle strength changes B. Reflexes become slower C. Blood volume increases D. High frequency tones less audible E. Decreased vision F. Decreased sensitivity to touch - Ans - A, B, D, E, F Rationale:These are all physiologic change in the elderly that could impact the alertness, reflexes, or sensory input needed to drive, except for blood volume. Blood volume decreases with age, impacting overall oxygenation. Which disaster management intervention by the nurse is an example of primary prevention? A. Emergency department triage B. Follow-up care for psychological problems C. Education of rescue workers in first aid D. Treatment of clients who are injured - Ans - C Rationale:Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to a disaster is an example of minimizing or preventing injury. Option A is an example of secondary prevention. Option B is an example of tertiary prevention. Option D is an example of secondary prevention. A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that further teaching is needed? (Select all that apply.) A. "I will not take my digoxin if my heart rate is higher than 100 beats/min." B. "I should weigh myself once a week and report any increases." C. "It is important to increase my fluid intake whenever possible." D. "I should report an increase of swelling in my feet or ankles." E. "I will call my health care provider if I have diarrhea for more than a day." - Ans - A, B, C Rationale:An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider. Diarrhea can predispose the client to digitalis toxicity. Digitalis should be held when the heart rate is lower than 60 beats/min. The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb. An increase in fluid can worsen heart failure. The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of a client's lower lung fields. Which documentation of this finding is correct? A. Fine crackles B. Wheezes C. Course crackles D. Stridor - Ans - C Rationale:Course crackles are caused by air passing through airways that are intermittently occluded by mucus. Fine crackles are a series of short-duration, discontinuous, high-pitched sounds. Wheezes are continuous, high-pitched, musical or squeaking-type sounds. Stridor is a continuous croupy sound of constant pitch and indicates partial obstruction of the airway. The client with a new onset of a temperature of 102°F/38.9°C - Ans - D Rationale:The change in the client's condition is the indication for the nurse's attention. The remaining clients have no indication that there is a change in condition. The nurse delegates a dressing change to the LNP/LVN. The nurse provided care to the client immediately after returning from surgery 1 day ago. Which are the best statements for the RN to say to the LPN/LVN? (Select all that apply.) A. "I took care of the client yesterday. The client was very drowsy upon arrival from surgery." B. "Yesterday, the client's midline dressing was dry and intact upon arrival from surgery." C. "I changed the dressing yesterday and noted oozing at the distal portion of the incision." D. "Please let me know if the incision is not well approximated and is still oozing." E. "You can teach the client's spouse about how to change the dressing." - Ans - B, C, D Rationale:The RN must supervise the care of the dressing change and notify the care personnel of the condition of the wound. The client would expect to be drowsy upon arrival from surgery and that statement does not pertain to the dressing change. Teaching is the responsibility of the RN and not the LPN/LVN. The nurse is assessing 38-year-old client with tuberculosis who is taking rifampin. Which finding would be most important to report to the primary health care provider immediately? A. Orange-colored urine B. Potassium level, 4.9 mEq/L C. Elevated liver enzyme levels D. Blood urea nitrogen (BUN) level, 12 mg/dL. - Ans - C Rationale:Rifampin can cause hepatotoxicity, so elevated liver enzyme levels need to be closely monitored and reported to the health care provider. Orange discoloration of the urine is an expected side effect of this medication. The potassium level is normal. A BUN level of 12 mg/dL is within defined parameters. The nurse is reviewing safety precautions with a client preparing to return home after a hip fracture. What instructions will the nurse include in the client's plan of care? (Select all that apply.) A. Move electrical wires under the carpet. B. Keep kitchen utensils in the same place. C. Secure throw rugs with tape around the edges. D. Purchase night lights for bathrooms, hallways, and bedrooms. E. Keep paths free from clutter. - Ans - B, D, E Rationale:The home needs to be free from trip hazards. Placing electrical cords under a carpet is a fire hazard. Keeping utensils in the same place decreases the need to move around to find objects. Throw rugs need to be removed. The edges of a taped down rug may curl and make a trip