Free HESI LPN CAT Exams practice for HESI CAT Exam 2022 (HESI LPN). Answer 93 nursing exam-style questions with rationales, exam mode, and progress tracking on
After medicating the client for pain and collecting granules and stones from strained urine, which action is most important for the nurse to implement next?
Select the best answer.
Explanation:
Sending the calculi for analysis is crucial in determining the type of stone present. Identifying the stone composition helps in developing an effective treatment plan and preventive measures to avoid future episodes of urolithiasis. This step is essential in providing targeted care for the client. Options B, C, and D are not the most important actions at this point. While evaluating for persistent pain is essential, determining the stone composition takes precedence to guide appropriate interventions.
Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?
Select the best answer.
Explanation:
The correct answer is D. Diaphragmatic breathing is a beneficial intervention for clients with COPD as it helps improve breathing efficiency and manage symptoms by promoting better air exchange in the lungs. It aids in achieving better exhalation, reducing air trapping, and enhancing overall lung function. Choices A, B, and C are incorrect. While reducing risk factors for infection is important for overall health, it is not a specific long-term intervention for COPD. Administering high-flow oxygen during sleep may be necessary in some cases but is not typically a long-term strategy for managing COPD. Limiting fluid intake to reduce secretions is not recommended as hydration is essential for individuals with COPD to maintain optimal respiratory function and prevent complications like mucus plugs.
Several months after a foot injury, an adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will 'finally go away.' How should the nurse respond?
Select the best answer.
Explanation:
The correct answer is B: 'Assist the client in developing a goal of managing the pain.' In cases of chronic neuropathic pain, complete resolution is often not achievable. Therefore, the most appropriate approach is to help the client develop strategies to manage the pain effectively. Choice A is incorrect because it may give false hope of immediate resolution, which is unlikely with neuropathic pain. Choice C is incorrect as it does not directly address the client's need for pain management. Choice D is incorrect as it focuses on functional ability assessment, which is not the priority when addressing the client's pain concerns.
A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?
Select the best answer.
Explanation:
Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.
The public health nurse received funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?
Select the best answer.
Explanation:
The correct answer is C: Vitamin supplements for high-risk pregnant women. This option aligns with primary prevention by preventing deficiencies before they occur, which is a key aspect of primary prevention. Providing vitamin supplements to high-risk pregnant women can help prevent birth defects and complications. Choices A, B, and D do not align with primary prevention strategies. Case management and screening for clients with HIV (Choice A) is more of a secondary prevention strategy aimed at early detection and management. A regional relocation center for earthquake victims (Choice B) is focused on addressing the aftermath of a disaster rather than preventing it. Lead screening for children in low-income housing (Choice D) is more about early detection and intervention rather than primary prevention.
For a client with pneumonia, the prescription states, "Oxygen at liters/min per nasal cannula PRN difficult breathing." Which nursing intervention is effective in preventing oxygen toxicity?
Select the best answer.
Explanation:
Choice A is the correct answer because prolonged exposure to high levels of oxygen can lead to oxygen toxicity. Administering oxygen at high levels for extended periods can overwhelm the body's natural defenses against high oxygen levels, causing toxicity. Choices B, C, and D are incorrect. Choice B is unrelated to preventing oxygen toxicity. Choice C is unsafe as removing the nasal cannula can deprive the client of necessary oxygen. Choice D, running oxygen through a hydration source, is not a standard practice for preventing oxygen toxicity.
The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child's back. Which statement by the parents indicates that they understand this procedure?
Select the best answer.
Explanation:
The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.
A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, 'Is my friend who was in the car with me ok?' What response is best for the nurse to provide?
Select the best answer.
Explanation:
The correct answer is A: 'I am sorry, but your friend was killed in the accident.' In this situation, honesty and compassion are essential. The nurse should provide the client with truthful information, acknowledging the client's need to know the reality of the situation. Choice B is dismissive and does not address the client's inquiry directly. Choice C is a deflecting question and does not offer the direct information the client is seeking. Choice D provides false reassurance, which is not appropriate in this circumstance where the reality needs to be communicated.
What action should the nurse take after a client produces the first of a series of sputum samples for cytology?
Select the best answer.
Explanation:
The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.
What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?
Select the best answer.
Explanation:
The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.
The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?
Select the best answer.
Explanation:
The correct answer is D: Bloody emesis. Bloody emesis indicates potential bleeding or severe irritation, which should be reported immediately. In the context of acute gastritis, bloody emesis could indicate a more serious complication that requires urgent medical attention. Choices A, B, and C are not typically associated with acute gastritis caused by contaminated water and do not signal as critical of a condition as bloody emesis. Low-grade fever, bruising of the skin, and abdominal cramping are more commonly associated with other conditions or may be less urgent in this context.
When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)
Select the best answer.
Explanation:
By calculating the infusion rate based on the given chart information, the correct value is 42 ml/hr. This rate ensures proper fluid administration to the laboring client. Choices B (38), C (48), and D (50) are incorrect as they do not align with the calculated infusion rate needed for the client's condition, as per the chart data provided.
A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
Select the best answer.
Explanation:
The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.
The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?
Select the best answer.
Explanation:
The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.
In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?
Select the best answer.
