Comprehensive HESI 1 -RN Case studies

Comprehensive HESI 1 -RN Case studies 1. A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma? A. - Metoprolol tartrate (Lopressor). B. Carteolol (Ocupress). С. Pindolol (Wisken). D. Propranolol hydrochloride (Inderal). The best antihypertensive agent for clients with asthma is metoprolol (Lopressor) (C), a beta2 blocking agent which is also cardioselective and less likely to cause bronchoconstriction. Pindolol (A) is a beta2 blocker that can cause bronchoconstriction and increase asthmatic symptoms. Although Carteolol (B) is a beta blocking agent and an effective antihypertensive agent used in managing angina, it can increase a client's risk for bronchoconstriction due to its nonselective beta blocker action. Propranolol (D) also blocks the beta2 receptors in the lungs, causing bronchoconstriction, and is not indicated in clients with asthma and other obstructive pulmonary disorders. 2. . A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his ID: 697. blood pressure has been normal for the past three months. Which instruction should the nurse provide? A. Stop the medication and keep an accurate record of blood pressure. B. Obtain another antihypertensive prescription to avoid withdrawal symptoms, C. Report any uncomfortable symptoms after stopping the medication. D. - Ask the healthcare provider about tapering the drug dose over the next week. Correct Although the healthCare provider discontinued the propranolol, measures to prevent rebound Cardiac excitation, such as progressively reducing the dose Over one to two weeks (C), should be recommended to prevent rebound tachycardia, hypertension, and wentricular dysrhythmias. Abrupt cessation (A and B) of the beta-blocking agent may precipitate tachycardia and rebound hypertension, so gradual Weaning should be recommended. (D) is not indicated. 3. A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make? |D: 6ցT 4.B75204 A. How long has the client been taking the medication? Correct B. Did the client miss any doses of the medication? C. Has the client experienced constipation recently? D. Does the client use any tobacco products? 4. The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain ID: 697. the reason for the prescribed medication. What response is best for the nurse to provide? A. | du Ce relaxati Om before in du Citi Om Of arēStheSia. B. Minimize the amount of analgesia needed postoperatively. C. Provide a more rapid induction of anesthesia. D. Decrease the risk of bradycardia during surgery. Correct Atropine may be prescribed preoperatively to increase the automaticity of the sinoatrial node and prevent a dangerous reduction in heart rate (B) during surgical anesthesia. (A, C and D) do not address the therapeutic action of atropine use perioperatively 5. An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential |D 6974 BT 6286 development of urinary retention in this geriatric client? A. - Tricyclic antidepressants, correct B. Anta.Cd5. C. |ISLIlir. D. Nonsteroidal antiinflammatory agents. Drugs with anticholinergic properties, such as tricyclic antidepressants (C), can exacerbate urinary retention associated with opioids in the older client. Although tricyclic antidepressants and antihistamines with opioids can exacerbate urinary retention, the concurrent use of A and B) with opioids do not. Nonsteroidal antiinflammatory agents (D) can increase the risk for bleeding, but do not increase urinary retention with opioids (D). 6. A client with osteoarthritis is given a new prescription for a nonsteroidal antiinflammatory drug (NSAID). The client asks the nurse, "How is this medication ID: 697. different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide? A. Increase hepatotoxic side effects. B. Provide antiinflammatory response. correct C. Cause gastrointestinal bleeding. D. Are less expensive, Nonsteroidal antiinflammatory drugs (NSAIDs) have antiinflammatory properties (B), which relieves pain associated with osteoarthritis and differs from acetaminophen, a non-narcotic analgesic and antipyretic. (A) does not teach the client about the medication's actions. Although NSAIDs are irritating to the gastrointestinal(GI) system and can cause GI bleeding (C), instructions to take with food in the stomach to manage this as an expected side effect should be included, but this does not answer the client's question. Acetaminophen is potentially hepatotoxic (D), not NSAIDs. 7. A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to ID: 697. TOTitOr? A. Cardiorespiratory. B. Sensory. C. Liver, correct D. Kidney. Acetaminophen and alcohol are both metabolized in the liver. This places the client at risk for hepatotoxicity, so monitoring liver (A) function is the most important assessment because the combination of acetaminophen and alcohol, even in moderate amounts, can cause potentially fatal liver damage. Other non-narcotic analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs), are more likely to promote adverse renal effects (B). Acetaminophen does not place the client at risk for toxic reactions related to (C or D). 8. The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of Verapamil (Calan) for a client with atrial flutter. Which action ID: Ճց74B751 1D should the nurse implement? A. Administer the dose as prescribed. Correct B. Recheck the wital signs in 30 minutes and then administer the dose. C. S. Give intrawenous (IV) Calcium glu Conate, D. Withhold the drug and notify the healthcare provider. Verapamil slows sinoatrial (SA) nodal automaticity, delays atrioventricular (AV) nodal conduction, which slows the wentricular rate, and is used to treat atrial flutter, so (A) should be implemented, based on the client's heart rate and blood pressure. (B and C) are not indicated. (D) delays the administration of the scheduled dose. 9. A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan ID: 697. of care? A. TWO acute illnesses. B. TWO ChrOriC ille SS eS. C. - One chronic and one acute illness. correct D. One acute and one infectious illness. The plan of care should include goals that are specific for chronic and acute illnesses. Adult-onset diabetes is a life-long chronic disease, whereas influenza is an acute illness with a short term duration (C). (A, B, and D) do not include the correct duration categories for this situation. 10. Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which |D: ՃցT 4.B77ց 14 information should the nurse provide? A. Facilitate maternal-infant bonding. B. Prevent neonatal hypoglycemia. C. Stimulate contraction of the uterus, correct D. Initiate the lactation process, When the infant suckles at the breast, oxytocin is released by the posterior pituitary to stimulates the "letdown" reflex, which causes the release of colostrum, and contracts the uterus (C) to prevent uterine hemorrhage. (A and B) do not support the client's need in the immediate period after the emergency delivery. Although maternal-newborn bonding (D) is facilitated by early breastfeeding, the priority is uterine Contraction stimulation. 11. Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit? ID: 5974-87.504 A. Fullrooming-in for the infant and mother, B. Re:Strict WiSitOS WTO irritate the Cliert. C. Supervised and guided visits with infant. Correct D. Daily visits with her significant other, Structured visits (C) provide an opportunity for the mother and infant to bond and should be facilitated and encouraged according to the client's pace of progress. (A) is unrealistic and may not be safe for the baby or the client. (B) is an unrealistic expectation. Although daily visits may provide support, the significant other may not be able to be there every day (D) based on other family responsibilities. 12. A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to ID: 5974-873,535 immobilize the fracture. Which action should be implemented to obtain a valid informed Consent? A. Instruct the client sign the consent before giving medications. B. Notify the non-custodial parent to also sign a consent form. С. Obtain the signature of the client's stepfather for the surgery. D. s. Obtain the permission of the custodial parent for the surgery. Correct custodial parent (B). (A) is not a legal option. A stepparent is not a legal guardian for a minor unless the child has been adopted by the stepparent (C). The non-custodial parent does mot need to co-sign this form (D). 13. During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first? ID: 5974BF825B A. - Identify the problem. correct B. Predict the likelihood of the OutCome, C. Consider alternatives, D. Choose the most successful approach. The sequential steps in problem-solving are to first identify the problem (B), then consider alternatives (C), consider outcomes of the alternatives (D), predict the likelihood of the outcomes occurring, and choose the alternative with the best chance of success (A). 14. The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased ID: 697.487,5112 intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short-term goal is best for this client? A. Demonstrate progressive Weight gain toward the ideal Weight, B. Verbalize understanding of plan and of intention to eat meals. C. - Eat 50% of six small meals each day by the end of one week. D. Meals prepared during hospitalization Will be fed by the nurse. Short-term goals should be realistic and attainable and should have a timeline of 7 to 10 days before discharge. (A) meets those criteria. (B) is nurse-oriented. (C) may be beyond the capabilities of a confused client. (D) is a long-term goal 15. A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn't |D: Յց74ET355ց want any more contact with the hospital. How should the nurse respond? A. This hospital does not need to keep it if you are leaving and not returning here. B. The information in your chart is confidential and cannot leave this facility legally, C. The chart is the property of the hospital but I will see that a copy is made for you. D. Because you are leaving against medical advice, you may not have your chart. The chart is the property of the facility, but the client has a legal right to the information in it, even if he is leaving AMA, so a copy of the record (D) should be provided. The client does not lose his legal rights to his medical record if he leaves AMA (A). The medical record is confidential, but the hospital protects the client's privacy by not allowing unauthorized access to the record, so the hospital may provide the client with a copy (B). The hospital must maintain records of the care provided and should not release the Original record (C). 16. The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for ID: Ճց74ET FցD5 selected nursing activities in the daily assignment? A. Medication administration. Correct B. Client personal hygiene. C. Colostomy care instruction. D. Tracheostomy tube suctioning. In developing organizational skills, medication administration is based on a prescribed schedule that is time-sensitive in the delivery of nursing care and should be the priority in scheduling nursing activities in a daily assignment. Although suctioning a client's tracheostomy takes precedence in providing care, the client's PRN need is less amenable to apreselected schedule. (B and C) can be scheduled around time-sensitive delivery of care. 17. What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period? |D 6974 BT622O A. Primary nursing. B. Case management. C. Functional nursing. D. Team nursing. Primary nursing (B) is a model of delivery of care where a nurse is accountable for planning care for clients around the clock. Functional nursing (D) is a care delivery model that provides client care by assignment of functions or tasks. Team nursing (A) is a care delivery model where assignments to a group of clients are provided by a mixed-staff team. Case management (C) is the delivery of care that uses a collaborative process of assessment, planning, facilitation, and advocacy for options and services to meet an individual's health needs and promote quality Cost-effective Outcomes. 18. Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should ID: 697. follow in resolving the conflict? A. Deal with issues and not personalities. Correct B. Require the UAPs to reach a compromise. C. Encourage the two to wiew the humor of the conflict. D. Weigh the consequences of each possible solution. Dealing with the issues which are concrete, not personalities (A) which include emotional reactions, is one of seven important key behaviors in managing conflict. (B, C, and D) do not resolve the conflict when diverse opinions are expressed emotionally. 19. The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 |Dէ 5ց "48.735 31 pm. Which client response should the nurse document that indicates a successful outcome? A. Demonstrates adequate fluid intake and output. B. Verbalizes abdominal comfort without pressure. C. Voids at least 1000 mL between 7 am and 3 pm. D. Drinks 240 mL of fluid five times during the shift. correct The nurse should evaluate the client's outcome by observing the client's performance of each expected behavior, so drinking 240 mL of fluid five or six times during the shift (D) indicates a fluid intake of 1200 to 1440 mL, which meets the objective of at least 1000 mL during the designated period. (A) uses the term "adequate," which is not quantified. (B) is not the objective, which establishes an intake of at least 1000 mL. (C) is not an evaluation of the specific fluid intake. 20. The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem? |D: 5374B73553 A. Noncompliance with prescribed exercise plan. B. Ineffective management of treatment regimen. C. Activity intolerance related to postoperative pain. correct D. Knowledge deficit regarding impending surgery. Pain, fatigue, or anxiety can interfere with the ability to pay attention and participate in learning, so the nursing diagnosis in (A) indicates a need to postpone teaching. (B, C, and D) indicate a need for instruction. 21. A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement? A. Assign the client to a negative air-flow room. Correct B. Don a clean gown for client care. C. Place an isolation cart in the hallway. D. Fit the client with a respirator mask. Active tuberculosis requires implementation of airborne precautions, so the client should be assigned to a negative pressure air-flow room (D). Although (A and C) should be implemented for clients in isolation with contact precautions, it is most important that airflow from the room is minimized when the client has TB. (B) should be implemented when 22. A client is receiving atenolol (Tenormin)25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats perminute. What action should the ID: 697.487.3585 nurse implement next? A. Administer the medication. B. Notify the healthcare provider, C. Measure the blood pressure. D. Reassess the apical pulse. Atenolol, a beta-blocker, blocks the beta receptors of the sinoatrial node to reduce the heart rate, so the medication should be administered (C) because the client's apical pulse is greater than 60, (A, B, and D) are not indicated at this time. 23. The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation? |D: 5974B75 175 A. - Thyroid cyst. B. Hypothyroidism. C. C. Hyperthyroidism. Correct D. Thyroid cancer. Hyperthyroidism (D) is an enlargement of the thyroid gland, often referred to as a goiter, and a bruit may be auscultated over the goiter due to an increase in glandular vascularity which increases as the thyroid gland becomes hyperactive. A bruit is not common with (A, B, and C). 24. A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child | D: 597 BFS2 FO abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding Would be consistent with a basilar skull fracture? A. Asymmetry of the face and eye movements. B. Hematemesis and abdominal distention. C. Abnormal position and movement of the arm. D. Rhinorrhoea or otorrhoea with Halo sign. correct Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ear over the mastoid process) are both signs of a basilar skull fracture, so the nurse should assess for possible meningeal tears that manifest as a Halo sign with CSF leakage from the ears or nose (D). (A) is consistent with orbital fractures. (B) occurs with Wrenching traumas of the shoulder or arm fractures. (C) occurs with blunt abdominal injuries. 25. The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, ID: 59.483.555 prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder? A. Cushing syndrome. B. Multiple sclerosis. C. Addi SOS di Sea Se. D. - Grave's disease. This client is exhibiting symptoms associated with hyperthyroidism or Grave's disease (A), which is an autoimmune condition affecting the thyroid. (B, C, and D) are not associated With these symptoms. 26. The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the ID: 697.4875.146 nurse use to document this finding? A. Exophthalmos on the right. B. Ptosis on the left eyelid. Correct С. Anystagmus on the left. D. Astigmatism on the right. Ptosis is the term to describe an eyelid droop that covers a large portion of the iris (A), which may result from oculomotor nerve or eyelid muscle disorder (B) is characterized by rapid, rhythmic movement of both eyes. (C) is a distortion of the lens of the eye, causing decreased visual acuity. (D) is a term used to describe a protrusion of the eyeballs that occurs. With hyperthyroidism. 27. The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the |D: ՃցT 4.B75 125 child's weight is in the 95th percentile for the child's height. What action should the nurse take? A. Recommend a daily intake of at least four glasses of whole milk. B. Assess for signs of poor nutrition, such as a pale appearance. C. Encourage giving two additional snacks each day to the child. D. Question the type and quantity of foods eaten in a typical day. Correct The child is overweight for height, so assessment of the child's daily diet (C) should be determined. The child does not need (A or B), both of which will increase the child's weight. Poor nutrition (D) is commonly seen in underweight children, not overweight. 28. A child is receiving maintainance intravenous (IV) fluids at the rate of 1000 mL for the first 10 kg of body weight, plus 50 mL/kg per day for each kilogram between 10 and ID. 69TABT62O2 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.) A. 24 B. 58 C. s. 61 correct D. 73 The formula for calculating daily fluid requirements is: 0 to 10 kg, 100 mL/kg per day; or 10 to 20 kg, 1000 mL for the first 10 kg of body weight plus 50 mL/kg per day for each kilogram between 10 and 20. To determine an hourly rate, divide the total milliliters per day by 24, 19.5 kg x 50 mL/kg = 475 mL + 1000 mL = 1475 mL / 24 hours = 6.1 mL/hour 29. The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take? D. O A. Withhold the medication and contact the healthcare provider, correct B. Assess respiratory rate for one minute next. C. Give the medication dosage as scheduled. D. Wait 30 minutes and give half of the dosage of medication. Bradycardia is an early sign of digoxintoxicity, so if the infant's pulse rate is less than 100 beats/minute, digoxin should be withheld and the healthcare provider should be notified (D). Assessing the respiratory rate (A) is not indicated before administering Lanoxin. (B and C) place the infant at further risk for digoxin toxicity. 30. The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include? |D: ՃցT 4.B73557 A. Shower with the brace directly against the skin. B. Dress with the brace over regular clothing. C. Wear the brace over a T-shirt 23 hours per day. D. Remove the brace just before going to bed. Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Early treatment uses a Milwaukee brace that places pressure against the lateral spinal curvature, under the neck, and against the iliac crest, so it should be worn for 23 hours per day over a T-shirt (D) which reduces friction and chafing of the skin. (A, B, and C) reduce 31. A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond? A. "Your condition could be spread to staff and other clients in the hospital." B. "After taking medication for 24 hours a gown and mask won't be needed." C. "To protect you because you can get an infection very easily." correct D. "There are many forms of bacteria and germs in the hospital." Reverse isolation precaution implement measures to protect the client from exposure to microorganisms from others (B). Although microbes are prevalent in all environments, others (D) at risk for infection. 32. The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of |D: 5374B7523D the phototherapy? A. "I need to change the baby's position every four hours." B. "I should dress the baby in light clothing when the baby is under the light." C. "I will keep the baby's eyes covered when the baby is under the light." Correct D. "I should leave the baby under the light all of the time." Neonatal jaundice is related to subcutaneous deposition of fat-soluble (indirect) bilirubin, which is converted to a water-soluble form when the skin is exposed to an ultraViolet light, so the infant's eyes should be protected (C) by closing the eyes and placing patches over them before placing the baby under the phototherapy light source. The baby's position should be changed about every two hours, not (A), so that the light reaches all areas of the body to promote conversion to a water-soluble form of bilirubin, which is excreted in the urine. The infant can be removed from the light for feedings and diaper changes, but should receive phototherapy exposure for 18 hours a day (B). The baby should be naked or dressed in Only a diaper to expose as much skin as possible to the light (D). 33. A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and Complains of dry mouth. Which action should the nurse D: implement? A. E. Offer the client ice chips and instruct client to spit out the Water. AllOW the cliënt to drink Water and record On the land OriëCOrd. C. - Apply a water soluble lubricant to the lips, oral mucosa and nares, correct D. Put petroleum jelly on the lips and around the nasogastric tube. To ease the client's discomfort, a water soluble lubricant to the lips and nares assists to keep the mucous membranes moist (D). (A) is a petroleum-based product and should not be used because it is flammable. (B and C) should not be given to the client with a nasogastric tube to suction because it can cause further distension and interfere with fluid and electrolyte balance. 34. The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical ID: 59.89). picture? A. Blood urea nitrogen 40 m and creatinine 1.0. B. Hemoglobin of 10 g and hypophosphatemia. C. Cloudy, amber urine with sediment, specific gravity of 1,040. stimulates the release of PTH causing resorption of calcium and phosphate from the bone. A decreased tubular excretion and a decreased glomerular filtration rate results in hypocalcemia, hyperphosphatemia, and hyperkalemia (C). (A) is reflective of a non-renal cause, such as dehydration or liver pathology. (B) is more indicative of infection. Renal failure causes anemia and hyperphosphatemia, not (D). 35. Which information should the nurse give a client with chronic kidney disease (CKD)? ID: 5ց74EF51ցD A. - Avoid salt substitutes, correct B. Increase daily intake of fiber. C. Obtain monthly B12 injections, D. Re:StriCt Cal Ciuri-ri Ch fOCOS. A client with CKD should restrict sodium and potassium dietary intake, and salt substitutes usually contain potassium, so (C) should be taught. Hypocalcemia is a complication of CKD and calcium supplements are often needed, not (A). Anemia related to CKD is treated with iron, folic acid, and erythropoietin, not (B). Although (D) is a common dietary recommendation, it not an essential part of client teaching for CKD. 36. A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Novadex). ID: Which response should the nurse provide? A. Low doses of tamoxifen prevent menopausal hot flashes. LLSS S La LLaa L LL LaLa LLa LL C LL LLaaaa LLa aL LLaaaaaaSS C. This anti-estrogen drug inhibits malignancy growth, D. Part of a combination of chemotherapeutic agents used to treat tumors. Tamoxifen (Novadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit the growth-stimulating effects (C) of estrogen by blocking estrogen receptor sites on malignant cells. A side effect of tamoxifen is hot flashes (A), which is related to the decreased estrogen. Tamoxifen is used for Women with estrogen receptor-positive breast Cancer, not all Women (B), and is classified as a hormonal agent, not (D), used to suppress malignant Cell growth. 37. A 56-year-old female client is receiving intracawitary radiation via a radium implant. Which nurse should be assigned to care for this client? ID: 59.858 A. A nurse with Oncology experience who may be pregnant. B. The nurse who is caring for another client receiving intracawitary radiation. C. The nurse who is caring for another client who has Clostridium difficile. D. s. A nurse with Marfan's syndrome who is postmenopausal. correct A client receiving intracavity radiation poses a radiation hazard as long as the intracavity radiation source is in place. A nurse's ability to care of this client is not affected by Marfan's syndrome (B), which is a hereditary disorder of connective tissues, bones, muscles, ligaments and skeletal structures. The goal is to limit any one staff member's exposure to the calculated time span based on the half-life of radium, such as the number of minutes at the bedside per day, so (A) should not be assigned. (C) should not be exposed to the radiation due to the possible effect on the fetus. A radiation exposure decreases the immune response in the client who should not be exposed to the potential inadvertent transmission of an infectious organism (D). 38. Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer? A. Notify the healthcare provider if heavy waginal discharge occurs. B. Use condoms for sexual intercourse during the next week, C. s. Use a sanitary napkin instead of a tampon. Correct LS S LaLLS a LaLaL LLa0LL Laa L 0L LLaaLLHaaLa LL0L a LL LLS Clients should avoid the use of tampons for 3 to 6 weeks (D) after the procedure to reduce the risk of infection. A heavy, watery vaginal discharge is expected during this time, so Cancerous lesion and should be reported. 39. Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers? |D: ՃցT 4BF3525 A. Quality manager. B. - Case manager. C. Discharge manager. D. Nurse-manager. The role of the case manager (A) is to assist the continuum of care for the client, and coordinate the plan of care, evaluate client needs, and collaborate with the interdisciplinary healthcare team to ensure that goals are met, quality is maintained, and progress toward discharge is made. (B) focuses on staffing and assigning Work on client units. (C) reviews research and assesses opportunities for process improvement, implement changes, measure outcomes, and start the improvement process. (D) is responsible for all of the discharge needs of clients at the time of discharge but Would not be involved With client admission activities. 40. The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider? ID: 59E596 A. Reports a history of hives after eating shellfish. B. Expresses fear about the surgical procedure. C. States has a history of post-operative na usea. D. Recalls drinking a glass of juice after midnight. The risk of aspiration while under general anesthesia is increased when the stomach is not empty prior to a surgical procedure, so the client's intake of juice (B) after midnight should be reported the healthcare provider. Preoperative fear and anxiety (A) are common and should be further explored by the nurse. (C) should be communicated using allergy identification tags on the client's records and bracelets on the client's wrist. (D) is a common and expected side effect of perioperative medications. 41. The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide? A. Adolescents who demonstrate labile behaviors are at risk for self-injury. B. The parents should consider hospitalization to prevent self injury. C. - Early adolescence is a developmental stage of normal experimentation. Correct D. Rebelliousness requires consequences to prevent socially deviant behavior. The nurse should support the parents by explaining that early adolescence is a developmental change spurred by hormonal increases in pubescence and teenage experimentation with values, choices, and peer acceptance (C). (A, B, and D) are not applicable in the context of this adolescent's behavior. 42. The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the ID: 697. nurse to implement? A. Ask the spouse to step out for a few minutes. Correct B. Direct the questions to the spouse whenever possible. C. Ask another nurse to complete the interview. D. Repeat each question and tell the client to speak up. The nurse should ask the spouse to step out of the room (D), which maintains the client's privacy and allows the client to respond, without confronting the spouse. (A) reinforces the spouse's responses. (B) may not eliminate the spouse's responses on behalf of the client. (C) does not foster the nurse-client relationship. 43. The nurse determines that a client's body weight is 1.05% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem, ID: 697. "Imbalanced nutrition: more than body requirements?" A. Morbidly obese. B. Markedly obese. C. - Inadequate lifestyle changes in diet and exercise. сотесt D. Increased morbidity and mortality risks. Obesity is a body weight that is 20% above desirable weight for a person's age, sex, height, body build, and calculated body mass index (BMI). (C) best identifies factors that contribute to the formulation of the nursing diagnosis. (A and B) are medical classifications for a client's weight. Although the client is at an increased risk for several chronic illnesses (D), such as heart disease, diabetes mellitus, hypertension, coronary artery disease and hyperlipidemia, this is not a contributing cause or related factor that supports the nursing diagnosis. 44. The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding? D: . A. Purplish-red pinpoint lesions of the skin. correct B. Small circumscribed elevations containing purulent fluid. C. Purple to bluish discoloration of the skin. D. Generalized reddish discoloration of an area of skin. Petechiae are described as purplish to red, non-blanchable, pinpointlesions (A) that are tiny hemorrhages within the dermal or submucosal layers. (B) describes ecchymosis caused by trauma to the underlying blood vessels. (C) describes pustules. (D) is nonspecific and incomplete. 45. The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation? ID: . A. O A Hispanic client may hawe in Ward-turned eyelashes, B. A Caucasian client may have a slightly protruding eyeball. C. An African-American client may have slightly yellow sclerae. correct D. An Asian client may have a horizontal palpebrale fissure. Recognizing normal variations that are common in different racial groups helps the nurse differentiate an early sign of pathology, such as yellow sclerae. A slightly yellow color of the sclera for (C) is a normal racial variation found in the African-American population. (A, B, and D) are findings not related to one racial group. 46. During the physical assessment, which finding should the nurse recognize as a normal finding? |D A. : Regular pulsation at the epigastric area when the client is supine. Correct B. Point of maximal impulse at the third intercostal space in the right midclavicular line. C. Apical pulse noted over an area 4 to 5 centimeters with a duration of 2 seconds. D. Jugular venous pressure palpable with the client in an upright position. Recognizing normal findings in the physical exam is a necessity. The regular and reCurrent expansion and Contraction of an artery produced by Waves of pressure caused by the ejection of blood from the left wentricle as it contracts is a normal finding (A). (B, C, and D) are abnormal findings that require further assessment. 47. The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most ID: 697. Sēm Siti Wēi imidication of altērēd Cērēbral function? A. Umecqual pupils. B. inability to open the eyes. C. Change in level of consciousness. D. LOSS Of Central reflexes. Neurological vital signs include serial assessments of TPR, blood pressure, and components of the Glasgow coma scale (GCS), which includes Verbal, musculoskeletal, and pupillary responses. A change in the client's level of consciousness (D), as indicated by responses to commands during the GCS, is the first and the most sensitive sign of change in cerebral function. (A, B, and C) are late signs of altered cerebral function. 48. When documenting assessment data, which statement should the nurse record in the narrative nursing notes? |D: 5974B75274 A. Hair is Within normal limits. B. Most all permanent teeth are present. С. Slight tenderness in the left upper quadrant. D. - S1 murmur auscultated in Supine position. Correct Documentation of subjective and objective data obtained from the physical assessment should be communicated using precise, descriptive, clear, and accurate information, such as auscultated heart sounds while the client is in a specified position (C). (A, B, and D) are nonspecific. 9. A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having? |D: Ճց74ETEքTք A. Dë|USiOrhal. B. Paraid, С. PODIC. D. s. Obsessive. Obsessive thoughts (A) are thoughts that the client is unable to control. (B) are irrational fears. (C) are false beliefs. (D) are suspicious thoughts. 50. The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the |D: 5ց74BF3555 answering service offers to take a message, which nursing action is best for the nurse to take? A. Ask the receptionist to notify the client's family if the healthcare provider cannot be contacted. B. Provide the receptionist with the client's name, age, and type of reaction. C.. O Ask when the healthcare provider plans to return to the office and the usual office hours. D. Tell the receptionist to have the healthcare provider return the phone call, correct The best nursing action is to ask for a return call from the healthcare provider (B) because the nurse must maintain the client's confidentiality. (A) is acceptable, but the best action is to leave a telephone number and request a return call. (C or D) do not promote confidentiality. 51. A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which ID: 697. position should the nurse place the client? A. Supine with the foot of the bed elevated. B. Left supine with thighs flexed on her abdomen. С. Semi-Fowler's with head of bed elevated 30 degrees. D. Right lateral side with both legs flexed, The supine position with the foot of the bed elevated (D) (Trendellenburg) is one position used to alleviate gravitational pressure by the fetus on the prolapsed umbilical cord, (A, B, and C) do not alleviate pressure on the umbilical cord. 52. The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these |D- ից 74EFEFED ClaSSes? A. Participants can identify at least three coping strategies to use during labor correct B. Educate significant others about providing support for their partner during labor. C. Introduce comfort measures that are effective techniques to use during labor and delivery. D. Teach and practice breathing techniques to help cope with contractions during labor. An expected outcome is a specific, measurable change in a client's status that occurs in response to nursing interventions. (B) meets the criteria for an expected outcome. (A, C, and D) are nursing interventions that should lead to the expected outcome. 