hazard. Nightlights illuminate pathways frequently used at night. Keeping areas free from clutter reduces the risk of falls. The family of a male adult with schizophrenia does not want the client to be involved in decisions regarding his treatment. The nurse should inform the family that the client has a right to be involved in his treatment planning based on which law? A. Social Security Act of 1990 B. American with Disabilities Act of 1990 C. Medicaid Act of 1965 D. Mental Health Act of 1946 - Ans - B Rationale:The Americans with Disabilities Act guarantees the client the right to participate in treatment planning. Option A is a federal insurance program that provides benefits to retired persons, the unemployed, and the disabled. Option C is a program for eligible individuals and/or families with low income and resources. Option D provides for public education regarding psychiatric illnesses. The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse take? A. Increase the rate of the heparin infusion using a nomogram. B. Decrease the heparin infusion rate and give vitamin K IM. C. Continue the heparin infusion at the current prescribed rate. D. Stop the heparin drip and prepare to administer protamine sulfate. - Ans - D Rationale:An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate. Increasing the rate would increase the risk for hemorrhage. The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin). Keeping the infusion at the current rate would increase the risk for hemorrhage. A client is admitted to the unit who has a history of seizure activity. What precautions will the nurse implement for this client? (Select all that apply.) A. Place the bed in high position B. Place suction equipment at the bed side C. Place a padded tongue blade at the bed side D. Pad the side rails of the bed E. Keep the lighting dim F. Have a sitter in the room at all times - Ans - B, D, E Rationale:Seizure precautions include placing the bed in low position or the mattress on the floor; place suction and oxygen at the bedside, pad the side rails, decrease environmental stimuli. Placing the bed in high position could place the client at risk for a fall. Tongue blades are not used in keeping the client's mouth open. An airway may be placed after the client has been placed in the recovery position. A sitter will not prevent a seizure. Which vital sign in a pediatric client is most important for the nurse to report to the primary health care provider? A. Newborn with a heart rate of 140 beats/min B. Three-year-old with a respiratory rate of 28 breaths/min C. Six-year-old with a heart rate of 130 beats/min D. Twelve-year-old with a respiratory rate of 16 breaths/min - Ans - C Rationale:The normal heart rate for a 6- to 10-year-old is 70 to 110 beats/min. Options A, B, and D are all within normal range for those ages. The quality control (QC) nurse is reviewing multiple chart entries. Which entries will the QC nurse need to bring to the attention of the nurse manager? (Select all that apply.) A. MSO4 administered IVP B. 10 u of insulin administered sub q C. 0.2 mL of normal saline mixed D. 2000 IU of Vitamin D E. Digoxin po qd - Ans - A, B, D, E Rationale:Positioning the client in a high Fowler position with dangling feet will decrease further venous return to the left ventricle. Options A, B, and D should be performed after the change in position. The nurse witnesses a physical therapist roughly handle a client while transferring from the bed to the chair. Who should the nurse contact with this information? A. The Director of Physical Therapy B. The client's family C. The client's health care provider D. The nurse manager - Ans - D Rationale:In this case, the nurse must implement the chain of command. The nurse manager is the person next in the chain. The manager will launch an investigation with this information. The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing action has the greatest priority when planning this client's care? A. Palpate for pitting edema. B. Provide meticulous skin care. C. Administer phosphate binders. D. Monitor serum potassium levels. - Ans - D Rationale:Clients with CRF are at risk for electrolyte imbalances, and imbalances in potassium can be life threatening. One sign of fluid retention is pitting edema, but it is an expected symptom of renal failure and is not as high a priority as option D. Options B and C are common nursing interventions for CRF but not as high a priority as option D. The nurse is caring for a client immediately after electroconvulsive therapy (ECT). Which nursing action is next? A. Reorient the client to surroundings. B. Assess blood pressure every 15 minutes. C. Determine if muscle soreness is present. D. Maintain a patent airway. - Ans - D Rationale:The client is typically unconscious immediately following ECT, and nausea is a common side effect. The nurse should take measures to prevent aspiration