Additional HESI Fundamentals Recommended Sets (Latest UPDATES STUDY) Exam Reviews Questions and Verified Answers 100% Correct Grade A

Additional HESI Fundamentals Recommended Sets (Latest 2024 _ 2025 UPDATES STUDY) Exam Reviews _ Questions and Verified Answers _ 100% Correct _ Grade A Additional HESI Fundamentals Recommended Sets B - -Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires the most immediate action by the nurse? A. Surgical consent form is not signed B. Preoperative serum potassium level is 2.8 mEq/L (2.8mmol/L) C.Preoperative chest x-ray report is not available D. Client's pulse oximeter reading is 96% C - -One hour after major abdominal surgery, a client in the post anesthesia care unit (PACU) has a blood pressure (BP) of 136/80 mmHg. Fifteen minutes later it is 114/72 mmHg. Which action should the nurse take first? A. Increase frequency of BP assessments B. Review the client's baseline BP trends C. Check the abdominal surgical dressing D. Encourage the client to breathe deeply B - -The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides evidence of its normal function? A. Ecchymotic area B. Enlarged vein C. Pulselessness D. Redness C - -Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? A. Encourage the client to lie down and rest after meals B. Remind the client to avoid high-fiber foods C. Teach the client to elevate the head of the bed on blocks D. Instruct the client to use antacids only as a last resort B - -Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is important for the nurse to include in the discharge teaching plan? A. Avoid driving a car for 2 weeks B. Drink 3 liters of water each day C. Eliminate all spicy foods from your diet D. Clamp the catheter when taking a shower A - -A client with chronic cirrhosis has esophageal varies. It is most important for the nurse to monitor the client for the onset of which problem? A. Brown, foamy urine B. Anorexia C. Clay-colored stool D. Hematemesis B - -After three days of persistent epigastric pain, a female client presents to the clinic. She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/min, respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70mmHg. The nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical? A. Irregular pulse rate B. ST elevation in three leads C. Complaint of radiating jaw pain D. Bile colored emesis A - -A client's laboratory findings indicate elevations in thyroxine and triiodothyronine hormones. The nurse suspects that the client may have hyperthyroidism. Which assessment finding is most often associated with hyperthyroidism? A. Increased pulse rate B. Diarrhea stools C. Atrophied thyroid gland D. Periorbital edema D - -A young adult male client has a diagnosis of epididymitis and a positive culture for Escherichia coli. Which information should the nurse include in the teaching plan? A. Avoid penile contact with the rectal area B. Epididymitis is a pre-cancerous condition C. Obtain an annual prostate digital exam D. Surgical intervention is often indicated C - -The drainage in the chest tube of a client with emphysema has changed from viscous green to clear watery fluid. Which action is best for the nurse to take? A. Obtain a specimen of the drainage for culture B. "Milk" the tube to remove any clots C. Maintain the current IV antibiotic schedule D. Schedule a portable chest x-ray per PRN protocol B - -While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative problem of pain. What is the etiology of this problem? A. Diminished blood flow B. Compression of a nerve C. Irritation of nerve endings D. Ischemic tissue changes D - -A client is being treated for acute kidney injury. On examination, the client has a weight gain of 4.4 lbs (2kg) in 24 hours and exhibits changes in mental status. Which intervention should the nurse implement? A. Monitor daily sodium intake B. Assess for dependent pitting edema C. Record usual eating patterns D. Obtain serum creatine levels daily A - -A female client who works as a data entry clerk is concerned as to how her recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client? A. Use a space heater to keep the workplace warm B. Obtain a keyboard designed to limit wrist flexion C. Keep both hands elevated during work breaks D. Take a multivitamin that contains vitamin D daily B - -A client has an absolute neutrophil count (ANC) of 500/mm^3 after completing chemotherapy. Which intervention is most important for the nurse to implement? A. Implement bleeding precautions B. Place the client in protective isolation C. Assess vital signs every 4 hours D. Review need for pneumococcal vaccine A - -A client is receiving chemotherapy for treatment of metastatic carcinoma. When monitoring the client for systemic side effects, which assessment finding warrants intervention by the nurse? A. Leukopenia B. Polycythemia C. Ascites D. Nystagmus C - -A client is diagnosed with diverticulosis following a colonoscopy. The client denies any symptoms, and asks the nurse what to expect. Which is the best response by the nurse? A. Episodes of burning pain are commonly experienced B. Appetite loss, with resultant feelings of weakness, are common problems C. Symptoms may not occur unless sacs become inflamed D. As the sacs enlarge pain may be experienced in the lower abdomen D - -A client is admitted with a deep and productive cough, hemoptysis, and a low-grade fever. The client's Mantoux skin test has a 15mm induration. Which intervention should the nurse implement first? A. Administer the initial dose of rifampin and isoniazid B. Collect a sputum specimen for acid-fast bacillus C. Provide a mask for the client to wear in public areas D. Initiate