Explanation:
Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.
An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions clearly. What action should the nurse implement first?
Select the best answer.
Explanation:
The correct action for the nurse to implement first is to assess the surroundings for noise and distractions. This step is crucial as environmental factors can affect the client's ability to respond clearly. By minimizing noise and distractions, the nurse can create a more conducive environment for effective communication. Providing a printed form (Choice B) may help but addressing environmental factors should come first. Deferring the health history (Choice C) or asking the family member to answer the questions (Choice D) should not be the initial steps, as they do not directly address the issue of unclear communication with the client.
Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?
Select the best answer.
Explanation:
In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.
The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, what action should the nurse take?
Select the best answer.
Explanation:
The correct answer is D. The moist cough that worsens during and after meals suggests possible dysphagia, a condition related to swallowing difficulties. Requesting a consultation for dysphagia is essential for an accurate diagnosis and appropriate management. Encouraging the client to perform deep breathing exercises (choice A) may not address the underlying issue of dysphagia. Offering additional clear fluids (choice B) may not be appropriate for someone with swallowing difficulties. Collecting a sputum specimen (choice C) is not the priority in this scenario as the focus should be on identifying and managing the swallowing problem.
A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab value is important for the nurse to review before contacting the health care provider?
Select the best answer.
Explanation:
The correct answer is C: Serum calcium. Numbness and tingling can be indicative of hypocalcemia, which can affect the nervous system. Reviewing serum calcium levels is crucial to address this potential issue. Options A, B, and D are not directly related to the symptoms described by the client and are not typically associated with numbness and tingling around the mouth and fingers. Capillary glucose levels are more relevant in assessing for diabetes or monitoring glucose control. Urine specific gravity is useful in evaluating hydration status. White blood cell count is typically checked to assess infection or immune response, which are not indicated by the client's symptoms of numbness and tingling.
Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client's plan of care?
Select the best answer.
Explanation:
The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.
A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care?
Select the best answer.
Explanation:
Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.
The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective?
Select the best answer.
Explanation:
The correct answer is A because in tertiary prevention, the focus is on managing complications and providing rehabilitation. Choice B is more aligned with primary prevention as it focuses on early diagnosis. Choice C's attendance in education sessions is not a direct indicator of managing complications. Choice D's improvement in knowledge does not directly measure the program's effectiveness in managing complications.
What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS?
Select the best answer.
Explanation:
The correct answer is C: 'Recent history of recurrent pneumonia.' Recurrent pneumonia is a hallmark indicator of progression to AIDS in clients with HIV infection. It signifies advanced immunosuppression when the body is unable to fight off infections effectively. Enlarged and tender cervical lymph nodes (Choice A) are more indicative of local infections or inflammation rather than AIDS progression. The presence of a low-grade fever and sore throat (Choice B) may be common in various infections and are not specific to AIDS progression. While a CD4 blood cell count of 300 (Choice D) is below the normal range and indicates immunosuppression, it alone may not be sufficient to suspect progression to AIDS without other supporting indicators like opportunistic infections such as recurrent pneumonia.
When designing a program to provide primary preventative health care to a community-based healthcare system, which service should the nurse consider for inclusion in the program? Select all that apply.
Select the best answer.
Explanation:
The correct answer is A: Breast screening for older women. In the context of primary preventative health care, breast screening for older women is crucial for early detection of breast cancer. Choice B, rehabilitation services for stroke victims, focuses on rehabilitative care rather than primary preventative care. Choice C, blood pressure assessments, is important for monitoring health status but not exclusive to primary prevention. Choice D, antepartum nutritional counseling, is more related to prenatal care than primary preventative health care. Therefore, choices B, C, and D do not directly align with the primary preventative health care objective of the grant.
When caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?
Select the best answer.
Explanation:
When caring for a client with Cushing syndrome, monitoring glucose levels is crucial as Cushing syndrome often leads to hyperglycemia. Elevated glucose levels are a common manifestation of Cushing syndrome due to increased cortisol levels. Monitoring glucose helps in assessing and managing the client's condition effectively. Lactate levels are not typically affected by Cushing syndrome. Hemoglobin and creatinine levels are important for other conditions like anemia and kidney function, but they are not the priority in Cushing syndrome.
To prevent aspiration in a client on mechanical ventilation receiving continuous enteral feedings through a nasogastric tube, which intervention is most important for the nurse to implement?
Select the best answer.
Explanation:
The most important intervention to prevent aspiration in a client receiving continuous enteral feedings through a nasogastric tube while on mechanical ventilation is to maintain the head of the bed elevated while the feeding is infusing. This position helps reduce the risk of regurgitation and aspiration. Options A, C, and D are not as crucial as maintaining proper positioning to prevent aspiration. Verifying tube position with a daily chest x-ray is important but not the most crucial. Checking tube placement with an air bolus and aspirating stomach contents are important procedures but do not directly address the prevention of aspiration during enteral feedings.
A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?
Select the best answer.