and maintain a patent airway. Clients may be confused after ECT, but reorientation is not as high a priority as the airway. Although vital signs should be assessed, the airway is a higher priority. Muscle soreness is an expected finding after ECT. While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the client's health care provider is on the telephone. What action should the nurse instruct the unit secretary to implement? A. Transfer the call into the room of the client. B. Instruct the secretary to explain the reason for the call. C. Ask another nurse to take the phone call. D. Ask the health care provider to see the client on the unit. - Ans - C Rationale:Another nurse should be asked to take the phone call, which allows the nurse to stay at the bedside to complete the assessment of the client's chest pain. Options A and B should not be done during an acute change in the client's condition. Requesting the health care provider to come to the unit is premature until the nurse completes assessment of the client's status. Which monitored pattern of fetal heart rate alerts the nurse to seek immediate action by the health care provider? A. An increase from 142-150 to 160-168 beats/min with fetal movement B. A decrease from the baseline of 138-148 to 128-132 beats/min that mirrors the contraction pattern C. A baseline fetal heart rate from 112 to 120 beats/min between contractions D. A baseline fetal heart rate from 168 to 170 beats/min with a decline in the heart rate after the onset of a contraction - Ans - D Rationale:Late decelerations indicate uteroplacental insufficiency and can be indicative of complications. When occurring with absent variability and tachycardia, the situation is ominous. 130 beats/min is an expected heart rate. Options A and B are not as critical. Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? A. Limit fluids to prevent infection to the surgical site. B. Place the infant in the prone position. C. Provide a low-residue diet to limit bowel movements. D. Cover sac with a moist sterile dressing. - Ans - B Rationale:The infant should be placed in the prone position to alleviate pressure on the surgical site, which is in the sacrum. Fluids should be increased postoperatively to prevent dehydration. A high-fiber diet should be implemented to prevent constipation. After the repair, the sac is no longer exposed, so option D does not apply. Which instructions should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) A. Keep the medication in your pocket so that it can be accessed quickly. B. Call 911 if chest pain is not relieved after one nitroglycerin. C. Store the medication in its original container and protect it from light. D. Activate the emergency medical system after three doses of medication. E. Do not use within 1 hour of taking sildenafil citrate (Viagra). - Ans - B, C Rationale:Emergency action should be taken if chest pain is not relieved after one nitroglycerin tablet (B). The medication should be kept in the original container to protect from light (C). Keeping the medication in the shirt pocket provides an environment that is too warm (A). The newest guidelines recommend calling 911 after one nitroglycerin tablet if chest pain is not relieved (D). Nitroglycerin and other nitrates should never be taken with sildenafil (E). A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection? A. A 17-year-old who is sexually active with numerous partners B. A 45-year-old lesbian who has been sexually active with two partners in the past year C. A 30-year-old cocaine user who inhales the drug and works in a topless bar D. A 34-year-old male homosexual who is in a monogamous relationship - Ans - A Rationale:Option A is at greatest risk for contracting sexually transmitted diseases, including HIV, because the greater the number of sexual partners, the greater the risk for contracting an STD. Option B comprises the group of lowest infected persons because there is little transfer of body fluid during sexual acts. Option C, who free- bases, would not be sharing needles, so contracting an STD is not necessarily a risk. A male homosexual in a monogamous relationship has a decreased risk of contracting HIV as long as both partners are monogamous and neither is infected. A 12-year-old boy complains to the nurse that he is "short" (4′5″ [53 inches]). His twin sister is 5 inches taller than he is (4′10″ [58 inches]). Based on these findings, what conclusion should the nurse reach? D. Calcium level, 10 mEq/L - Ans - B Rationale:Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higher than 5.0 mEq/L indicates hyperkalemia. Options A, C, and D are normal findings. The nurse plans to teach blood glucose self-monitoring to a client who is newly diagnosed with diabetes mellitus type 1. The health care provider has given the client a schedule for blood glucose testing. In addition to the prescribed schedule, what