airborne particulate isolation precautions A - -A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? A. Irregular apical pulse B. Pitting ankle edema C. Quarter size blood spot on dressing D. Purple marks on skin of the abdomen A - -A female client who recently married returns to the clinic with recurrent cystitis and urethritis. The client presents with pain on urinating, urinary frequency, and urgency. Which additional information should the nurse obtain? A. Review a recent urinalysis for calcium oxalate B. Examine a client's history for any genetic renal disease C. Ask if she has recently has a streptococcus infection D. Inquire about hygiene practices after sexual intercourse B - -The nurse provides dietary instructions about iron rich foods to a client with iron deficiency anemia. Which food selection made by the client indicates a need for additional instructions? A. Liver B. Oranges C. Leafy green vegetables D. Kidney beans A - -A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care? A. Begin straining all urine B. Implement seizure precautions C. Administer a PRN dose of a laxative D. Initiate cardiac telemetry D - -The nurse is caring for a client on a rehabilitation unit who has right cerebrovascular accident and is struggling with independent self-care. The nurse places a large mirror in the client's room. Which instruction should the nurse provide the client? A. Mirrors reflect light to brighten the room so you can see better B. A hoe-like environment helps you relax and feel more confident C. Check your appearance before leaving the room D. Use the mirror to watch yourself while dressing A, D, E - -An older client who us agitated, dyspneic, orthopneic, and using accessory muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minute and irregular respirations 38 breaths/minute, blood pressure 168/100 mmHg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV, which assessments should the nurse obtain to determine the client's response to the treatment? (Select all that apply) A. Oxygen saturation B. Skin elasticity C. Pain scale D. Lung Sounds E. Urinary output A - -While caring for a client with a full-thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provide, the nurse should review which of the client's laboratory values? A. White blood cell count B. Blood pH level C. Platelet count D. Hematocrit A, B, C, E - -During the admission assessment, the nurse identifies multiple bruises at various stages of healing on a male client recently diagnosed with aplastic anemia. The nurse reviews his stat serum laboratory values which reveal platelets 50,000/mm^3, white blood cells 3,000/mm^3, and red blood cells 2.5 million/mm^3. Which actions should the nurse implement? (Select all that apply) A. Initiate sepsis protocol B. Provide a soft-bristle tooth brush C. Monitor for signs of bleeding D. Implement contact precautions E. Infuse blood products as prescribed A - -The nurse auscultates a client's heart sounds and hears a mid-systolic click associated with mitral valve prolapse. Which diagnostic test should the nurse prepare the client to expect the healthcare provider to prescribe? A. 12-lead electrocardiogram B. 2D-echocardiograhy C. Troponin and CK-MB levels D. . CT scan of the chest C - -The nurse is developing plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes. Which outcome should the nurse include in the plan of care for this client? A. The nurse will encourage the client to walk 30 minutes every day B. The client's blood pressure readings will be less than 160/90 mmHg C. The client's hemoglobin A1c will be less than 7.0% in 3 months D. The nurse will demonstrate the procedure for accurate eye care A - -The nurse is developing a plan of care for an adult client with cardiovascular disease who reports blurred-vision. Which outcome should the nurse include in the plan of care for this client? A. The client's daily blood pressure will be less than 140/80 mmHg this month B. The nurse will encourage the client to walk 30 minutes every day C. The client's blood pressure readings will be less than 160/90. mmHg D. The client will take up to 4 nitroglycerine tablets sublingually for chest pain B - -When planing care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing problem of, "visual sensory/perceptual alterations." This problem is based on which etiology? A. Limited eye movement B. Decreased peripheral vision C. Blurred distance vision D. Photosensitivity B, C, D - -The nurse is assessing a client who has a bowel obstruction. Which observations should the nurse expect to find? (Select all that apply) A. Peristaltic waves observed B. Abdominal distention C. High-pitch bowel sounds D. Dullness on percussion E. Abdomen soft on palpations B - -A male client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for his oral temperature of 103 degrees F and an infusion of normal saline is initiated at 250 mL/hour. Which assessment finding should the nurse report to the healthcare provider immediately. A. Severe headache with photosensitivity B.Petechial hemorrhage under client's eyes C. Right lower abdomen rebound tenderness D. Dark green color emesis D - -A client who fractured the right femur from a fall at home is placed in a skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement? A. Insert an indwelling catheter preoperatively B.Release the traction so the client can use a bedpan C. Log roll the client and place adult disposable briefs beneath the client D. Maintain traction while the client uses a female urinal B - -When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include? A. Reduces the inflammatory process improving nerve transmission and function