53. A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the ID: 59E532 eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this StLatiO? A. Primary prevention. B. Tertiary prevention. С. Health promotion. D. Secondary prevention. Secondary prevention (B) attempts to halt the progression of the disease process, in this case, an escalation in the battering, by educating the client about prevention strategies. The nurse has identified client injuries that Create a suspicion of battering and domestic violence. (A) Would be activities that occur before the disease process begins, such as providing community seminars on the risks, and signs and symptoms of domestic violence. (C) occurs after the disease process has started, and includes referring the client to a battered Women's shelter for treatment following unabated, chronic abuse. Health promotion can be incorporated in all levels of prevention (D). 54. Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each ID: 59485.82 staff nurse include in the portfolio? A. Letters of support from family members and friends who are healthcare professionals. B. Copies of any articles the nurse has read that relate to client care on the nursing unit. С. Evaluations by past nursing faculty and employers to document ongoing competence, D. s. A self-evaluation that identifies how the nurse has met professional objectives and goals. Correct A clinical portfolio should include pertinent information that assists in providing a comprehensive view of the employee's performance. A self-evaluation (D) provides an important assessment of the nurse's strengths, weaknesses, and progress toward the achievement of professional goals. (A) is not pertinent nor useful evaluative data regarding current performance. While documentation of continuing education and any certifications achieved are important to include in a clinical portfolio, (B) is not necessary. (C) is not a significant component of a clinical portfolio. 55. When engaging in planned change on the unit, what should the nurse-manager establish first? ID: ՃցT 4.B73553 A. Resources needed for the change are available. B. Goals for achieving the change are established. С. Options for accomplishing the change are explored. D. : Staff members are aware of the need for change, correct The first step in planned change involves establishing a relationship with those involved in the change process and instilling knowledge and awareness of the need for change (D). The nurse-manager should next implement (C), and then (A and B). 56. A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in ID: 5ցT 4.B762ED developing the new care map? A. Surgical staff group. B. Multidisciplinary group. correct C. Nurse-manager group. D. Single-discipline group. In a multidisciplinary Work group (B), a number of individuals from a variety of disciplines are involved in developing the care map, but each works independently to implement the care plan. Single-discipline work groups (C), such as (A or D), are likely to focus on the aspects of the care map related only to their specific discipline, 57. The scope of professional nursing practice is determined by rules promulgated by which organization? | D: GF BF3557 A. National Labor Relations Board (NLRB). B. American Nurses Association (ANA). C. State's Board of Nursing. D. State Nursing Associations. The state's Board of Nursing (A) is authorized to promulgate rules and regulations that carry the Weight of law. The State Legislature delegates its law-making authority to this administrative law body. (B and C) are influential in defining and describing nursing standards of care, but neither have the authority to pass laws that legally define the professional scope of nursing practice. Although (D) may rule on issues important to nursing practice, the scope of professional nursing practice is determined by the laws, rules, and regulations promulgated by state Boards of Nursing. 58. An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the |D: Ճ974E751 Ա2 subcutaneous tissue. At which stage should the nurse document this finding? A. Stage 4. B. Stage 1. C. - Stage 3. correct D. Stage 2. underlying tissue. The stage of the pressure area is determined by the depth of tissue damage, and this client's lesion should be documented as a Stage 3 (C) because it is a full thickness tissue loss with visible subcutaneous fat that does not expose bone, tendon, or muscle. (A) is a nonblanchable pressure point over intact skin. (B) is a partial thickness includes undermining and tunneling. 59. After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first? |D: ՃցT 4ET3551 A. The client with type 2 diabetes mellitus who has a call light on. B. An anxious client who is 3 days post myocardial infarction. C. The client who has a new onset of difficult breathing. correct D. A client whose blood transfusion is near completion. Based on Maslow's hierarchy of needs and the need to address airway, breathing, and circulation (ABCs), the client with a new onset of difficulty breathing (A) should be assessed first. (B, C and D) do not have the priority of (A). 60. When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care? |D: Յց74EF52 12 A. - Coordinating and educating about multidisciplinary services. B. Referring and consulting with other healthcare specialities. C. Informing about the findings that determine clinical diagnosis. D. Providing information om financial assistance programs. Clinical decisions to achieve client outcomes require collaborative efforts between the interdisciplinary team and the client-family cooperation. The nurse's role as collaborator of care is best displayed by coordinating and educating the client and family about multidisciplinary services (A). Information about financial assistance programs (B) is most often a role of social services. Although the nurse refers and consults with the healthcare team (C), client-focus care is best identified within a collaborative nurse-client-family relationship. Informing the client about a clinical diagnosis (D) is the responsibility of the healthcare provider. 61. Preoperatively, a client is to receive 75 mg of meperidine (Demero) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer? A. 2 TIL. B. O.5 TL. C. 1 TIL D. - 1.5 mL. Carect To correctly solve this problem, use the formula: Desired/On Hand, or the algebraic formula: 75: x = 50: 1. 50x = 75. x = 75/50 or reduced to 1.5 mL (C). 62. A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid? |D: 5ց74EFFg|B A. - Dried prunes. Correct B. Mashed potatoes, C. Mustard greens. D. Cottage cheese. A serving of dried prunes (D) contains more than 300 mg of potassium, and should be avoided. The richest dietary sources of potassium are unprocessed foods (especially fruits), many vegetables, and some dairy products, so the client should avoid these food groups. Servings of foods containing less than 150 mg of potassium, such as (A, B, and C), are good choices for a low potassium diet. 63. A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical ID: manifestations? A. Thin, fragile skin, ecchymoses, and complaints of weakness, B. Headache, diaphoresis, and palpitations. C. Hypotension, rapid weak pulse, and rapid respiratory rate. correct D. Abrupt onset of hyperpyrexia, extreme tachycardia, and delirium. The clinical manifestations of Addisonian crisis are often the manifestations of shock (C); the client is at risk for circulatory collapse and shock. (A) indicates clinical manifestations of Cushing's syndrome, (B) of pheochromocytoma (tumor of adrenal medulla), and (D) of thyroid storm (thyrotoxic crisis). 64. The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the ID: 69. nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client? A. Suction for only 5 seconds since the client has only one lung and cannot hold his breath for very long. B. Suction deeply and vigorously to ensure that all secretions are removed in order to prevent atelectasis. C. c. Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning. Correct D. Have another person available to hold the client's hands to prevent inadvertent removal of the suction tube. A soft rubber catheter with a blunt tip is preferable (B) and deep, vigorous suctioning (D) should be avoided. The client should not hold his breath (A) whether he has one or two lungs and 5 seconds of suctioning is not enough to justify the trauma caused by suctioning. Having another person available for restraint is a good idea if the client is combative or confused, but (C) is not the best answer to this question. It is important to avoid (D) in order to avoid perforating the sutures on the bronchial stump following a pneumonectomy, 65. A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client? |D: 5974B73537 A. Rebreather mask. B. Venturi mask. C. Nasal cannula. D. Harid-held rl EDL liZEr. (C) will provide oxygen without covering the client's face. (A and B) are also masks and will not alleviate the problem offeeling "smothered." (D) is used for medication administration father than Oxygen. 66. Following major abdominal surgery, a male client's arterial blood gas analysis reveals PaC295 mmHg and PacO250 mmHg. He is receiving oxygen by nasal cannula at 4 ID: 59.483.58 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time? A. : Encourage the use of an incentive spirometer correct B. Increase the oxygen flow to 6 liters/minute. С. Notify the healthcare provider of the crisis blood gas values. D. Encourage the client to breathe slower. The blood gas reveals adequate oxygenation (PaD295) and hypoVentilation (PaCO2 > 45). The client needs to be encouraged in activities that increase the depth of breathing (e.g., use of the incentive spirometer) (B). (A) will only increase an already adequate PaC2. These are not crisis blood gas findings (C). (D) will only worsen the hypoVentilation. 67. A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to D: 59E554. express feelings of anger." Which nursing interwention is most important to include in the client's plan of care? A. Gather more data about social support. B. Teach that anger will subside after two weeks on antidepressants. С. Collaborate with the treatment team about revising the goal. D. s. Ask client to describe triggers of anger. Depression is associated with feelings of anger, and clients are often not aware of these feelings. Awareness is the first step in dealing with anger (or any other feeling), so the nurse's efforts should be directed toward increasing the client's awareness of feelings (B). Anger may persist after beginning antidepressant therapy (A), and it may not be necessary to revise the goal (D). (C) can assist the client to cope, but it's most important to ask the client to describe triggers of anger. 68. The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary ID: characteristic of addiction? A. Addiction causes people to steal and lie. B. Those who are unhappy with themselves are more likely to become addicts, C. Wanting the drug is all that matters to an addict. D. Addicts who use illegal drugs are trying to escape reality. The hallmark characteristic of addiction is impaired control (D): all that matters is obtaining the drug of choice. (A) may or may not be true, but is not the primary characteristic of addiction. (B) is a manifestation of impaired control. Addiction is not caused by being unhappy with one's self, but such unhappiness is usually a result of addiction (C). 69. The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? A client with ID: A. spinal cord injury. Correct B. diabetes insipidus, C. congestive heart failure. D. gastrointestinal hemorrhage. Spinal cord injuries (C) place the client at high risk for the development of neurogenic distributive shock. The development to watch for in (A) is cardiogenic shock, in (B) is hemorrhagic shock, and in (D) is hypovolemic shock. 70. Which statement by the community health nurse is most helpful to an adult who is in a crisis situation? ID: A. Based on past coping, I believe you will be able to deal with future problems successfully. B. You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it? correct C.. I have a plan of action that I think will help you. Would you like to see if it will work for you? D. I will be your primary resource person, and will gather the information you need to get through this situation. (D) acknowledges the stress and encourages the client to discuss Options to deal with the problems. Recognizing early signs/symptoms of heightened stress can help to averta crisis. (A and C) deny the client the opportunity to take control of the problem and use problem solving techniques to resolve the situation. (B) may be offering false reassurance. 71. A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan? |D: ՃցT 4.B75 1BB A. Avoid sharing towels and washcloths with siblings, correct B. Wear sunglasses to protect eyes from sunlight. C. Apply Warm Compresses to reduce SWelling. D. Take acetaminophen Tylenol) for any eye discomfort. All of the information is important to include in the teaching plan, but it is most important to avoid spreading the bacterial infection. The child should avoid sharing towels and Washcloths (D) and should stay home from school for the first 24 hours after antibiotics are started, to prevent contamination of others. (A, B, and C) are important measures to reduce the child's discomfort, but inhibiting the spread of the infection is the priority intervention. 72. The school nurse is reviewing health risks associated with extracurricular activities of grade-school children. Regular participation in which activity places the child at highest ID: 697. risk for developing external otitis? A. Batting practice at a batting cage, B. Soccer practice at an outdoor field. C. Roller skating at an indoor rink. D. Swimming lessons in an indoor pool. External otitis is commonly caused by exposure to bacteria while swimming (C). In addition, chlorine tends to alter the normal flora of the external ear canal, increasing the risk for infection. Participation in (A, B, or D) may increase the child's risk for trauma, and families should be instructed to use protective equipment to reduce this risk. 73. The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy ID: BET 4.B75քD5 demands A. A school-aged child. B. A teenager beginning puberty. C. - A pregnant Woman. Correct D. A 3-month-old infant. A pregnant Woman's (A) metabolic demands are 20 to 24% more than the basic metabolic rate. (B, C, and D) require only 15 to 20% more than the basic metabolic rate. 74. The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the ID: 697"4B7"51BO inservice presentation about the care of clients with hypertension? A. Caregivers should only conduct blood pressure checks under a registered nurse's direct supervision. B. As long as clients receive daily antihypertensive medications, no further interventions are needed. C. Clients with an elevated blood pressure often exhibit a stiffneck and are diaphoretic. D. Frequent blood pressure checks, including readings taken by automated machines, are recommended. Frequent blood pressure checks (D) are recommended for hypertensive clients to evaluate the effectiveness of treatment. Symptoms such as (A) are not typical of essential hypertension, which is an asymptomatic disease. Treatment (B) usually includes dietary modifications and exercise, which should not be discontinued when medications are added to the treatment plan. While the RN is ultimately responsible for the assessment of blood pressures (C), caregivers are not restricted from obtaining the blood pressure readings. 75. A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission? |D: ՃցT 4.B75225 A. O. Monitor for increased blood pressure and pulse. Correct B. - Administerthiamine (B1) to prevent Korsakoffs syndrome. C. Administer a PRN benzodiazepine as needed for anxiety. D. Encourage fluid intake of non-caffeinated beverages. Clients with alcohol dependency experience withdrawal symptoms, which include elevated blood pressure, pulse, and temperature, so (B) has the highest priority. (A) will prevent Korsakoff's syndrome (secondary dementia caused by thiamine deficiency, associated with malnutrition secondary to excessive alcohol intake), but this intervention does not have the priority of (B). (C and D) are important for alcohol detoxification, but do not have the priority of (B). 76. The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg PO. The 10 mL vial is labeled "Mucomyst 20% solution (20 grams/100 mL)." ID: 5974B752BE What volume of medication in milliliters should the nurse administer? (Enter numeric value only) 3 Correct 20 grams is equivalent to 20,000 mg. 20,000 mg/100 mL = 200 mg/1 mL. Using Desired. Have X Volume: 600 mg/200 mgX 1 mL = 3 mL. 77. A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low calorie diet. At dinner the nurse notes that he is trying to get |D: Ճց74BFFցDB other clients on the unit to give him part of their meals. What intervention should the nurse implement? A. Report the behawior to the on-cal psychologistimmediately. B. Remo We the client from the table and have him sit alone. C. Send the client back to his room and do not allow him to eat. D. Confront the client about the consequences of the behavior, correct The nurse should provide a reality check by helping the client realize that there are consequences to his behavior (D). (A and B) do not help the client realize that his behavior is manipulative and harmful to himself as well as others. This behavior needs to be documented, but (C) does not need to be implemented. 78. In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition? ID: 5374B75 124 A. Swelling around the eyes and face. B. Increased thirst. Correct C. || || Soft anter| Or fortare, D. Cool, dia pohoretic skin. (A) is a primary factor in monitoring effectiveness of treatment for diabetes insipidus. A child with diabetes insipidus does not want to eat, and only wants to drink; in fact he or she may even drink water from toilets and vases. The anterior fontanel usually closes at about 18 months of age; therefore, (B) is not an appropriate measure of dehydration for a 3year-old. The skin of a child with diabetes insipidus is usually warm and dry, not (C). (D) is not characteristic of diabetes insipidus, but is characteristic of hypothyroidism, Cushing syndrome, or nephrotic syndrome. 79. A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never ID: 697. performed a wound packing. Which intervention should the charge nurse implement? A. Demonstrate the wound care procedure to the PN while the PN assists. correct B. Note the PN's learning need to perform a wound packing and contact nursing education to schedule a time for instruction. С. Perform the wound care and have the PN provide the client's morning care. D. Advise the PN to review the procedure in the procedure manual and then complete the wound care. It is within the PN's scope of practice to perform sterile wound care. The best learning of skills is through demonstration and return demonstration, therefore (D) promotes safe practice while allowing the PN the best opportunity to learn. (A) does not allow the PN to gain the experience needed to perform her role. (B) does not provide the best learning opportunity for the PN, or ensure safe practice. While (C) would provide a safe method for learning the Wet-to-dry procedure, it doesn't address the problem immediately and is a more costly way for the PN to learn. 80. A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse can lessen the symptoms of this "TET spell?" |D: 5974B73573 A. Place child in knee-chest position. Correct B. Remove child's constrictive clothing. C. Hawe child stop all current activity. D. Administer a dose of digoxin stat. The child should be placed on his or her back in the knee-to-chest position (B) to increase blood vessel resistance. The increased pressure reduces the rush of blood through the septal hole and improves blood circulation. (A) has nominal effects in hypercyanosis. (C) is self-regulating. (D) is not indicated for immediate relief of tet spells. It is used to improve Cardiac Output. 81. During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not ID: 697. lether return home, and she does not have transportation or a job. Which client goal is most important for this client? A. Become familiar with public transportation. B. Begin vocational rehabilitation. C. Taking medication, with community follow-up. D. Obtain housing, with possibility of returning home. The most important goal for discharge is for the client to take medications (A), which will stabilize her mood and promote an optimum level of functioning. (B, C, and D) are important goals, but first the client needs to be stabilized on her medication. 82. The nurse is preparing to administer