additional testing times will the nurse include in the clients instructions? A. Any time the client awakens during the night B. Whenever the client has feelings of dizziness C. Right after meals if insulin is not administered 30 minutes before the meal D. Only at scheduled times; additional testing is harmful to fingertips - Ans - B Rationale:Clients should be instructed to always check their blood glucose level whenever they feel faint or dizzy. There is great variability in recommendations for the frequency of blood glucose testing. When first diagnosed, clients are often advised to test before and after meals and at bedtime, and then after meals and at bedtime for a short period. Once they are stable, clients may be advised to test four times a day or as little as once each week, depending on the consistency of their diet and exercise and stability of their blood sugar level. Options A, C, and D provide inaccurate information. The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer? A. Stage I B. Stage II C. Stage III D. Stage IV - Ans - C Rationale:The statement above describes a stage III ulcer, which is defined as full- thickness tissue loss in which subcutaneous fat may be exposed but without exposure of bone, tendon, or muscle. A stage I ulcer includes intact skin with nonblanchable redness of a localized area. A stage II ulcer is described by partial-thickness loss of dermis, including a shallow open ulcer with a pinkish red wound bed. Full-thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is indicative of a stage IV ulcer. The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? A. "I know many women who have survived ovarian cancer." B. "Let's talk about the treatments of ovarian cancer." C. "In my opinion I would suggest getting a second opinion." D. "Tell me about what you are feeling right now." - Ans - D Rationale:The most therapeutic action for the nurse is to be an active listener and to encourage the client to explore her feelings. Giving false reassurance or personal suggestions are not therapeutic communication for the client. The nurse is providing care to a client who was newly prescribed clopidogrel. Which black box warning will the nurse review for prior to administering the medication? A. This drug could cause heart attack or stroke when taken by clients with certain genetic conditions. B. Clopidogrel helps prevent platelets from sticking together and forming clots in the blood. C. This drug can be taken in combination with aspirin to reduce the risk of acute coronary syndrome. D. Clopidogrel can reduce the risk of a future heart attack when taken by clients with peripheral artery disease. - Ans - A Rationale:A black box warning is a notice required by the FDA on a prescription drug that warns of potentially dangerous side effects. Options B, C, and D are all desired effects of the drug. The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment (PPE) indicates the student requires further teaching regarding PPE? (Select all that apply.) A. Head covering B. fitted respirator or mask C. Sterile gloves D. Goggles E. Gown - Ans - A, C, D, E Rationale:The use of personal protective equipment (PPE) for airborne precautions includes a properly prefitted N95 respirator or mask. Options A, C, D, and E do not provide the appropriate respiratory equipment for airborne precautions. A surgical mask is used for preventing transmission of droplet precautions. A nurse is assessing a client with heart failure who has been prescribed digoxin. Which finding concerns the nurse with the medication management? A. Regular heart rate of 88 beats/min B. Serum potassium level, 2.9 mEq/L C. Weight decreases by 1 lb daily. D. Serum sodium level, 138 mEq/L - Ans - B Rationale:A serum potassium level of 2.9 mEq/L is low, and side effects of digoxin toxicity are exacerbated when the potassium level is low. Options A, C, and D are all expected findings when caring for a client with congestive heart failure. A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral abdominal area. Which drug should the nurse anticipate the health care provider to prescribe which medication to treat this condition? A. Levofloxacin B. Acyclovir sodium C. Fluconazole D. Esomeprazole - Ans - B Rationale:The clinical manifestations listed are consistent with herpes zoster (shingles). Acyclovir sodium is an antiviral used to treat herpes zoster or shingles. Levofloxacin is an antibiotic and may be used to treat pneumonia or other infections in the HIV client. Fluconazole is an antifungal and is used to treat candidiasis in the HIV client. Esomeprazole is a protein pump inhibitor used for gastroesophageal reflux disease. When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? A. Ascending numbness from the feet to the knees B. Decrease in cognitive status of the client C. Blurred vision and sensation changes D. Persistent unilateral headache - Ans - B