Explanation:
The correct answer is to encourage the client to perform BSE 2 to 3 days after her menstrual period ends. This timing is recommended because breasts are least tender and swollen at this point, making it easier to detect any abnormalities. Choice A is incorrect because while scheduling an annual mammogram is important, it is not the immediate action needed based on the client's statements. Choice B is incorrect as the client's BSE technique timing needs adjustment rather than an in-depth review by a nurse practitioner. Choice D is incorrect because the client should modify the timing of the BSE for better effectiveness.
The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?
Select the best answer.
Explanation:
The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.
A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?
Select the best answer.
Explanation:
The correct action for the nurse to take in this situation is to explain the surgery to the client in clear terms that they can understand. This will help alleviate the client's anxiety and ensure they are well-informed about the procedure they are about to undergo. Choice A is incorrect because while reassurance is important, it does not address the client's specific concern about understanding the surgery. Choice C is not the initial step; the nurse should first attempt to clarify the information themselves. Choice D is not the priority when the client is seeking clarification about the surgery.
What nursing intervention is most important to implement after a client has completed a myelogram?
Select the best answer.
Explanation:
The correct answer is C: Neurovascular assessment of the lower extremities. After a myelogram, it is crucial to monitor the neurovascular status to detect any signs of complications such as impaired circulation or nerve damage. This assessment helps in identifying early signs of vascular compromise or neurological deficits. Choices A, B, and D are not the priority after a myelogram. Lie-sit-stand blood pressure measurement is not directly related to post-myelogram care. Abdominal assessment and skin assessment are important but not the priority immediately after this procedure.
After a client with leukemia undergoes a bone marrow biopsy and is found to have thrombocytopenia, which nursing assessment is most important following the procedure?
Select the best answer.
Explanation:
The correct answer is to observe the aspiration site. Thrombocytopenia, characterized by a low platelet count, increases the risk of bleeding. Therefore, monitoring the biopsy site for bleeding or hematoma is crucial to ensure early detection and intervention. Assessing body temperature (choice B) is not directly related to the increased bleeding risk associated with thrombocytopenia. Monitoring skin elasticity (choice C) and measuring urinary output (choice D) are important assessments but are not the priority in this situation where bleeding risk needs immediate attention.
When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?
Select the best answer.
Explanation:
The correct action for the nurse in this situation is to leave the room and close the door quietly. This response respects the client's privacy, maintains professionalism, and avoids interrupting the client's personal moment. Choice A is incorrect because ignoring the behavior is not appropriate and may invade the client's privacy further. Choice B is incorrect as it can embarrass the client and the visitor, breaching their privacy and dignity. Choice D is also incorrect as the immediate priority is to respect the client's privacy and address the situation discreetly.
A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?
Select the best answer.
Explanation:
The correct answer is A because counseling will help the woman understand her risk and options for surveillance or preventive measures. At this point, it is crucial to address the woman's immediate concerns related to the BRCA1 gene mutation. Choice B is incorrect as the focus should be on the woman's individual risk due to the specific gene mutation she carries. Choice C is not the priority as treatment options come after assessing the risk and deciding on surveillance or preventive measures. Choice D is incorrect because discussing survival rates is not the immediate need for someone who has just received information about having a genetic mutation.
An older client is having photocoagulation for macular degeneration. What intervention should the nurse implement during post-procedure care in the outpatient surgical unit?
Select the best answer.
Explanation:
The correct intervention is to apply bilateral eye patches while sleeping. This measure helps protect the eyes and support healing following photocoagulation for macular degeneration. Choice B is incorrect as using a whiteboard is not directly related to post-procedure care for this intervention. Choice C is incorrect as arranging food on the plate in a clockwise order is not relevant to the post-procedure care of photocoagulation. Choice D is incorrect as verbally identifying oneself when entering the room is important for communication but not specific to the post-procedure care in this scenario.
What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?
Select the best answer.
Explanation:
The correct answer is B: 'The technique is intended to maintain straight spinal alignment.' Log-rolling is a technique used to move a person as a single unit to maintain the alignment of the spinal column. This is crucial to prevent spinal cord injury, especially in clients with suspected spine fractures. Choice A is incorrect because log-rolling focuses on spinal alignment, not just decreasing back injury risks. Choice C is incorrect because the number of people involved is not the primary purpose of log-rolling, which is maintaining spinal alignment. Choice D is incorrect because while turning instead of pulling may help prevent skin damage, the primary goal of log-rolling is to protect the spine, not the skin.
The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?
Select the best answer.
Explanation:
The correct instruction for the adult male client to follow when collecting a 24-hour urine specimen for a creatinine clearance test is to urinate at the specified time, discard this urine, and collect all subsequent urine over the next 24 hours. This method ensures proper collection for an accurate creatinine clearance measurement. Choice B is incorrect as it describes a different procedure for a clean-catch urine sample, not suitable for creatinine clearance. Choice C is incorrect as it suggests catheterization, which is not typically done for a creatinine clearance test, and it is not necessary for this procedure. Choice D is incorrect as it does not follow the standard procedure for a 24-hour urine collection for creatinine clearance; the urine should be collected continuously over 24 hours, not at specified intervals.
A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client's dichotomous tendency?
Select the best answer.
Explanation:
Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.
A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?
Select the best answer.
Explanation:
The correct action for the nurse to take first is to discontinue the IO infusion. The client's symptoms of severe pain, numbness, pale skin, and edema below the IO site suggest a complication, such as extravasation or compartment syndrome. By discontinuing the infusion, further harm can be prevented. Administering an analgesic via the IO site or elevating the extremity would not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider can be done after stopping the infusion to seek further guidance or intervention.
On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?
Select the best answer.
Explanation:
Identifying the specific medications taken during a suicide attempt is crucial for determining the appropriate treatment and assessing the potential toxicity or interactions. This information helps healthcare providers initiate the necessary interventions promptly. Option A is not as critical as knowing the medications used. Option B focuses on the timing of the last medication intake rather than the specific drugs taken for the overdose. Option D, while relevant, does not provide immediate actionable information compared to identifying the substances involved in the suicide attempt.
When planning to contact the healthcare provider about a client's need for a belt restraint, what information is most important to report?
Select the best answer.
Explanation:
The correct answer is B. When reporting to the healthcare provider about a client's need for a belt restraint, it is crucial to provide information on the measures already taken to maintain client safety. This includes detailing alternative strategies that have been tried before considering restraint use. This information helps the healthcare provider assess the situation comprehensively and explore other safety interventions. Choices A, C, and D, though relevant to the client's care, are not as critical to report when discussing the need for a belt restraint. Pressure ulcers (Choice A) are important but not directly related to the need for a belt restraint. The presence of special mattresses (Choice C) may influence overall care but is not the most pertinent information when considering restraints. Current vital signs and oxygen saturation (Choice D) are essential for the client's overall assessment but do not directly address the need for a belt restraint.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
Select the best answer.
Explanation:
The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.
The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?
Select the best answer.
Explanation:
The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.
An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?
Select the best answer.
Explanation:
The best schedule for administering the IV antibiotic in 4 divided doses is 0800, 1200, 1600, and 2000. This timing allows for equal spacing between doses, ensuring consistent therapeutic levels of the medication in the client's system. Choice A provides doses too close together, increasing the risk of medication errors and potential toxicity. Choice B's suggestion of giving doses during waking hours is vague and lacks specific timing, which may result in irregular dosing intervals. Choice C, administering with meals and a bedtime snack, is unrelated to the timing of the antibiotic doses and does not optimize the drug's effectiveness.
A client with metastatic breast cancer refuses to participate in a clinical trial and further treatments. Her children ask the nurse to convince their mother to reconsider. How should the nurse respond?
Select the best answer.
Explanation:
The correct response is to explore the client's decision to refuse treatment and offer support. In this situation, it is crucial for the nurse to respect the client's autonomy and decisions regarding her own health. By exploring the client's reasons for refusal, the nurse can better understand her perspective and provide appropriate support. Option A is incorrect as it focuses on questioning the client in front of her children, potentially pressuring her. Option B is inappropriate as it disregards the client's autonomy and tries to persuade her to participate. Option C is also incorrect as it dismisses the client's decision and fails to address the family's concerns in a supportive manner.
After medicating the client for pain and collecting granules and stones from strained urine, which action is most important for the nurse to implement next?
Select the best answer.
Explanation:
Sending the calculi for analysis is crucial in determining the type of stone present. Identifying the stone composition helps in developing an effective treatment plan and preventive measures to avoid future episodes of urolithiasis. This step is essential in providing targeted care for the client. Options B, C, and D are not the most important actions at this point. While evaluating for persistent pain is essential, determining the stone composition takes precedence to guide appropriate interventions.
Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)?
Select the best answer.
Explanation:
The correct answer is D. Diaphragmatic breathing is a beneficial intervention for clients with COPD as it helps improve breathing efficiency and manage symptoms by promoting better air exchange in the lungs. It aids in achieving better exhalation, reducing air trapping, and enhancing overall lung function. Choices A, B, and C are incorrect. While reducing risk factors for infection is important for overall health, it is not a specific long-term intervention for COPD. Administering high-flow oxygen during sleep may be necessary in some cases but is not typically a long-term strategy for managing COPD. Limiting fluid intake to reduce secretions is not recommended as hydration is essential for individuals with COPD to maintain optimal respiratory function and prevent complications like mucus plugs.
Several months after a foot injury, an adult woman is diagnosed with neuropathic pain. The client describes the pain as severe and burning and is unable to put weight on her foot. She asks the nurse when the pain will 'finally go away.' How should the nurse respond?
Select the best answer.
Explanation:
The correct answer is B: 'Assist the client in developing a goal of managing the pain.' In cases of chronic neuropathic pain, complete resolution is often not achievable. Therefore, the most appropriate approach is to help the client develop strategies to manage the pain effectively. Choice A is incorrect because it may give false hope of immediate resolution, which is unlikely with neuropathic pain. Choice C is incorrect as it does not directly address the client's need for pain management. Choice D is incorrect as it focuses on functional ability assessment, which is not the priority when addressing the client's pain concerns.
A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?
Select the best answer.
Explanation:
Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.
The public health nurse received funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?
Select the best answer.
Explanation:
The correct answer is C: Vitamin supplements for high-risk pregnant women. This option aligns with primary prevention by preventing deficiencies before they occur, which is a key aspect of primary prevention. Providing vitamin supplements to high-risk pregnant women can help prevent birth defects and complications. Choices A, B, and D do not align with primary prevention strategies. Case management and screening for clients with HIV (Choice A) is more of a secondary prevention strategy aimed at early detection and management. A regional relocation center for earthquake victims (Choice B) is focused on addressing the aftermath of a disaster rather than preventing it. Lead screening for children in low-income housing (Choice D) is more about early detection and intervention rather than primary prevention.
For a client with pneumonia, the prescription states, "Oxygen at liters/min per nasal cannula PRN difficult breathing." Which nursing intervention is effective in preventing oxygen toxicity?
Select the best answer.
Explanation:
Choice A is the correct answer because prolonged exposure to high levels of oxygen can lead to oxygen toxicity. Administering oxygen at high levels for extended periods can overwhelm the body's natural defenses against high oxygen levels, causing toxicity. Choices B, C, and D are incorrect. Choice B is unrelated to preventing oxygen toxicity. Choice C is unsafe as removing the nasal cannula can deprive the client of necessary oxygen. Choice D, running oxygen through a hydration source, is not a standard practice for preventing oxygen toxicity.
The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child's back. Which statement by the parents indicates that they understand this procedure?
Select the best answer.
Explanation:
The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.
A client is being treated for minor injuries following an automobile accident in which the only other passenger was killed. The client asks the nurse, 'Is my friend who was in the car with me ok?' What response is best for the nurse to provide?
Select the best answer.
Explanation:
The correct answer is A: 'I am sorry, but your friend was killed in the accident.' In this situation, honesty and compassion are essential. The nurse should provide the client with truthful information, acknowledging the client's need to know the reality of the situation. Choice B is dismissive and does not address the client's inquiry directly. Choice C is a deflecting question and does not offer the direct information the client is seeking. Choice D provides false reassurance, which is not appropriate in this circumstance where the reality needs to be communicated.
What action should the nurse take after a client produces the first of a series of sputum samples for cytology?
Select the best answer.
Explanation:
The correct action for the nurse to take after a client produces the first of a series of sputum samples for cytology is to transport the sputum container to the laboratory in a biohazard bag. This is important to ensure proper handling and prevent contamination of the sample. Choice A is incorrect because there is no need to keep the client NPO until all samples are collected. Choice C is incorrect as the initial sample should not be discarded but rather transported to the laboratory. Choice D is also incorrect as documenting the time the client last ate or drank is not directly relevant to the immediate action needed for the sputum sample.
What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?
Select the best answer.
Explanation:
The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.
The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?
Select the best answer.
Explanation:
The correct answer is D: Bloody emesis. Bloody emesis indicates potential bleeding or severe irritation, which should be reported immediately. In the context of acute gastritis, bloody emesis could indicate a more serious complication that requires urgent medical attention. Choices A, B, and C are not typically associated with acute gastritis caused by contaminated water and do not signal as critical of a condition as bloody emesis. Low-grade fever, bruising of the skin, and abdominal cramping are more commonly associated with other conditions or may be less urgent in this context.
When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.)
Select the best answer.
Explanation:
By calculating the infusion rate based on the given chart information, the correct value is 42 ml/hr. This rate ensures proper fluid administration to the laboring client. Choices B (38), C (48), and D (50) are incorrect as they do not align with the calculated infusion rate needed for the client's condition, as per the chart data provided.
A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
Select the best answer.
Explanation:
The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.
The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?
Select the best answer.
Explanation:
The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.
In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?
Select the best answer.
Explanation:
Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.
An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions clearly. What action should the nurse implement first?
Select the best answer.
Explanation:
The correct action for the nurse to implement first is to assess the surroundings for noise and distractions. This step is crucial as environmental factors can affect the client's ability to respond clearly. By minimizing noise and distractions, the nurse can create a more conducive environment for effective communication. Providing a printed form (Choice B) may help but addressing environmental factors should come first. Deferring the health history (Choice C) or asking the family member to answer the questions (Choice D) should not be the initial steps, as they do not directly address the issue of unclear communication with the client.
Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?
Select the best answer.
Explanation:
In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.
The nurse notes that an older adult client has a moist cough that increases in severity during and after meals. Based on this finding, what action should the nurse take?
Select the best answer.
Explanation:
The correct answer is D. The moist cough that worsens during and after meals suggests possible dysphagia, a condition related to swallowing difficulties. Requesting a consultation for dysphagia is essential for an accurate diagnosis and appropriate management. Encouraging the client to perform deep breathing exercises (choice A) may not address the underlying issue of dysphagia. Offering additional clear fluids (choice B) may not be appropriate for someone with swallowing difficulties. Collecting a sputum specimen (choice C) is not the priority in this scenario as the focus should be on identifying and managing the swallowing problem.
A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab value is important for the nurse to review before contacting the health care provider?
Select the best answer.
Explanation:
The correct answer is C: Serum calcium. Numbness and tingling can be indicative of hypocalcemia, which can affect the nervous system. Reviewing serum calcium levels is crucial to address this potential issue. Options A, B, and D are not directly related to the symptoms described by the client and are not typically associated with numbness and tingling around the mouth and fingers. Capillary glucose levels are more relevant in assessing for diabetes or monitoring glucose control. Urine specific gravity is useful in evaluating hydration status. White blood cell count is typically checked to assess infection or immune response, which are not indicated by the client's symptoms of numbness and tingling.
Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client's plan of care?
Select the best answer.
Explanation:
The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.
A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care?
Select the best answer.
Explanation:
Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.
The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective?
Select the best answer.
Explanation:
The correct answer is A because in tertiary prevention, the focus is on managing complications and providing rehabilitation. Choice B is more aligned with primary prevention as it focuses on early diagnosis. Choice C's attendance in education sessions is not a direct indicator of managing complications. Choice D's improvement in knowledge does not directly measure the program's effectiveness in managing complications.
What assessment data should lead the nurse to suspect that a client has progressed from HIV infection to AIDS?
Select the best answer.
Explanation:
The correct answer is C: 'Recent history of recurrent pneumonia.' Recurrent pneumonia is a hallmark indicator of progression to AIDS in clients with HIV infection. It signifies advanced immunosuppression when the body is unable to fight off infections effectively. Enlarged and tender cervical lymph nodes (Choice A) are more indicative of local infections or inflammation rather than AIDS progression. The presence of a low-grade fever and sore throat (Choice B) may be common in various infections and are not specific to AIDS progression. While a CD4 blood cell count of 300 (Choice D) is below the normal range and indicates immunosuppression, it alone may not be sufficient to suspect progression to AIDS without other supporting indicators like opportunistic infections such as recurrent pneumonia.
When designing a program to provide primary preventative health care to a community-based healthcare system, which service should the nurse consider for inclusion in the program? Select all that apply.
Select the best answer.
Explanation:
The correct answer is A: Breast screening for older women. In the context of primary preventative health care, breast screening for older women is crucial for early detection of breast cancer. Choice B, rehabilitation services for stroke victims, focuses on rehabilitative care rather than primary preventative care. Choice C, blood pressure assessments, is important for monitoring health status but not exclusive to primary prevention. Choice D, antepartum nutritional counseling, is more related to prenatal care than primary preventative health care. Therefore, choices B, C, and D do not directly align with the primary preventative health care objective of the grant.
When caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor?
Select the best answer.
Explanation:
When caring for a client with Cushing syndrome, monitoring glucose levels is crucial as Cushing syndrome often leads to hyperglycemia. Elevated glucose levels are a common manifestation of Cushing syndrome due to increased cortisol levels. Monitoring glucose helps in assessing and managing the client's condition effectively. Lactate levels are not typically affected by Cushing syndrome. Hemoglobin and creatinine levels are important for other conditions like anemia and kidney function, but they are not the priority in Cushing syndrome.
To prevent aspiration in a client on mechanical ventilation receiving continuous enteral feedings through a nasogastric tube, which intervention is most important for the nurse to implement?
Select the best answer.
Explanation:
The most important intervention to prevent aspiration in a client receiving continuous enteral feedings through a nasogastric tube while on mechanical ventilation is to maintain the head of the bed elevated while the feeding is infusing. This position helps reduce the risk of regurgitation and aspiration. Options A, C, and D are not as crucial as maintaining proper positioning to prevent aspiration. Verifying tube position with a daily chest x-ray is important but not the most crucial. Checking tube placement with an air bolus and aspirating stomach contents are important procedures but do not directly address the prevention of aspiration during enteral feedings.
A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client's statements?
Select the best answer.
Explanation:
The correct answer is to encourage the client to perform BSE 2 to 3 days after her menstrual period ends. This timing is recommended because breasts are least tender and swollen at this point, making it easier to detect any abnormalities. Choice A is incorrect because while scheduling an annual mammogram is important, it is not the immediate action needed based on the client's statements. Choice B is incorrect as the client's BSE technique timing needs adjustment rather than an in-depth review by a nurse practitioner. Choice D is incorrect because the client should modify the timing of the BSE for better effectiveness.
The nurse discontinues a continuous IV heparin infusion for a male client on strict bedrest and is now preparing to administer the client's first dose of enoxaparin. Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse?
Select the best answer.
Explanation:
The correct answer is D. Bruised areas on the client's upper extremities bilaterally indicate an increased risk of bleeding, which requires careful assessment before administering enoxaparin. Bruising suggests potential issues with clotting and hemostasis, making it crucial for the nurse to further evaluate the client's bleeding risk. Choices A, B, and C do not directly relate to the assessment of bleeding risk associated with enoxaparin administration and are therefore incorrect. Choice A provides information about the client's Aptt, which is not directly relevant to assessing bleeding risk for enoxaparin. Choice B addresses pain management, and Choice C involves the client's daily activities with no direct link to the bleeding risk assessment.
A client who is scheduled to have surgery in two hours tells the nurse, 'My doctor was here and used a lot of big words about the surgery, then asked me to sign a paper.' What action should the nurse take?
Select the best answer.
Explanation:
The correct action for the nurse to take in this situation is to explain the surgery to the client in clear terms that they can understand. This will help alleviate the client's anxiety and ensure they are well-informed about the procedure they are about to undergo. Choice A is incorrect because while reassurance is important, it does not address the client's specific concern about understanding the surgery. Choice C is not the initial step; the nurse should first attempt to clarify the information themselves. Choice D is not the priority when the client is seeking clarification about the surgery.
What nursing intervention is most important to implement after a client has completed a myelogram?
Select the best answer.
Explanation:
The correct answer is C: Neurovascular assessment of the lower extremities. After a myelogram, it is crucial to monitor the neurovascular status to detect any signs of complications such as impaired circulation or nerve damage. This assessment helps in identifying early signs of vascular compromise or neurological deficits. Choices A, B, and D are not the priority after a myelogram. Lie-sit-stand blood pressure measurement is not directly related to post-myelogram care. Abdominal assessment and skin assessment are important but not the priority immediately after this procedure.
After a client with leukemia undergoes a bone marrow biopsy and is found to have thrombocytopenia, which nursing assessment is most important following the procedure?
Select the best answer.
Explanation:
The correct answer is to observe the aspiration site. Thrombocytopenia, characterized by a low platelet count, increases the risk of bleeding. Therefore, monitoring the biopsy site for bleeding or hematoma is crucial to ensure early detection and intervention. Assessing body temperature (choice B) is not directly related to the increased bleeding risk associated with thrombocytopenia. Monitoring skin elasticity (choice C) and measuring urinary output (choice D) are important assessments but are not the priority in this situation where bleeding risk needs immediate attention.
When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?
Select the best answer.
Explanation:
The correct action for the nurse in this situation is to leave the room and close the door quietly. This response respects the client's privacy, maintains professionalism, and avoids interrupting the client's personal moment. Choice A is incorrect because ignoring the behavior is not appropriate and may invade the client's privacy further. Choice B is incorrect as it can embarrass the client and the visitor, breaching their privacy and dignity. Choice D is also incorrect as the immediate priority is to respect the client's privacy and address the situation discreetly.
A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?
Select the best answer.
Explanation:
The correct answer is A because counseling will help the woman understand her risk and options for surveillance or preventive measures. At this point, it is crucial to address the woman's immediate concerns related to the BRCA1 gene mutation. Choice B is incorrect as the focus should be on the woman's individual risk due to the specific gene mutation she carries. Choice C is not the priority as treatment options come after assessing the risk and deciding on surveillance or preventive measures. Choice D is incorrect because discussing survival rates is not the immediate need for someone who has just received information about having a genetic mutation.
An older client is having photocoagulation for macular degeneration. What intervention should the nurse implement during post-procedure care in the outpatient surgical unit?
Select the best answer.
Explanation:
The correct intervention is to apply bilateral eye patches while sleeping. This measure helps protect the eyes and support healing following photocoagulation for macular degeneration. Choice B is incorrect as using a whiteboard is not directly related to post-procedure care for this intervention. Choice C is incorrect as arranging food on the plate in a clockwise order is not relevant to the post-procedure care of photocoagulation. Choice D is incorrect as verbally identifying oneself when entering the room is important for communication but not specific to the post-procedure care in this scenario.
What explanation is best for the nurse to provide a client who asks the purpose of using the log-rolling technique for turning?
Select the best answer.
Explanation:
The correct answer is B: 'The technique is intended to maintain straight spinal alignment.' Log-rolling is a technique used to move a person as a single unit to maintain the alignment of the spinal column. This is crucial to prevent spinal cord injury, especially in clients with suspected spine fractures. Choice A is incorrect because log-rolling focuses on spinal alignment, not just decreasing back injury risks. Choice C is incorrect because the number of people involved is not the primary purpose of log-rolling, which is maintaining spinal alignment. Choice D is incorrect because while turning instead of pulling may help prevent skin damage, the primary goal of log-rolling is to protect the spine, not the skin.
The nurse plans to collect a 24-hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?
Select the best answer.
Explanation:
The correct instruction for the adult male client to follow when collecting a 24-hour urine specimen for a creatinine clearance test is to urinate at the specified time, discard this urine, and collect all subsequent urine over the next 24 hours. This method ensures proper collection for an accurate creatinine clearance measurement. Choice B is incorrect as it describes a different procedure for a clean-catch urine sample, not suitable for creatinine clearance. Choice C is incorrect as it suggests catheterization, which is not typically done for a creatinine clearance test, and it is not necessary for this procedure. Choice D is incorrect as it does not follow the standard procedure for a 24-hour urine collection for creatinine clearance; the urine should be collected continuously over 24 hours, not at specified intervals.
A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client's dichotomous tendency?
Select the best answer.
Explanation:
Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.
A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?
Select the best answer.
Explanation:
The correct action for the nurse to take first is to discontinue the IO infusion. The client's symptoms of severe pain, numbness, pale skin, and edema below the IO site suggest a complication, such as extravasation or compartment syndrome. By discontinuing the infusion, further harm can be prevented. Administering an analgesic via the IO site or elevating the extremity would not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider can be done after stopping the infusion to seek further guidance or intervention.
On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?
Select the best answer.
Explanation:
Identifying the specific medications taken during a suicide attempt is crucial for determining the appropriate treatment and assessing the potential toxicity or interactions. This information helps healthcare providers initiate the necessary interventions promptly. Option A is not as critical as knowing the medications used. Option B focuses on the timing of the last medication intake rather than the specific drugs taken for the overdose. Option D, while relevant, does not provide immediate actionable information compared to identifying the substances involved in the suicide attempt.
When planning to contact the healthcare provider about a client's need for a belt restraint, what information is most important to report?
Select the best answer.
Explanation:
The correct answer is B. When reporting to the healthcare provider about a client's need for a belt restraint, it is crucial to provide information on the measures already taken to maintain client safety. This includes detailing alternative strategies that have been tried before considering restraint use. This information helps the healthcare provider assess the situation comprehensively and explore other safety interventions. Choices A, C, and D, though relevant to the client's care, are not as critical to report when discussing the need for a belt restraint. Pressure ulcers (Choice A) are important but not directly related to the need for a belt restraint. The presence of special mattresses (Choice C) may influence overall care but is not the most pertinent information when considering restraints. Current vital signs and oxygen saturation (Choice D) are essential for the client's overall assessment but do not directly address the need for a belt restraint.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
Select the best answer.
Explanation:
The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.
The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?
Select the best answer.
Explanation:
The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.
An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?
Select the best answer.
Explanation:
The best schedule for administering the IV antibiotic in 4 divided doses is 0800, 1200, 1600, and 2000. This timing allows for equal spacing between doses, ensuring consistent therapeutic levels of the medication in the client's system. Choice A provides doses too close together, increasing the risk of medication errors and potential toxicity. Choice B's suggestion of giving doses during waking hours is vague and lacks specific timing, which may result in irregular dosing intervals. Choice C, administering with meals and a bedtime snack, is unrelated to the timing of the antibiotic doses and does not optimize the drug's effectiveness.
A client with metastatic breast cancer refuses to participate in a clinical trial and further treatments. Her children ask the nurse to convince their mother to reconsider. How should the nurse respond?
Select the best answer.
Explanation:
The correct response is to explore the client's decision to refuse treatment and offer support. In this situation, it is crucial for the nurse to respect the client's autonomy and decisions regarding her own health. By exploring the client's reasons for refusal, the nurse can better understand her perspective and provide appropriate support. Option A is incorrect as it focuses on questioning the client in front of her children, potentially pressuring her. Option B is inappropriate as it disregards the client's autonomy and tries to persuade her to participate. Option C is also incorrect as it dismisses the client's decision and fails to address the family's concerns in a supportive manner.
Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client's dressing. Which additional assessment finding warrants immediate intervention by the nurse?
Select the best answer.
Explanation:
Tongue deviation to the left is the correct answer. It could indicate a complication such as nerve injury or hematoma, which requires immediate attention. A sore throat when swallowing may be expected postoperatively but does not indicate an immediate complication. Palpable temporal pulses are a normal finding and do not require immediate intervention. A temperature of 99.2°F (37.3°C) is slightly elevated but does not suggest a critical issue related to the surgery.
The nurse is assessing a first-day postpartum client. Which finding is most indicative of a postpartum infection?
Select the best answer.
Explanation:
A foul-smelling lochia is indicative of a postpartum infection, such as endometritis. Foul-smelling lochia suggests the presence of infection due to the breakdown of tissue by bacteria, leading to the malodor. An oral temperature elevation and an elevated white blood cell count are nonspecific and can be present in various conditions other than postpartum infections, making them less indicative. A blood pressure within normal limits is not typically associated with postpartum infections.
A client presents to the healthcare provider with fatigue, poor appetite, general malaise, and vague joint pain that improves mid-morning. The client has been using over-the-counter ibuprofen for several months. The healthcare provider makes an initial diagnosis of rheumatoid arthritis (RA). Which laboratory test should the nurse report to the healthcare provider?
Select the best answer.
Explanation:
The correct answer is A: Sedimentation rate. Sedimentation rate, Anti-CCP antibodies, and C-reactive protein are commonly used laboratory tests to indicate inflammation and help diagnose rheumatoid arthritis. An elevated sedimentation rate is a nonspecific indicator of inflammation in the body, which is often seen in RA. White blood cell count is not specific for RA and is not typically significant in the diagnosis. Anti-CCP antibodies are specific to RA and are useful in confirming the diagnosis. Activated Clotting Time is not relevant to the diagnosis of rheumatoid arthritis as it is not specific to this condition.
An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)
Select the best answer.
Explanation:
To calculate the volume to administer, use the formula: Desired dose (220,000 units) / Dose on hand (600,000 units) x Volume of the available dose (1 ml). This results in 0.4 ml to be administered. Choice A is correct. Choice B, C, and D are incorrect as they are not provided.
The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be infused over 4 hours. The IV administration set delivers 10gtt/ml. How many gtt/minute should the nurse regulate the infusion? (Enter a numeric value only. If rounding is required, round to the nearest whole number.)
Select the best answer.
Explanation:
To calculate the rate: (1000 ml / 4 hours) = 250 ml/hour; (250 ml/hour) / (60 minutes/hour) = 4.17 ml/minute; (4.17 ml/minute) * (10 gtt/ml) = 41.7 gtt/minute, rounded to 42 gtt/minute. Therefore, the nurse should regulate the infusion at 42 gtt/minute to deliver the prescribed fluid challenge accurately. The other choices are incorrect as they do not reflect the correct calculation based on the given information.
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