B Increases the amount of dopamine available for muscles to function correctly C. Slows the scarring in the myelin sheath improving muscle tone and strength D. Acts as an antiseizure medication reducing the tremors caused by the disease A - -A client with chronic kidney disease is started on hemodialysis. During the first dialysis treatment, the client's blood pressure drops from 150/90 mmHg to 80/30 mmHg. Which action should the nurse take first? A. Lower the head of the chair and elevate feet B. Monitor blood pressure q45 minutes C. Administer 5% albumin IV D. Stop the dialysis treatment D - -A male client with acquired immune deficiency syndrome (AIDS) and Pneumocystis carinii pneumonia has a CD4+ T cell count of 200 cells/microliter. The client asks the nurse why he keeps getting these massive infections. Which pathophysiologic mechanism should the nurse describe in response to the client's question? A. Bone marrow suppression of white blood cells causes insufficient cells to phagocytize organisms B. Exposure to multiple environmental infectious agents overburdens the immune system until it fails C. The humoral immune response lacks B cells that form antibodies and opportunistic infections result D. Inadequate numbers of T lymphocytes are available to initiate cellular immunity and macrophages A - -The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition? A. Has everyone at home already had varicella? B. Have the anti fungal creams been effective? C. Do your family members share combs and brushes? D. Do you have any dry patches on your feet and hands? D - -A client with renal calculus is complaining of severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority? A. Risk for aspiration related to vomiting B. Nutritional deficit related to nausea C. Impaired renal function related to pain D. Acute pain related to real calculus B - -When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the healthcare provider? A. Slight blood-tinged sputum B. Dyspnea and dysphagia C. No gag reflex after 30 minutes D. Sore throat and hoarseness B, C, D, F - -The nurse prepares a teaching plan for an adult client with metabolic syndrome. Which findings should the nurse address to help the client reduce the risk for diabetes mellitus and vascular disease? (Select all that apply) A. Hypothyroidism B. Increased triglyceride levels C. Hyperglycemia D. Blood pressure of 150/96 E. Elevated high density lipoproteins F. Abdominal obesity A - -Which food is most important for the nurse to encourage a client with osteomalacia to include in a daily diet? A. Fortified milk and cereals B. Citrus fruits and juices C. Red meats and eggs D. Green leafy vegetables C - -The nurse reviews the laboratory results of a client during an annual physical examination and identifies a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review? A. Whit blood cell count B. Glucose C. Platelet count D. Amylase A - -The home health nurse is evaluating a male client who manages his asthma and measures his peak expiratory flow rate (PEFR). Today he is experiencing an acute exacerbation and tells the nurse his PEFR is 60% of his personal-best reading. He is experiencing expiratory and inspiratory wheezes and has a RR of 24 breaths/minute, and oxygen saturation rate of 94% on room air. Which PRN medication should the nurse instruct the client to use? A. Albuterol 2.5 to 5 mg per nebulization B. Epinephrine auto-injector 0.15 mg C. Salmeterol 2 puffs per measured-dose inhaled D. Oxygen at 6 liter/minute by nasal cannula A - -A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next? A. Prepare the client to return to the operating room B. Obtain a sample of the drainage to send to the lab C. Auscultate the abdomen for bowel sound activity D. Bring additional sterile dressing supplies to the room D - -After several days of coughing and taking acetaminophen to treat temperature of 101 F, a client with diabetes mellitus (DM) is admitted to the hospital with an upper respiratory infection. Several hours after admission, the client reports having a severe headache and feeling dizzy. Which intervention should the nurse implement first? A. Reassess vital signs B. Administer an antipyretic C. Obtain a sputum for culture D. Obtain a fingerstick glucose D - -Following a lumbar puncture, a client voices several concerns.Which concern indicates to the nurse that the client is experiencing a complication from the procedure? A. "My throat hurts badly when I swallow and when I talk" B. "I feel sick to my stomach and am going to throw up" C. "I am having pain in my lower back when I move my legs" D. "I have a headache that gets worse when I sit up" C - -While assisting a client to the toilet, the client begins to have a seizure and the nurse eases the client to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? A. Observe for lacerations to the tongue B. Document details of the seizure activity C. Observe for prolonged periods of apnea D. Evaluate for evidence of incontinence A - -An adult client comes to urgent care clinic 5 days after being diagnosed with influenza. The client is short of breath, febrile, and coughing green-colored sputum. Which intervention should the nurse implement first? A. Obtain a sputum sample for culture B. Check his oxygen saturation level C. Auscultate bilateral lung sounds D. Administer an oral antipyretic C, D, E - -An older adult recently diagnosed with type 2 diabetes mellitus (DM) suddenly becomes confused and weak, with cool, clammy skin. The client is unable to remember what to do for such symptoms and is taken to a near-by urgent care facility by a neighbor. Which nursing interventions should the nurse implement? (select all that apply) A. Prepare to administer regular insulin B. Palpate for bladder for pain or distention C. Check a blood sample for glucose level D. Report any changes in blood pressure E. Observe respiratory rate and pattern D - -An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer during the acute phase of the client's burn recovery? A. 5% dextrose in water B. total parenteral nutrition C. 5% dextrose in 0.25 normal saline D. Lactate Ringers C - -A client with eczema is applying 10% urea cream onto the affected skin areas. Which finding reflects the expected therapeutic response? A. Reduced pain in eczematous areas : B. Decreased weeping of ulcerations in affected areas C. Healing with a return to normal skin appearance D. Hydration of affected dry skin areas D - -When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include? A. Schedule rest periods between activities to minimize fatigue B. Teach coping skill for living with a chronic illness C. Provide assistive devices to empower client independence D. Implement measures to manage chronic pain C - -The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a Thoracotomy two hours ago. The nurse observes the following vital signs: heart rate 140 beats/minute, respirations 26 breaths/minute, and blood pressure 140/90 mmHg. Which intervention is most important for the nurse to implement? A. Administer IV fluid bolus as prescribed by the healthcare provider B. Medicate for pain and monitor vital signs according to protocol C. Encourage the client to splint the incision with a pillow to cough and deep breathe D. Apply oxygen at 10 L via non-rebreather mask and monitor pulse oximeter D - -An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI) Prescriptions for intravenous antibiotics and insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? A. blood ph of 7.30 B. glucose of 350 mg /dl C. white blood cell count of 15000mm D. potassium of 2.5 meq/l A - -A healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurse's assessment of the test after 72 hours indicates 5mm of erythema without induration. What is the best initial nursing action? A. Review client's history for possible exposure to TB B. Instruct the client to return for a repeat test in 1 week C. Refer client to a healthcare provider for isoniazid (INH) therapy D. Document negative results in the client's medical record C - -Which laboratory test result is most important for the nurse to report to the surgeon prior to a client's scheduled abdominal surgery? A. Potassium level of 4 mEq/liter B. Blood glucose of 90 mg/dl C. Serum creatinine of 5 mg/dl D. Hemoglobin level of 13 grams C - -The nurse admits a client who has a medical diagnosis of bacterial meningitis to the unit. Which intervention has the highest priority in providing care for this client? A. Administer initial dose of broad-spectrum antibiotic B. Instruct the client to force fluids hourly C. Obtain results of culture and sensitivity of CSF D. Assess the client for symptoms of hyponatremia Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet. Correct Answer: A, B, C, E - -64.A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A. Snack of potato chips, and diet soda. B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. C. Breakfast of eggs, bacon, toast, and coffee. D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E. Bedtime snack of crackers and milk. The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be used to cover both, but no bandage should be put under it (B). The Unna's paste boot should be applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h. Weekly removal is reasonable (D). Correct Answer: A - -65.What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? A. Check capillary refill of toes on lower extremity with Unna's paste boot. B. Apply dressing to wound area before applying the Unna's paste boot. C. Wrap the leg from the knee down towards the foot. D. Remove the Unna's paste boot q8h to assess wound healing. When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution. Correct Answer: D - -66.A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A. Review the client's most recent laboratory reports. B. Refer the client and family members for hospice care. C. Notify the hospital ethics committee of the client situation. D. Determine who is legally empowered to make decisions. According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency (D), and in this case safe nursing practice constitutes refusal to perform the procedure because of a lack of experience. Although state mandates, agency policies, and continued education and experience identify tasks that are within the scope of nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue opportunities to enhance their competency (A, B, and C). Correct Answer: D - -67.The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. Review the steps in the procedure manual. B. Ask another nurse to assist while implementing the procedure. C. Follow the agency's policy and procedure. D. Refuse to perform the task that is beyond the nurse's experience. The nurse took the correct action and should document the events that occurred in the nurses' notes (C). (A) did not occur and (B) is not indicated. The medication administration record is part of the client's medical record and should be placed in the chart, (D) when no longer current. Correct Answer: C - -68.Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Notify the charge nurse that a medication error occurred. B. Submit a medication variance report to the supervisor. C. Document the events that occurred in the nurses' notes. D. Discard the original medication administration record. Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation is not painful following most surgeries, and many analgesics used postoperatively cause constipation, so (D) is contraindicated. Correct Answer: B - -69.On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. Remind the client to turn every two hours while lying in bed. B. Provide warm prune juice before the client goes to bed at night. C. Teach the client to splint the incision while walking to the bathroom. D. Administer an analgesic before the client attempts to defecate. Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a fluid volume deficit. Correct Answer: D - -70.The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. Disturbed sleep pattern. B. Caregiver role strain. C. Impaired skin integrity. D. Fluid volume imbalance. Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options for ensuring informed consent. Correct Answer: A - -71.After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. Notify the surgeon that the consent form has not been signed. B. Read the consent form to the client before witnessing the client's signature. C. Determine if the client's spouse is willing to sign the consent form. D. Administer an opioid antagonist prior to obtaining the client's signature. The nurse should implement (D), because orthostatic hypotension is a common result of immobilization, causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will increase the potential for complications associated with prolonged immobility. Correct Answer: D - -72.A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Encourage the client to take several slow, deep breaths while ambulating. B. Help the client to remain standing by the bedside until the dizziness is relieved. C. Instruct the client to remain on bedrest until the healthcare provider is contacted. D. Advise the client to sit on the side of the bed for a few minutes before standing again. Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause. Correct Answer: A - -74.A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client's pain is gone before assisting with personal care. D. This client's pain will be difficult to manage, since the cause is unknown. Written informed consent is required prior to any invasive procedure. The healthcare provider must explain the procedure to the client, but the nurse can witness the client's signature on a consent form (A). (B) is not necessary since written consent must be obtained. (C) is not correct because written consent has not been obtained. (D) must occur after written consent is obtained. Correct Answer: A - -75.A male client arrives at the outpatient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the healthcare provider. What action should the nurse implement? A. Witness the client's signature on the consent form. B. Verify the client's consent with the healthcare provider. C. Notify the healthcare provider that the client is ready for the procedure. D. Document that the client has given consent for the needle aspiration. Deep palpation may be required to palpate the femoral pulse; and, when palpated, the nurse should document the presence and volume of the pulse (B). The site is best palpated with the client supine; elevation of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a problem requiring further assessment, such as (C), and does not reflect the presence of edema (D). Correct Answer: B - -76.In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. Elevate the head of the bed and attempt to palpate the site again. B. Document the presence and volume of the pulse palpated. C. Use a thigh cuff to measure the blood pressure in the leg. D. Record the presence of pitting edema in the inguinal area. The presence of rectal bleeding is generally a contraindication for the insertion of a rectal suppository, so the nurse should withhold the medication and notify the healthcare provider (C). (A and D) may cause increased rectal bleeding. Prior to asking the pharmacist for another form of the medication, the nurse must have a new prescription from the healthcare provider (B). Correct Answer: C - -77.A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement? A. Administer the medication as scheduled after assessing the client's vital signs. B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit. C. Withhold the administration of the suppository until contacting the healthcare provider. D. Insert the suppository very gently being careful not to further injure the rectal mucosa. To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. Correct Answer: B - -78.The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution. Maintaining a closed urinary drainage system is important to prevent infection, so the most immediate priority is to close the clamp (B) to reduce the risk for ascending microorganisms. If the drainage tubing is secured over the siderail (A), urine will not be able to flow out of the bladder, so the nurse should next reposition the tubing. (C and D) indicate correct care of the urinary drainage system, so documentation of an intact system is the last intervention needed. Correct Answer: B - -79.When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. The drainage tubing is secured over the siderail. B. The clamp on the urinary drainage bag is open. C. There are no dependent loops in the drainage tubing. D. The urinary drainage bag is attached to the bed frame. During administration of a rectal suppository, the client is asked to take slow deep breaths through the mouth to relax the anal sphincter (D). Bearing down (A) will push the suppository out of the rectum, so the suppository should not be inserted while the client is bearing down (B). Further data is needed before performing an invasive digital exam to check for fecal impaction (C). Correct Answer: D - -80.While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. Advise the client to continue to bear down without holding his breath. B. Gently insert the lubricated suppository four inches into the rectum. C. Perform a digital exam to determine if a fecal impaction is present. D. Instruct the client to take slow deep breaths and stop bearing down. When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding (A) to prevent further vomiting. (C) should then be implemented to reduce the risk of aspiration. After that, (B and D) can be implemented as indicated. Correct Answer: A - -82.While the nurse is administering a bolus feeding to a client via nasogastric tube, the client begins to vomit. What action should the nurse implement first? A. Discontinue the administration of the bolus feeding. B. Auscultate the client's breath sounds bilaterally. C. Elevate the head of the bed to a high Fowler's position. D. Administer a PRN dose of a prescribed antiemetic. Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves. Correct Answer: D - -84.Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? A. Removing the empty food tray from a client with a urinary catheter. B. Washing and combing the hair of a client with a fractured leg in traction. C. Administering oral medications to a cooperative client with a wound infection. D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Wet or damp areas on a sterile field allow organisms to wick from the table surface and permeate into the sterile area, so the field is considered contaminated if it becomes wet (B). Outdated liquids may be contaminated and should be discarded, not used (A). The container's cap should be removed, placed facing up, and off the sterile field, not (C). To prevent contamination of the sterile field, liquids should be held close (6 inches) to the receptacle when pouring to prevent splashing, and the receptacle should be placed near the front edge to avoid reaching over or across the sterile field (D). Correct Answer: B - -85.What action should the nurse implement when adding sterile liquids to a sterile field? A. Use an outdated sterile liquid if the bottle is sealed and has not been opened. B. Consider the sterile field contaminated if it becomes wet during the procedure. C. Remove the container cap and lay it with the inside facing down on the sterile field. D. Hold the container high and pour the solution into a receptacle at the back of the sterile field. Any possible break in surgical asepsis that is identified when others are unaware should be considered contaminated and new sterile supplies added to maintain the sterile field (D). Reporting the healthcare provider is not indicated (A). When sterility is suspect during aseptic technique, it should not be questioned (C) but all members of the team should move forward with reestablishing a sterile field. Allowing the procedure to progress under unsterile conditions (B) places the client at risk for infection and is an act of omission (negligence) by the nurse and other healthcare team members. Correct Answer: D - -86.A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? A. Report the healthcare provider for the violation in aseptic technique. B. Allow the completion of the procedure. C. Ask if the glove and sterile field are contaminated. D. Identify the break in surgical asepsis and provide another set of sterile supplies. A client who can stand can safely be assisted to pivot and transfer with the use of a transfer belt (D). A mechanical lift (A) is usually used for a client who is obese, unable to be weight-bearing, and who is unable to assist. Roller boards (B) placed under a sheet are used to facilitate the transfer of a recumbent client who is being transferred to and from a stretcher. Lifting a client (C) out of bed places the client and nurses at risk for injury and should only be implemented by skilled lift teams. Correct Answer: D - -87.An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point. Correct Answer: B - -88.What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? A. Maintain in a lateral position using protective wrist and vest devices. B. Position prone with a small pillow below the diaphragm. C. Raise the head and knee gatch when lying in a supine position. D. Transfer into a wheelchair close to the nurse's station for observation. A waist-high bed height (A) is a comfortable and safe working height to maintain the nurse's proper body mechanics and prevent back injury. The head should be flat for a Sim's side-lying position, not raised (B). (C) is implemented after the client is positioned laterally. (D) brings the client closer to the nurse when being turned. Correct Answer: A - -89.What action is most important for the nurse to implement when placing a client in the Sim's position? A. Raise the bed to a waist-high working level. B. Elevate the head of the bed 45 degrees. C. Place a pillow behind the client's back. D. Bring the client to one edge of the bed. Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times. Correct Answer: D - -90.The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A. Raise the bed to a comfortable working level. B. Bend the client's knee. C. Move the knee toward the chest as far as it will go. D. Cradle the client's heel. Active, rather than passive, ROM is best to restore strength and (B) is an effective schedule. Passive ROM 4 times a day (A) is not as beneficial for the client as (B). With weights (C), the client may fatigue quickly and develop muscle soreness. ROM is not performed beyond the point of resistance or pain (D) because of the risk of damage to underlying structures. Correct Answer: B - -91.The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which range of motion (ROM) exercises? A. Passive ROM exercises to all joints on all extremities four times a day. B. Active ROM exercises to both arms and legs two or three times a day. C. Active ROM exercises with weights twice a day with 20 repetitions each. D. Passive ROM exercises to the point of resistance and slightly beyond. Pull the pin Aim for the base of the flames Squeeze handle Sweep - -What does PASS stand for? Rescue the patient Activate alarm Confine or contain Extinguish - -What does RACE stand for? Because fever up to a certain point is beneficial - -Why should you think carefully before giving an antipyretic? Supine with knees flexed; used to promote relaxation of abdominal muscles - -Dorsal recumbent position Dorsal recumbent position with feet in stirrups - -Lithotomy position Flexion of the hip and knees in a side-lying position; used to examine the rectal area and if a female is unable to assume the lithotomy position - -Sims' position Lying on stomach - -Prone position Laying on back with head of bed elevated 60 degrees for Fowler's and 30-45 degrees for semi-Fowler's - -Fowler's and semi-Fowler's position 1) Infectious agent 2) Reservoir 3) Portal of exit 4) Mode of transmission 5) Portal of entry 6) Susceptible host - -Chain of infection (6 links) Incubation, prodromal, illness, decline, convalescence - -5 stages of infection Absence of contamination (clean) - -Asepsis -Most common form of transmission -Use gown and gloves -Remove PPE and wash hands BEFORE leaving room - -Contact precautions -Wear gown, mask, gloves -Remove gloves first, then gown and mask - -Droplet precautions -Includes TB, varicella (chickenpox), SARS (pneumonia), and rubeola (measles) -Wear gown, N-95 mask, gloves -Remove mask OUTSIDE the room after closing the door - -Airborne precautions -Immunosuppressed patients (low WBC counts, chemotherapy, large open wounds) -Make sure equipment is disinfected BEFORE it is taken into the room - -Protective, or reverse isolation Falls - -What is the most common incident reported in hospitals? 2 - -Release restraints at least every ____ hours. Distal to proximal (upward motion to increase circulation) - -When giving a bed bath, wash from _____ to _____. Check the patient (take VS) - -What do you do first if you commit a medication error? 1) Before you pour, mix, or draw up a medication 2) After you prepare the medication 3) At the bedside - -3 checks of safe medication administration 1) Right drug 2) Right patient 3) Right dose 4) Right route 5) Right time 6) Right documentation Others: 7) Right reason 8) Right to know 9) Right to refuse - -Rights of medication Vastus lateralis muscle - -What is the preferred IM site for infants? -Ventrogluteal muscle -Landmarks are the greater trochanter, anterior superior iliac spine, and iliac crest - -What is the site of choice for IM injections? Folic acid, iron, calcium (vitamin D) - -What supplements do pregnant women need to take? 0.5-1.2 mg/dL - -Normal creatinine levels Albumin - -Low levels of _____ are associated with malnutrition. Cessation of bowel peristalsis - -Paralytic ileus Vagus - -Digital removal can stimulate the _____ nerve, so stop the procedure if the patient accumulates bradycardia. 50-60 mL/hr or 1500 mL/day - -Normal urine output 30 mL/hr - -Urine output indicating renal failure Measure of dissolved solutes in a solution; an increase in fluid intake dilutes and makes urine lighter as it approaches 1.000; low fluid intake or fluid loss (diarrhea or vomiting) darkens urine and makes the specific gravity rise - -Specific gravity 1.002 to 1.028 - -Normal specific gravity range Abdomen - -For men, if the catheter will remain in place long-term, secure tubing to the ______ to prevent damage to penile-scrotal juncture. 1) Transduction 2) Transmission 3) Perception 4) Modulation - -What happens when someone has pain? Prostaglandin (activate nociceptors so trigger pain) - -NSAIDS decrease _______ response. Frontal cortex - -What do you perceive pain? 1=awake and alert 2=slightly drowsy, easily aroused 3=frequently drowsy, arousable by voice 4=arousable by shaking* 5=somnolent, not arousable* *Stimulate patient and notify physician - -Sedation rating scale For shortness of breath; leaning forward over a table with a pillow - -Orthopneic position Oxygen and PRBCs (packed red blood cells) - -What orders would you expect if a patient had low H&H? Kussmaul's (trying to get rid of CO2) - -What breathing is noted with diabetic ketoacidosis? Non-rebreather - -Which mask can deliver 100% oxygen? 15 - -In emergencies, turn oxygen all the way up to ______ liters. -anxiety, -restlessness -inability to concentrate -increases in heart rate -increased respiratory rate and blood pressure -cardiac dysrhythmias - -Early Signs of Hypoxia -paresthesias followed by numbness -hyperactive deep tendon reflexes -a positive Trousseau's or Chvostek's sign -neuromuscular excitability -muscle cramps -twitching -tetany -seizures, irritability, and anxiety -increased gastric motility, hyperactive bowel sounds, abdominal cramping, and diarrhea. - -Signs of Hypocalcemia Trousseau sign of latent tetany is a medical sign observed in patients with low calcium. To elicit the sign, a blood pressure cuff is placed around the arm and inflated to a pressure greater than the systolic blood pressure and held in place for 3 minutes. This will occlude the brachial artery. In the absence of blood flow, the patient's hypocalcemia and subsequent neuromuscular irritability will induce spasm of the muscles of the hand and forearm. - -Trousseau Sign -Hyperactive Bowels Sounds -Muscle Weakness -Increased Urine Output -Decreased specific gravity of urine would be noted - -Hyponatremia Signs 2.7-4.5 mg/dL - -Normal Phosphorus Level bleeding - -Prothrombin time greater than 30 seconds places the client at risk for what? 9.6-11.8 seconds - -PT Male 9.5-11.3 seconds - -PT Female 1.5 - 2 times higher than the normal level. Approx. 18-23 seconds - -Warfarin Therapeutic PT -a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. -Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. - A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. -A normal troponin I level is lower than 0.6 ng/mL. - -Troponin -The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. -The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. -This means that the client's value should not be less than 30 seconds or greater than 90 seconds. - -Activated Partial Thromboplastin -Rescue Patients -Alarm -Confine -Extinguish - -RACE C) Examining a chest x-ray obtained after the tubing was inserted Both (A and B) are methods used to determine proper placement of the NG tubing. However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper placement - -Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted. C) I will limit my intake of beef to 4 ounces per week Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need to decrease rather than increase - -The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format (C). (A, B, and D) do not address the concepts of informatics and legal issues - -A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified A) Acknowledge that she is supporting the arm correctly The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement - -While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion. C) Infuse 10 percent dextrose and water at 54 ml/hr TPN is discontinued gradually to allow the client to adjust to decreased levels of glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the client from experiencing hypoglycemia until the next TPN solution is available. The client could experience a hypoglycemic reaction if the current level of glucose (A) is not maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat blood glucose level (D) and the healthcare provider cannot do anything about this situation - -The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr D) Obtain a stat blood glucose level and notify the healthcare provider. D) Immediately after the assessments are completed Documentation should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained (D). (A, B, and C) do not address the concepts of legal recommendations for information management and informatics. - -At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed B) 1.5 ml - -The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. B) 1.5 ml. C) 1.75 ml. D) 2 ml. D) Notify the healthcare provider of the family's request The nurse should first communicate with the healthcare provider (D). Hospice care is provided for clients with a limited life expectancy, which must be identified by the healthcare provider. (A) is not necessary at this time. Once the healthcare provider supports the transfer to hospice care, the nurse can collaborate with the hospice staff and healthcare provider to determine when (B and C) should be implemented - -An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request. C) Document in the medical record that these normal findings are expected outcomes The results are all within normal range.(C) No changes are needed. (A,B, and D) - -A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV. B) During the inhalation The client should be instructed to deliver the medication during the last part of inhalation (B). After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and breath held for several seconds to allow for distribution of the medication. The client should not deliver the dose as stated in (A or D), and should deliver no more than two inhalations at a time (C). - -The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A) Immediately after exhalation. B) During the inhalation. C) At the end of three inhalations. D) Immediately after inhalation D) Ensure the accuracy of the blood type match All interventions should be implemented prior to administering blood, but (D) has the highest priority. Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction - -A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match. B) Battery Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request - -On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment. B) Fowler's The client should be positioned in a semi-sitting (Fowler's) (B) position during feeding to decrease the occurrence of aspiration. A gastrostomy tube, known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk of aspiration - -An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's. C) Sims'. D) Supine. D) Rashes in the axillary, groin, and skin fold regions Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity - -An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so (D) provides the surgeon with culturally sensitive information. (A) may be necessary if a language barrier exists, but the son is the patriarch in the client's family at this time. It is culturally insensitive to encourage the woman to go against her religious and cultural worldview, as in (B). Family members are more likely to misinterpret medical information, but the son should be the primary decision-maker for his mother (C). - -An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage t