Med Surg Hesi and study guide (100% CORRECT Solutions)

Med Surg Hesi and study guide 1. A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? Observe the color, consistency, and amount of spu ...

Med Surg Hesi and study guide 1. A client with a productive cough has obtained a sputum specimen for culture as instructed. What is the best initial nursing action? Observe the color, consistency, and amount of sputum. 2. A client is brought to the Emergency Department by ambulance in cardiac arrest with cardiopulmonary resuscitation (CPR) in progress. The client is intubated and is receiving 100% oxygen per self-inflating (ambu) bag. The nurse determines that the client is cyanotic, cold, and diaphoretic. Which assessment is most important for the nurse to obtain? Breath sounds over bilateral lung fields. 3. After a hospitalization of inappropriate antidiuretic hormone (SIADH), a client develops positive myelinolysis. Which intervention should the nurse implement first? Reorient client to his room. 4. A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? Evaluate swallow. 5. A male client with heart failure (HF) calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain? Has his weight changed in the last several days? 6. An older adult woman with a long history of chronic obstructive pulmonary disease (COPD) is admitted with progressive shortness of breath and a persistent cough. She is anxious and is complaining of a dry mouth. Which intervention should the nurse implement? Apply a high-flow venturi mask. 7. Client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucous, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care? Increase the daily intake of oral fluids to liquefy secretions. 8. A cardiac catheterization of a client with heart disease indicates the following blockages: 95% proximal left anterior descending (LAD), 99% proximal circumflex, and ? % proximal right coronary artery (RCA). The client later asks the nurse "what does all this mean for me?" What information should the nurse provide? Three main arteries have major blockages, with only 1 to 5% of blood flow getting through to the heart muscle. 9. A client who weighs 175 pounds is receiving IV bolus dose of heparin 80 units/kg. The heparin is available in a 2 ml vial, labeled 10,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.) 1.6 mL. 10. What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? Minimize symptoms by wearing loose, comfortable clothing. 11. The nurse is caring for a client with a lower left lobe pulmonary abscess. Which position should the nurse instruct the client to maintain? Left lateral. 12. A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nausea and vomiting. Which finding should the nurse report to the healthcare provider? Yellow sclera. 13. The nurse is planning care for a client following an incisional cholecystectomy for cholelithiasis. Which intervention is the highest nursing priority for this client? Assisting the client to turn, cough and deep breathe every 2 hours. 14. While caring for a client with Amyotrophic Lateral Sclerosis (ALS), a nurse performs a neurological assessment every 4 hours. Which assessment finding warrants immediate intervention by the nurse? Weakened cough effort. 15. The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client? The xenograft is taken from nonhuman sources. 16. A male client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning him, the wound dehiscences and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. What intervention should the nurse implement next? Prepare the client to return to the operating room. 17. A client with carcinoma of the lung is complaining of weakness and has a serum sodium level 117 mEq/L. Which nursing problem should the nurse include in this client's plan of care? Fluid volume excess. 18. A female client enters the clinic and insists on being seen. She is weak, nervous, and reports a racing heartbeat and recent weight loss of 15 pounds. After ruling out substance withdrawal, the healthcare provider suspects hyperthyroidism and admits her for further testing. Which action should the nurse implement? Space the client's care to provide periods of rest. 19. The nurse is teaching a client with glomerulonephritis about self-care. Which dietary recommendations should the nurse encourage the client to follow? Restrict protein intake by limiting meats and other high-protein foods. 20. An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.) • Check his fingerstick glucose level Assess his skin temperature and moisture Measure his pulse and blood pressure 21. A client with Cushing's syndrome is recovering from an elective laparoscopic procedure. Which assessment finding warrants immediate intervention by the nurse? Irregular apical pulse. 22. An adult woman with primary Raynaud phenomenon develops pallor and then cyanosis of her fingers. After warming her hands, the fingers turn red and the client reports a burning sensation. What action should the nurse take? Continue to monitor the fingers until color returns to normal. 23. A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first? Assess lower extremity circulation. 24. The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure? The client's blood pressure reading is 184/88 mm Hg. 25. A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse? Further decline in level of consciousness. 26. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client? Keep the drainage bag lower than the level of the bladder. 27. Which client has the highest risk for developing skin cancer? A 65-year-old fair-skinned male who is a construction worker. 28. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? Daily weight. 29. A female client who was involved in a motor vehicle collision is admitted with a fractured left femur which is immobilized using a fracture traction splint in preparation for an open reduction internal fixation (ORIF). The nurse determines that her distal pulses are diminished in the left foot. Which interventions should the nurse implement? (Select all that apply.) Verify pedal pulses using a doppler pulse device Monitor left leg for pain, pallor, paresthesia, paralysis, pressure Evaluate the application of the splint to the left leg 30. A male client with Herpes zoster (shingles) on his thorax tells the nurse that he is having difficulty sleeping. What is the probable etiology of this problem? Pain. 31. When planning care for a client newly diagnosed with open angle glaucoma, the nurse identifies a priority nursing diagnosis of, "visual sensory/perceptual alterations." This diagnosis is based on which etiology? Decreased peripheral vision. 32. A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management? Practice inhaling through the nose and exhaling slowly through pursed lips. 33. A client with cancer is receiving chemotherapy with a known vesicant. The client's IV has been in place for 72 hours. The nurse determines that a new IV site cannot be obtained and leaves the present IV in place. What is the greatest clinical risk related to this situation? Impaired skin integrity. 34. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post anesthesia unit. Before selecting which medication to administer, which action should the nurse implement? Compare the client's pain scale rating with the prescribed dosing. 35. While assisting a female client to the toilet, client begins to have a seizure and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first? Observe for prolonged periods of apnea. 36. A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse implement? Place warm blankets next to the client's feet. 37. During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms? A grandson and his new dog recently visited. 38. 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? Compression of a nerve. 39. The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? (Select all that apply). Skin integrity. Functional ability. Pain scale. 40. A male client tells the clinic nurse that he is experiencing burning on urination, and assessment reveals that he had sexual intercourse four days ago with a woman he casually met. Which action should the nurse implement? Obtain a specimen of urethral drainage for culture. 41. A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is most important for the nurse to monitor which serum laboratory value? Glucose. 42. A client with acquired immunodeficiency syndrome (AIDS) has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse? Diminished lung sounds. 43. An older male client tells the nurse that he is losing sleep because he has to get up several times at night to go to the bathroom, that he has trouble starting his urinary stream, and that he does not feel like his bladder is ever completely empty. Which intervention should the nurse implement? Palpate the bladder above the symphysis pubis. 44. Fluids are restricted to 1,500 ml daily for a male client with acute kidney injury (AKI). He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. Which intervention should the nurse implement? Restrict family visiting until the client's condition is stable. 45. A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse report to the healthcare provider? Jaundiced sclera. 46. Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia (VT). Which finding should the nurse document in the electronic medical record as a therapeutic response to the lidocaine infusion? Decreased frequency of episodes of VT. 47. After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement? Prepare a dose of epinephrine (Adrenalin). 48. The nurse reports that a client is at risk for a brain attack (stroke) based on which assessment finding? Carotid bruit. 49. The nurse is preparing to administer enoxaparin (Lovenox) 135 mg subcutaneously. The medication is available in a cartridge labeled 150 mg/ml. How many ml should the nurse administer? (enter numeric value only. If rounding is required, round to the nearest tenth.) 1.9 mL. 50. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take? Collect the blood sample. 51. A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement? Elevate head of bed 60 to 90 degrees. 52. A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement? Use an automated BP machine to monitor for hypotension. 53. The wife of a client with Parkinson's disease expresses concern because her husband has lost so much weight. Which teaching is best for the nurse to provide? Invite friends over regularly to share in mealtimes. 54. A client who was discharged 8 months ago with cirrhosis and ascites is admitted with anorexia and recent hemoptysis. The client is drowsy but responds to verbal stimuli. The nurse programs a blood pressure monitor to take readings every 15 minute. Which assessment should the nurse implement first? Evaluate distal capillary refill for delayed perfusion. 55. A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions? Monitor urinary stream for decrease in output. 56. A client diagnoses with stable angina secondary to ischemic heart disease has a prescription for sublingual (SL) nitroglycerin (NTG). The nurse should tell the client to follow which instructions if chest pain is not relieved after taking 3 NTG tables 5 min apart? Call 911 pain is unrelieved and chew a tablet of aspirin 325mg. 57. An adult woman with Grave’s disease is admitted with severe dehydration is currently restless and refusing to eat. Which action is most important for the nurse to implement? Maintain a patent intravenous site. 58. 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? Assess the client for symptoms of hyponatremia 59. The nurse assesses the dressing of a client who has just returned from post- anesthesia and finds that the dressing is wet with a moderate amount of bright red bloody drainage. What action should the nurse take? Call surgery and request that the surgeon see the wound prior to leaving the hospital. 60. While the home health nurse is making a home visit, a client with a history of seizures demonstrates tonic-clonic seizure activity. What action should the nurse implement first? Protect the client’s head with a pillow. 61. The nurse has conducted a cancer prevention community education program. In evaluating the participant’s understanding of the carcinogens, what statement indicated an accurate understanding? Substances that change a cell so that it becomes cancerous are potential sources of cancer. 62. The nurse discontinues a continuous IV heparin infusion for a male client on a strict bedrest, and is now preparing to administer the client’s first dose of enoxaparin (Lovenox). Prior to giving this subcutaneous injection, which assessment finding requires additional intervention by the nurse? The client states that his right calf is aching and wants pain medication. 63. 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? Administer initial dose of broad-spectrum antibiotic. 64. A client is admitted to the ED with anaphylactic shock. What treatment should the nurse prepare to do? An intravenous vasoconstricting agent. 65. The nurse is assessing a client who was admitted 24hrs ago to the critical care unit following a motorcycle collision. Which client finding requires intervention by the nurse to reduce the risk for a complication related to increased ICP? Change of pCO2 to 55 mm Hg (acidic) following ventilator setting adjustment. 66. A male client with skin grafts covering full-thickness burns on both arms and legs is scheduled for a dressing change. The client is nervous and requests that the dressing change be skipped this time. What action is most important for the nurse to take? Encourage the client to express his anxiety. 67. Which instruction should the nurse include when teaching plan of a client with portal hypertension and esophageal varices? Use stool softeners to avoid straining at stool. 68. A client has an absolute neutrophil (ANC) of 500 mm3 (0.5 x 103/L) after completing chemotherapy. Which intervention is most appropriate? Place the patient in protective isolation. 69. A client with a liver abscess undergoes surgical evacuation and drainage of the abscess. Which laboratory value is most important for the nurse to monitor following the procedure? White blood cell count. 70. A male client with bilateral carpal tunnel syndrome reports to the nurse that the pain and tingling he is experiencing worsens at night. What client teaching should the nurse provide? Wear braces as both wrists during the night. 71. A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse? Urine leaking around the meatus. 72. An adult female client is diagnosed with restless leg syndrome and is referred to the sleep clinic. The healthcare provider prescribes ferrous sulfate (feosol) 325 mg PO daily. Which laboratory values should the nurse monitor? Serum iron and ferritin. 73. A client returns to the unit following a suprapubic prostatectomy. He has a three-way catheter in place with a continuous bladder irrigation infusing. Which assessment finding warrants immediate intervention by the nurse? Schedule an appointment for the client to see the healthcare provider. 74. During preoperative teaching for a male client scheduled for repair of an inguinal hernia, the client tells the nurse that he has had several surgeries and understands the need to perform coughing and deep breathing exercises after surgery. How should the nurse respond? Explain that coughing should be avoided. 75. A client with ulcerative colitis is admitted to the medical unit during an acute exacerbation. The nurse should instruct the unlicensed personnel (UAP) to report which finding related to the client's bowel movements? Stool with fatty streaks or blood in the stool. 76. Nurse is evaluating a male client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behavior indicates that the client is adhering to the eating plan? Enjoy fat free yogurt as an occasional snack food. 77. An adult client is admitted with flank pain and is diagnosed with acute pyelonephritis. What is the priority nursing action? Administer IV antibiotics as prescribed. 78. An adult client is admitted with diabetic ketoacidosis (DKA) and a urinary tract infection (UTI). Prescriptions for intravenous antibiotics and an insulin infusion are initiated. Which serum laboratory value warrants the most immediate intervention by the nurse? Potassium of 2.5 mEq/L. 79. The healthcare provider prescribes epoetin alfa (Procrit) 8,200 units subcutaneously for a client with chronic kidney disease (CKD). The 2 mL multidose vial is labeled, “Each 1 mL of solution contains 10,000 units of epoetin alfa.” How many mL should the nurse administer? 1.8 mL. 80. An older male client with long-standing lung diseases is admitted to the medical unit for treatment of a pulmonary infection. In assessing for signs of increasing hypoxia, which actions should the nurse include? (select all that apply). Check for changes in mentation. Observe color of skin and nail beds. Assess breathing patterns. 81. A patient suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in the patient's plan of care? Continuous cardiac monitoring. 82. The nurse assists a male client with Parkinson’s disease (PD) to ambulate in the hallway. The client appears to “freeze” and then carefully lifts one leg and steps forward. He tells the nurse that he is pretending to step over a crack on the floor. How should the nurse respond? Confirm that this is an effective technique to help with ambulation. 83. In assessing a client with ulcers on the lower extremity, which findings indicate that the ulcers are likely to be of venous, rather than arterial, origin? Irregular ulcer shapes and severe edema. 84. A client with acute renal injury (AKI) who weighs 50 kg and has potassium level of 6.7 mEq/ L (6.7 mmol/L) is admitted to the hospital. Which prescribed medication should the nurse administer first? Sodium polystyrene (Kayexalate) 15 grams PO. 85. An older adult with heart failure is hospitalized during an acute exacerbation. To reduce cardiac workload, which intervention should the nurse include in the client’s plan of care? Provide a bedside commode for toileting. 86. Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement? Auscultate bowels sounds. 87. The nurse reviews the laboratory results of a client during an annual physical examination and identifies as a positive guaiac test of stool. Which additional serum laboratory test result should the nurse review? Platelet count. 88. An older female client with long term type 2 diabetes mellitus (DM) is seen in the clinic for a routine health assessment. To determine if the client is experiencing any long-term complications of DM, which assessments should the nurse obtain? (Select all that apply). Serum creatinine and blood urea nitrogen (BUN). Sensation in feet and legs. Skin condition of lower extremities. Visual acuity. 89. An older adult man recently diagnosed with chronic obstructive pulmonary disease (COPD) is admitted with shortness of breath. The nurse observes the client sitting upright and leaning over the bedside table, using accessory muscles to assist in breathing. What action should the nurse take? Instruct the client in pursed lip breathing techniques. 90. A client's telemetry monitor indicates ventricular fibrillation (VF). After delivering one counter shock, the nurse resumes chest compression. After another minute of compressions, the client's rhythm converts to supraventricular tachycardia (SVT) on the monitor. At this point, what is the priority intervention for the nurse? Give IV dose of adenosine rapidly over 1-2 seconds. 91. An adult female with multiple sclerosis (MS) fells while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first? Complete head to toe neurological assessment. 92. A hospitalized client with chemotherapy-induced stomatitis complains of mouth pain. What is the best initial nursing action? Administer a topical analgesic per PRN protocol. 93. A male client who had abdominal surgery 5 days ago, and hospitalized because of a surgical wound infection, tells the nurse that he feels like his insides just spilled out when he coughed. What action should the nurse take first? Visualize the abdominal incision. 94. The nurse is preparing a client for discharge who recently diagnosed with Addison's disease. Which instruction is most important for the nurse to include in the client's discharge teaching plan? Take prescribed cortisone accurately. 95. When providing care for a client following a bronchoscopy, which assessment finding should the nurse immediately report to the healthcare provider? Dyspnea and dysphagia. 96. To reduce the risk for pulmonary complication for a client with amyotrophic lateral sclerosis (ALS), what interventions should the nurse implement? (select all that apply). Teach the client breathing exercises. Perform chest physiotherapy. Encourage use of incentive spirometer. 97. In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? Increased restlessness. 98. A male client who reports feeling chronically fatigued has a Hgb of 11.0 grams/dl, hematocrit of 34%, and microcytic and hypochromic red blood cells. Based on these findings, which dinner selection should the nurse suggest to the client? Beef steak with steamed broccoli and orange slices. 99. Two days following abdominal surgery a client complains of cramping abdominal pain, and the nurse's inspection of the abdomen indicates slight distention. Which action should the nurse implement first? Auscultate abdomen. 1. The healthcare provider prescribes and IV solution of regular insulin (Humulin-R) 100 units in 250 ml of 0.45% saline to infuse at 12 units/hour. The nurse should program the infusion pump to deliver how many ml/hour? 12 Units x 250 / 100 = 30 mL/hr. 2. A nurse is caring for a client with Diabetes Insipidus (DI). Which data warrants the most immediate intervention by the nurse? Serum sodium of 185 mEq/L. 3. Which instruction should the nurse include in the discharge teaching for a client who has gastroesophageal reflux? Teach the client to elevate the head of the bed on blocks. 4. The clinic nurse is reviewing strategies for blood glucose monitoring with a client who is newly diagnosed with diabetes mellitus. When helping the client select a blood glucose meter, which client assessments should the nurse complete? Manual dexterity and visual acuity. 5. A fair-skinned female client who is an avid runner is diagnosed with malignant melanoma, which is located on the lateral surface of the lower leg. After wide margin resection, the nurse provides discharge teaching. It is most important for the nurse to emphasize the need to observe for changes in which characteristic? Appearance of any moles. 6. A male client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about the dietary restriction he should follow. In discussing fluid intake, the nurse should include which type of fluid limitation? Tea and hot chocolate. 7. A client who is receiving chemotherapy is vomiting. Which nursing intervention should the nurse implement first? Administer ondansetron hydrochloride (Zofran). 8. The nurse calculates the body mass index (BMI) for an obese adult. Which additional assessment finding places the client at high risk for cardiac disease? Large waist circumference with central fat. 9. An adult male client is admitted for Pneumocystis carinal pneumonia (PCP) secondary to AIDSs. While hospitalized, he receives IV pentamidine isethionate therapy. In preparing this client for discharge, what important aspect regarding his medication therapy should the nurse explain? It will be necessary to continue prophylactic doses of IV or aerosol pentamidine every month. 10. A client who has a history of long-standing back pain treated with methadone (Dolophines), is admitted to the surgical unit following urological surgery. Which modifications in the plan of care should the nurse make for this client's pain management during the postoperative period? Maintain client's methadone, and medicate surgical pain based on pain rating. 11. When planning care for a client with rheumatoid arthritis, which intervention is most important for the nurse to include in the plan of care? Implement measures to manage chronic pain. 12. A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucous production while exercising. Which action should the nurse implement? Determine if the client is using an inhaler before exercising. 13. An older woman who experienced a cerebrovascular accident (CVA) has difficulty with visual perception and she only eats half of the food on her meal tray. Her family expresses concern about her nutritional status. How should the nurse respond to the family's concern? Demonstrate the use of visual scanning during meals to the client and family. 14. A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with a severe dehydration. Which assessment finding warrants immediate intervention by the nurse. Gastroccult positive emesis. 15. Three days after a female client with multiple sclerosis (MS) is admitted to the hospital with a severe urinary tract infection, she reports experiencing double vision. Which intervention should the nurse implement? Patch one eye and then the other every few hours. 16. The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain? Eating patterns and dietary intake. 17. A male client with chronic kidney disease (CKD) is beginning his first hemodialysis 3 times per week. Which short-term goal is most important for the nurse to include in the plan of care for this client as he begins the series? Verbalizes understanding of the reasoning for dialysis. 18. An older client arrives at the outpatient eye surgery clinic for a right cataract extraction and lens implant. During the immediate postoperative period, which intervention should the nurse implement? Provide an eye shield to be worn while sleeping. 19. An ER nurse is completing an assessment on a patient that is alert but struggles to answer questions. When she attempts to talk, she slurs her speech and appears very frightened. What additional clinical manifestation does the nurse expect to find if Nancy's symptoms have been caused by a brain attack (stroke)? A carotid bruit. 20. Which clinical manifestation further supports an assessment of a left-sided brain attack? Global aphasia. 21. A hematoma at the femoral insertion site for cardiac catheterization can produce compression of the femoral artery that results in tingling and numbness and requires immediate intervention to prevent permanent distal tissue ischemia. 22. Eczema question – answer is moisturizing creams. 23. External fixation device question – answer is assess the foot’s perfusion. 24. When caring for a client with nephrotic syndrome, which assessment is most important for the nurse to obtain? Daily weight. 25. A female client with possible acute renal failure (ARF) is admitted to the hospital and mannitol (Osmitrol) is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? Obtain vital signs and breath sounds. 26. When preparing a patient for a non-contrast computed tomography (CT) scan STAT, what nursing intervention should the nurse implement? Explain that the client will not be able to move her head throughout the CT scan. 27. A neurologist prescribes a magnetic resonance imaging (MRI) of the head STAT for a patient. Which data warrants immediate intervention by the nurse concerning this diagnostic test? Right hip replacement. 1) 28. After a transurethral resection of the prostate (TURP), a client has blood urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter’s patency. Which action should the nurse implement? Clamp the catheter for 30 min prior to irrigating with saline. 29. A male client with a history of asthma reports having episodes of bronchoconstriction and increased mucus production while exercising. which action should the nurse implement? Determine if rescue inhaler is being used first during an acute episode. 30. A client with unstable asthma had an emergent cardiac catheterization. which complication should the nurse monitor for in the initial 24 hours after the procedure? Thrombus formation. 31. A client with CKD arrives at the clinic reporting shortness of breath on exertion and extreme weakness vital signs are temperature 100.4 F (38C), heart rate 110 beats/min, respirations 28 breaths/min, and blood pressure 175/98 mmHg. The client usually receives dialysis three times a week but missed the last treatment. STAT blood specimens are sent to the laboratory for analysis. Which laboratory result should the nurse report to the healthcare provider immediately? Potassium 6.5. 32. Which food is most important for the nurse to encourage a male client with Osteomalacia to include in his daily diet? Fortified milk and cereals. 33. A client with pheochromocytoma reports the onset of a severe headache. The nurse observes that the client is very diaphoretic. Which assessment data should the nurse obtain next? Blood pressure. 34. What information should the nurse include in the teaching plan of a client diagnosed with gastroesophageal reflux disease (GERD)? Do not lie down for 2 hours after eating. 35. A client with draining skin lesions of the lower extremity is admitted with possible methicillin-resistant staphylococcus aureus (MRSA). Which nursing interventions should the nurse include in the plan of care? Select all that may apply. Institute contact precautions for staff and visitors. Send wound exudate for culture and sensitivity. Monitor the clients WBC count. 36. A woman who works as a data entry clerk is concerned as to how recent diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction should the nurse provide this client? Use a space heater to keep the workspace warm. 37. The family suspects that AIDS dementia is occurring in their son who is HIV- positive. Which symptom confirms their suspicions? A change has recently occurred in his handwriting. 38. The nurse is providing discharge instructions to a client who is receiving prednisone (Deltasone) 5 mg PO daily for a rash due to contact with poison ivy. Which symptom should the nurse tell the client to report to the healthcare provider? Rapid weight gain. 39. A 70-year-old male client with type 2 diabetes mellitus is hospitalized with an infected ulcer on his great right toe which instruction should the nurse emphasize during discharge teaching? Check the insides and linings of all enclosed shoes before putting the shoes on. 40. The nurse determines that a client who arrives in the preoperative holding area before surgery is allergic to bananas. Which action should the nurse Implement prior to taking the client into the operative area? Banana allergy often also have latex allergy or it may say Replace latex- containing devices in the OR with alternative synthetic materials. 41. A client with type 2 diabetes mellitus is admitted to the hospital for uncontrolled DM. One therapy is initiated with an initial dose of Humulin N insulin at 0800. at 1600, the client complains of diaphoresis, rapid heartbeat, and feeling shaky. What should the nurse do first? Determine the client’s current glucose level. 42. When explaining dietary guidelines to a client with acute glomerulonephritis, which instruction should the nurse include in the dietary teaching? Restrict sodium intake. 43. A client with an acute exacerbation of rheumatoid arthritis has localized pain and inflammation of the fingers and feet; swelling, redness, and restricted joint motion; and reports feeling fatigued. Which nursing diagnosis has the highest priority for this client? Pain related to joint inflammation. 44. A client uses triamcinolone (Kenalog), corticosteroid ointment, to manage pruritus caused by chronic skin rash. The client calls the clinic nurse to report increased arrhythmia with purulent exudate at the side. Which action should the nurse implement? Schedule an appointment for the client to see the healthcare provider. 45. A female client who received partial thickness and full-thickness burns over 40% of her body in a house fire is admitted to the inpatient Burn Unit. What fluids should the nurse prepare to administer during the acute phase of the clients burn recovery? Ringer’s Lactate. 46. A client with Stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a one-to-ten scale. Which intervention should the nurse implement? Administer opioid and non-opioid medication simultaneously. 47. A male client complains of pain in his right calf, and the nurse determines that his calf is edematous and deep red. What intervention has the highest priority? Tell the client to remain in bed. 48. A male client with pernicious anemia takes supplemental folate and self- administered his monthly vitamin B12 injections. He reports feeling increasingly fatigued which laboratory value should the nurse review? Complete blood count. 49. The nurse is assessing a client who has tinea pedis. which question will allow the nurse to gather further information about this condition? Do you see any improvement when using Tolnaftate? 50. A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated. How should the nurse respond? Ask the client if the healthcare provider has giving her any information about the classification of her cancer. 51. An older client is admitted after falling while walking. The left leg is externally rotated and shorter than the right leg, and the client is having severe pain and tingling in the left foot. The nurse is unable to palpate the left pedal pulses. which action is most important for the nurse to implement? Use a doppler to assess bilateral pedal pulses. 52. A male client in skeletal traction tells the nurse that he is frustrated because he needs help repositioning himself in bed. Which intervention should the nurse implement? Provide an overhead trapeze to the bed for the client to use. 53. The nurse is assessing clients in an outpatient diabetic Clinic. Which entry provides the best medication that a client is adhering to the prescribed diabetic regimen? Hemoglobin A1C of 6.2%. deficits. Which action should the nurse include in the clients plan of care? Teach the client techniques for performing intermittent catheterization. 55. A client with Guillain-Barre syndrome has paralysis of all extremities and requires mechanical ventilation. The nurse observes that the client is not blinking. Which action should the nurse implement? Protect cornea with lubricant and eye shields. 56. A client with hypothyroidism reports difficulty falling asleep because of feelings of depression. Which action should the nurse implement? Review most recent thyroid function test results. 57. The nurse is teaching the importance of an exercise regimen that includes walking daily or a group of clients with asthma, chronic bronchitis, and emphysema at a pulmonary rehabilitation Clinic. Which rationale should the nurse include when motivating the clients? Daily exercise and walking enhances cardiovascular fitness. 58. Healthcare worker with no known exposure to tuberculosis has received a Mantoux tuberculosis skin test. The nurses’ assessment of the test after 62 hours indicates 5 mm of arrhythmia without induration. What is the best initial nursing action? Document negative results in the client's medical record. 59. When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include? Eat a high-fiber diet and increase fluid intake. 60. A female client who fractured her right femur when she fell at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse that she needs to urinate, which intervention should the nurse implement? Maintain traction while the client uses a female urinal. 61. The home health nurse instructs the client with chronic obstructive pulmonary disease (COPD) to report any respiratory infection to the healthcare provider as soon as possible. Which statement describes the first signs of infection this client should report? Change in color of sputum. 62. An adult client who had a gastric bypass surgery 2 weeks ago, is admitted with possible anastomosis leakage. The client’s abdomen is tender to touch, and their vital signs are: temp 101 F (38.3C), heart rate 130 beats/minute, respiratory rate 26 breaths/minute, and the blood pressure 100/50 mmHg. Which intervention is most important for the nurse to include in the client’s plan of care? Strict IV fluid replacement. 63. 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? Lactate Ringer’s. 64. 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.) Check a blood sample for glucose level. Report any changes in blood pressure. Observe respiratory rate and pattern. 65. A client with sickle cell anemia develops a fever during the last hour of administration of a unit of packed red blood cell. When notifying the healthcare provider what information should the nurse provide first using the SBAR communication process? Explain specific reason for urgent notification. 66. A client subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next? Collect a clean catch specimen. 67. A client tells the nurse that her biopsy results indicate that the cancer cells are well differentiated How should the nurse respond? Ask the client in the healthcare provider has giving her any information about the classification of her cancer. 68. A client with a chronic kidney disease is treated on hemodialysis. During the 1treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first? Stop dialysis treatment. 69. After several days of coughing and taking acetaminophen to treat temperatures 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 interventions should the nurse implement first? Obtain a fingerstick glucose. 70. The nurse learns during report that a postoperative client has a paralytic ileus. To monitor the status of this problem, what assessment should the nurse perform? Bowel sounds. 71. An older adult client with heart failure (HF) begins to experience nausea, vomiting, blurred vision and mild confusion. What information is most important for the nurse to obtain? Current medications. 72. The nurse is preparing an older client for discharge following cataract extraction. Which instructions should the nurse include in the discharge teaching? Avoid straining at stool, stooping, or lifting heavy objects. 73. An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse’s response should be based on which information about assistive devices? They decrease the risk for joint trauma. 74. When a nurse is caring for a client with acute hypothyroidism, which serum laboratory value requires immediate intervention? Serum sodium 122 mEq/L. 75. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use? Explain that the client may be placed in five positions. 76. The nurse is visiting an older client who is homebound. Which finding about the client’s nutritional status requires additional follow-up? Ate approximately 1,200 calories daily for the past two weeks. 77. A client with diabetes mellitus is admitted with an upper respiratory infection. Which changes in blood glucose management should the nurse tell the client to expect? Increased oral fluid intake. 78. Following an ileal conduit urinary diversion, a male client voices several complaints. Which finding indicates to the nurse that he is experiencing a complication? A dark purplish colored stoma. 79. The nurse is preparing discharge instructions for an older female client who is going home after a hip replacement. The client tells the nurse that she can hardly wait to get home and see her cat. Which instruction regarding the cat is most critical to the client’s safety at home? Do not bend over and pick up the cat. Teach him to jump up so that you can reach him. 80. The nurse is caring for an older client who is admitted due to a change in mental status after two days of nausea and vomiting. The client’s home medications include subcutaneous insulin, a daily antihypertensive, and a daily diuretic. Which intervention should the nurse implement first? Obtain a capillary blood glucose level. 81. The practical nurse (PN) reports to the charge nurse that a client who is receiving parenteral nutrition (PN) has a capillary glucose of 365 mg/dL. What action should the charge nurse implement? Determine if the client has a sliding scale insulin prescription. 82. The older female client experiences an exacerbation of her heart failure after eating Asian food at a restaurant with her family. The telephone triage nurse should encourage the family to bring the client to the emergency room immediately for which complaint? Dizziness and confusion. 83. Which outcome should the nurse use to evaluate the effects of Buck’s traction for a client with a fractured left hip? A palpable left dorsalis pedal pulse and the left foot is warm to touch. 84. What outcome state best evaluates the effective use of an incentive spirometer? Client’s breath sounds are clear to auscultation bilaterally. 85. The nurse is caring for a client who has thick, sticky bronchial secretions. What intervention should the nurse implement to maintain a patent airway? Give the client a glass of water hourly while awake. 86. An older adult is transferred to the hospital with anorexia, nausea, vomiting, and confusion. The client was started on oral digoxin (Lanoxin) 0.25 mg, furosemide (Lasix) 40 mg, and potassium (K-Dur) 10 mEq 3 months ago. Which action should the nurse take first? Apply a cardiac telemetry monitor. 87. An older client receives a prescription for hydrocodone bitartrate 5 mg/ acetaminophen 500 mg (Vicodin) 1 to 2 tablets q4h PRN pain. Which laboratory test findings indicate to the nurse that only 1 tablet should be administered? Blood urea nitrogen (BUN) 60 mg/dL and creatinine (CR) 4 mg/dL. 88. When assessing a client for risk factors related to hepatitis C, what information is most important for the nurse to obtain from a client who reports a history of multiple blood transfusions? If the individual experienced a blood transfusion reaction. 89. To ensure client adherence to the postoperative regimen, what content is most important for the nurse to include in the postoperative teaching? You will need to get out of bed the day after surgery. 90. Which nursing intervention should be implemented for a client with dysphagia and left-sided paresis following a stroke? Ensure the client sits erect while eating. 91. During the admission interview, an older client answers some questions inappropriately. The nurse notes that a hearing aid is in one ear. Sit with the light of the window behind you ask you speak. 92. The nurse assesses an adult male client 24 hours following abdominal surgery and finds that his blood pressure is 98/40 mm Hg, he is tachycardiac, restless, and irritable. What action should the nurse take first? Check under his back for evidence of bleeding. 93. In providing discharge teaching to a client with chronic obstructive pulmonary disease (COPD), which instruction is most important for the nurse to emphasize? Notify the healthcare provider of any change in sputum color. 94. Analysis of a client’s renal calculi reveals that they are formed from uric acid. What dietary instruction should the nurse include in the teaching plan of the client? Encourage the client to eat low-purine foods and avoid foods such as shellfish and organ meats. 95. The nurse is planning care for an older adult male who experienced a cerebrovascular accident several weeks ago. Because of his expressive aphasia, the client often becomes frustrated with the nursing staff. Which intervention should the nurse implement? Ask the client simple questions. 96. The nurse is developing a 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? The client’s hemoglobin A1C will be less than 7.0% in 3 months. 97. A chest tube is inserted for treatment of a pneumothorax and is attached to a disposable three-chamber drainage system. During the night, the client becomes disoriented, climbs out of bed, and accidentally knocks the system down, causing it to open and break the seal. Which action should the nurse take first? Place the end of the tube in a container of sterile water. 98. A client newly diagnosed with Type 2 diabetes mellitus (DM) receives a prescription for captopril 50 mg PO BID. The client has no history of hypertension, and the baseline blood pressure (BP) is 132/78 mm Hg. Which action should the nurse implement? Administer antihypertensive medication as prescribed. 1. An adult male with hypertension cannot control his blood pressure with oral medications, so he is admitted to the hospital for antihypertensive management and further evaluation. Laboratory findings include an elevated blood urea nitrogen (BUN), serum creatinine, and white blood cell count. When the client becomes dyspneic and reports heart palpitations, his heart rate is 150 beats/minute. Which intervention should the nurse implement? Initiate telemetry and supplemental O2. 2. The home health nurse has determined that an 80-year-old client has a priority nursing problem of altered nutrition. To assess the client’s functional ability related to the problem, which action should the nurse implement? Observe the client preparing a meal at home. 3. An elderly insulin-dependent male client arrives at the diabetic clinic complaining that his toenails are too long. The nurse notes that his toenails are very thick, scaly and crusty. Some are so long that they are piercing the next toe. What actions should the nurse take? Check his feet for cuts or injury, then refer him to a foot specialist for nail trimming. 4. 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? Maintain the current IV antibiotic schedule. 5. On the second postoperative day a client reports increasing abdominal pain. Assessment findings include a distended abdomen with absent bowel sounds. What interventions should the nurse anticipate implementing? Insertion of a nasogastric tube. 6. The healthcare provider prescribes the nonsteroidal anti-inflammatory drug (NSAID) naproxen (Naprosyn) 500 mg PO twice a day for a client with osteoarthritis. During follow-up visit one month later, the client tells the nurse, “The pills don’t seem to be working. They are not helping the pain at all.” Which factor should influence the nurse’s response? NSAID response is variable and another NSAID may be more effective. 7. The nurse is caring for a client who is 3 hours postoperative who also received hydromorphone IV 30 minutes ago for severe pain. On entering the client’s room the nurse notes the most recent blood pressure reading of 88/56. The client’s respiratory rate is now 14 breaths/minute and pulse rate is 94 beats/minute. Which assessment should the nurse complete next? Level of consciousness. 8. An older adult man who is legally blind in both eyes and who is taking diuretics requests assistance to the bathroom. Which interventions should the nurse implement? Provide client with a urinal. 9. While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client’s plan of care? Implement precautions when the client is judging distances during transfers. 10. The surgical team is ready to make the surgical incision for a client who is having a right below-the-knee amputation. Which actions is most important for the circulating nursing nurse to take first? Call a surgical team time-out to verbalize the identity of the client, extremity, and procedure. 11. An adult female client, who is an office working, comes to the occupational health clinic with an edematous right leg twice the size of the left leg. The client states that she is otherwise healthy, smokes 2 packs of cigarettes a day, and takes birth control pills on a regular basis. What initial nursing action should the occupational health nurse take? Check the leg for warmth and erythema. 12. When establishing a therapeutic environment for an older adult client, which interventions is most important for the nurse to implement? Allow additional time to complete tasks. 13. Following a small bowel resection, an older adult has a new colostomy and a midline abdominal dressing. The client is using a PCA pump for pain and is currently confused and uncooperative. Which interventions should the nurse implement? Reorient the client to person, place, and time. 14. After placing a client who is having a seizure in the side-lying position, which intervention should the nurse implement? Remove objects that could cause injury. 15. The nurse is pouring a bottle of sterile solution into a container on a sterile field that is set up on a client’s bedside table. Which action is in keeping with the principles of surgical asepsis? Avoid spilling or splashing the solution when pouring. 16. Several days after receiving a report of elder abuse on a nursing home unit with high staff turnover, the nurse manager identifies numerous discolorations on the arms and legs of one of the residents. What action should the nurse manager take first? Ask the client how the bruises occurred. 17. The intracranial pressure of a brain injured client who is on a ventilator has increased from 15mm hg to 25mmhg within the last 30minutes. The client is beginning to flex all extremities intermittently. Based on these findings, which immediate action should the nurse take? Assess the patency of the client artificial airway. 18. Which changes in lab values would indicate to the nurse that treatment for gout is successful. Decreased serum uric acid. 19. The home health nurse is caring for a client with Parkinson disease who is beginning to experience swallowing difficulties. Which intervention should the nurse include for this client? Encourage the client and his family to provide a semi-solid diet with thick liquids. 20. A young adult male client has a diagnosis of epididymitis and a positive culture for E-coli. Which information should the nurse include is his teaching plan? Avoid penile contact with the rectal area. 21. A young adult is burned when wearing a shorts that were stained with lighter fluid that started immediately. Without intubating the severe burn client, what should the nurse implement first? Place sterile bandage on both wrist. 22. Which findings should the nurse document as a primary manifestation of osteoporosis in an older woman? Loss of height over time. 23. An adult male who in an insulin dependent diabetes is admitted to the hospital because of recurrent headache when the client stiffens and begins to seize which intervention is most important for the nurse to implement. Pad all side rail with available pillows and blankets. 24. Following the administration of intravenous regular insulin to a client diagnosed with hyperkalemia the nurse should expect which outcome to occur. A temporary shift of potassium into the cells. 25. A female client returns to the clinic after being treated for chlamydia with Azithromycin IM and reports that she still has symptoms. The HCP obtains a swab of the discharge from the cervix for testing for chlamydia. The client reports maintaining a monogamous relationship when the laboratory result are positive for the sexually transmitted infection. Which information should the nurse obtain to evaluate the ineffective results of treatment? Ask the client if the complete course of antibiotics was taken. 26. The nurse is preparing to insert an indwelling catheter for a male client who had diabetes and a semi rigid penile implant. After placing the sterile drapes and prepping the meatus the nurse notes that the client penis is erect, which action should the nurse implement? Continue to insert the catheter. 27. A female client with chronic back pain had been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regimen. The client tells the nurse that she does not want to have surgery for a healed intervention and expect that she has not been acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide? Massage and hot pack treatment are less invasive and can provide temporary relief. 28. Prior to initiating peritoneal dialysis, which nursing action is most important for the nurse to implement? Obtain and record the client vital signs. 29. An adult client who had bariatric surgery two month ago has developed stricture. For the past week the client has experienced nausea, vomiting, and is admitted to the hospital for fluid resuscitation at the time for client decease which meds should the nurse administer? Encourage small frequent meals. 30. A client with hepatitis A is complaining of weakness and chronic fatigue, which intervention is most important for the nurse to implement? Ensure the client had scheduled rest periods every 4 to 6 hours during the day. 31. While assessing a client with diabetes mellitus the nurse observes an absence of hair growth on the client’s legs, what findings? Observe the appearance of the skin on the client’s leg. 32. A client is admitted with dehydration resulting from vomiting and diarrhea, the nurse knows that this client is at risk for developing which condition? Cardiac dysrhythmia. 33. A client who has abdominal surgery under general anesthesia is transferred to the anesthesia unit. What are the greatest changes the client may experience? Pneumonia and urinary retention. 34. A client with chronic cirrhosis had esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem? Hematemesis. 35. Following open heart surgery, a female client tells the nurse that she has made a decision to retire from her job of 20-years. Which response is best for the nurse to make? Would you like to talk with the social worker about you retired motions? 36. When assessing a client with serum potassium level of 25 mm Hg. Which intervention is most important for the nurse to implement? Determine apical pulse rate and rhythm. 37. The nurse is conducting discharge teaching for a male client with a prescription for magnesium hydroxide, 15 ml one time per day. His home medication cap is maintained in ounces. How many ounces should he take at each dose? 0.5 ounces. 38. In passing nursing care in the immediate postoperative period which factors had the highest priority in determining the frequent of vital signs assessment? Client’s condition. 39. The nurse is monitoring the capillary glucose every 4 hours of an adult women admitted with diabetes ketoacidosis (DKA). Two hours after receiving 10 unit of regular insulin for a glucose level of 255 mg/ml. the client is perspiring and complaining of shakiness. Which intervention should the nurse implement? Obtain another capillary glucose level. 40. Which prescription for oxygen therapy should the nurse suspect is an error and therefore seek clarification about before implementing? Oxygen per nasal cannula at 8 L/min. for an adult client. 41. The nurse includes the problem of risk for infection in the plan of care for a client with myelosuppression, which laboratory value provide the great support of the suspect problem? Red blood cell count of 3.5. 42. While performing assisted range of motion exercise for a client with osteoarthritis, the nurse notes joint crepitus. Which action should the nurse take? Continue the range of motion exercise. 43. The nurse implements a change in the approach to client care after gathering evidence in support of the new approach. What action should the nurse take next? Consult with a clinical nursing expert. 44. An older client who is agitated dyspnec, orthopneic, and using accessory muscle to breathe is admitted for further treatment. Initial assessment includes a heart rate 128 beats/minutes and irregular, respiration 36 breaths/minutes, blood pressure 168/100 mmhg, wheezes and crackles in all lung fields. An hour after the administration of furosemide 60mg IV, which assessment should the nurse obtain to determine the client response to treatment. (Select all that apply). Skin elasticity, Lung sounds, Urinary output. 45. A client laboratory findings indicate elevation in thyroxine and triodothyronine hormones. The nurse suspect that the client may have hyperthyroidism. Which assessment findings is most often associated with hyperthyroidism? Increased pulse rate. 46. A female client with metastatic breast cancer is admitted with shortness of breath and pleural effusion. The client has a living will and the family is requesting hospice information. Which information should the nurse provide regarding hospice, (select all that apply). Can be provided within comfort of home. Provides comfort, dignity, and emotional support. Hospice services can be initiated prior to discharge. Family members can be involved in the plan of care. 47. A client has a prescription for a viscous compound containing lidocaine HCL and diphenhydramine to relieve the discomfort of mycosis caused by radiation therapy. Which instructions should the nurse provide the client about administration of this prescription? Swish the solution around in the mouth then swallow the remaining solution. 48. When the nurse begins discharge instruction for a client and his spouse, the client who had an above the knee amputation for complication associated with diabetes, tells the nurse that she is not ready to go home and wants to stay in the hospital another day. Which interventions is most important for the nurse to implement? Tell the spouse to wait outside the room so the nurse can interview the client alone. 49. The ESR (sedimentation rate) of a client being treated with corticosteroids for rheumatoid arthritis has decreased. Which explanation should the nurse provide the client to explain this change in lab values? The client disease is currently in a remission. 50. A client who had a cast applied yesterday to the lower left arm comes to the clinic complaining of pain in the casted arm. Which assessment finding is most important for the nurse to identify? Location of burning pain below the cast. 51. The nurse review the laboratory value of a female client with metastasis breast cancer and notes that the client serum calcium level is 14mg/dl. The client is weak, fatigue, and depressed. New prescription includes increasing the rate of intravenous fluid. Which action should the nurse take first? Increase the intravenous fluid as prescribed. 52. A client with hypovolemic shock is admitted to the intensive care unit with an intraosseous (IO) vascular access device placed in the right proximal tibia. The client has received two liters of normal saline and one unit of packed red blood cells through the IO access device since admission. Which assessment finding warrants immediate intervention by the nurse? IO vascular access in place greater than 24 hours. 53. A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Which nursing action has the highest priority in responding to the symptoms of this syndrome? Maintain intravenous therapy. 54. A client with polycystic kidney disease is admitted because of an abrupt onset of massive polyuria. The client is pale, tachycardia, and febrile. Which serum laboratory findings requires immediate intervention by the nurse. Sodium 184mEq/L. 55. The nurse is preparing to administer enoxaparin 90mg subcutaneously daily to a client admitted with a pulmonary embolism. The pharmacy provided a prefilled syringe labelled enoxaparin 100mg/1ml. How many mL should the nurse administer? Numeric value only? 1.9 mL. 56. A client with renal calculi is complaining of severe right flank pain, nausea, and vomiting, which nursing problem has the highest priority? Acute pain related to renal calculi. 57. Magnesium hydroxide, 1.5 ounces PO is prescribed for a client complaining of heartburn. After taking the prescribed dose 3 times today how many mL of magnesium hydroxide has the client ingested? 135 mL. 58. A client tells the nurse I just received good news about my tumor. I have a neoplasm, but it is benign, how should the nurse respond? Reinforce the client’s joy and clarify the typical use of the term neoplasm. 59. A client with acute myogenic leukemia is admitted for chemotherapy using Cytarabine and the antitumor antibiotic Daunorubicin. Which measures are most important for the nurse to implement during the induction stage of chemotherapy? Precaution to prevent infection and bleeding. 60. A client with a medical diagnosis of a ruptured cerebral aneurysm exhibits these symptoms no eye opening, no sound vocalized and flexion to pain (decorticate posturing) when calculating the Glasgow coma scale, which value should the nurse document for this client? 5. 61. Which technique should the nurse used when assessing for early signs of rheumatoid arthritis? Observe the client fingers. 62. While performing a neurovascular assessment distal to a client fracture site. The nurse determines that the client pulse is present, regular and full. Which nursing actions should be taken next? Document the neurovascular assessment as normal. 63. The nurse is assessing a client diagnosed with a medical diagnosis of a Bartholin cyst. Which physical assessment technique should the nurse use to observe the cyst? Place the client in a lithotomy position to perform a pelvic examination. 64. A client returns to the unit following a craniotomy for removal of a brain tumor and is obtunded, but arouses to painful stimuli. Which assessment is most important for the nurse to obtain? Drainage on dressing. 65. Following a transurethral resection of the prostate (TURP) a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? Eliminate all spicy foods from your diet. 66. A male client is admitted to the rehabilitation unit following a cerebrovascular accident, which resulted in paralysis of his right arm. When the nurse enters the room, he is struggling to put on a shirt, and he curses at the nurse. What is the best first response by the nurse? Dressing must be a frustrating experience for you. 67. A young female visits the clinic for primary dysmenorrhea and tells the nurse that she started taking a calcium supplement to reduce her menstrual cramps but quit taking the calcium because it caused constipation. The client wants to know what she can do to relieve her menstrual cramps. Which action should the nurse implement first to address the client’s concern? Question the client about her use of birth control pills. 68. A young adult who suffered a severe brain injury in an automobile collision has been mechanically ventilated for the past three days and has no spontaneous respiratory effort. After serial electroencephalograms reveal no brain activity, the healthcare provider discusses end of life options with the family who agrees to discontinue life support. Which intervention should the nurse implement? Discuss the withdrawal procedure with the family and offer support. 69. The nurse obtains a finger stick blood glucose level utilizing bedside lancet glucose meter equipment from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dl (3.12mmol) at this time. Which intervention should the nurse implement first? Give the client six ounces of non-diet carbonated soda and instruct client to drink it entirely. 70. To achieve maximum mobility and independence for a client multiple sclerosis which intervention is most important for the nurse to implement? Teach strengthening exercise. 71. On the first postoperative day. The nurse finds an older male client disoriented and trying to climb over the bed railing. Previously he was oriented to person place and time on admission. Which intervention should the nurse implement first? Assess the client for pain. 72. A client is admitted to the hospitals with symptoms consistent with a right hemisphere stroke. Which neurovascular assessment require immediate intervention by the nurse? Unequal bilateral hand grip strengths. 73. The nurse is caring for a client with herpes zoster who reports painful red blisters that align from the back along with chest curvature to the anterior chest which intervention is the highest priority for the nurse? Administer antiviral medications. 74. Acute soft tissue injuries (i.e. sprains, strains) provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft- tissue injury? Apply ice intermittently for the first 24 hours. 75. The nurse is caring for an older male client with impaired skin integrity to shearing forces and pressure that is manifested as a draining stage 3 sacral ulcer. Which intervention is most important for the nurse to implement? Ensure that IV fluids are administered as prescribed. 76. An older female resident of a long-term care facility with early stage Alzheimer’s disease frequently wanders into the wrong room. To help this client recognize her room, which intervention should the nurse implement? Place a picture of the client on her door. 77. During an office visit with his primary healthcare provider, a middle-aged adult male describes having symptoms of angina pectoris when doing chores in his yard. Which additional finding should the nurse obtain? A description of chest pain when client is at rest. 78. The nurse is collecting a urine specimen for a client with symptoms related to urethritis. Which collection method should the nurse implement? A clean catch specimen. 79. The nurse is developing a plan of care for a client who reports blurred vision and who is diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client? The client’s daily blood pressure will be less than 140/80 mmHg this month. 80. A client is recovering from a transurethral prostatectomy. Which activity should be limited until after the first postoperative visit with his healthcare provider? Driving a car. 81. Which common physiological change that occurs with aging is likely to influence and older adult’s nutritional status? Diminished sense of smell. 82. A client with a history of gastrointestinal reflux disease (GERD) reports a new onset of painful swallowing to the home health nurse. How should the nurse respond? Measure the client’s vital signs and oxygen saturation immediately. 83. The healthcare provider described Liraglutide 1.2 mg subcutaneously daily for a client with type 2 diabetes mellitus. The liraglutide Pen contains 18 mg of liraglutide and will deliver doses of 0.6 mg, 1.2 mg, or 1.8 mg. When teaching the client about the use of the Liraglutide Pen, how many doses should the nurse tell the client is available in each Pen? (Enter the numerical value only?) 15 mg. 84. A postmenopausal obese female client who smokes who developed an intolerance to fatty foods and believes she is at risk for developing gallbladder problems. Which instruction should the nurse provide to help reduce the client’s risk for gallbladder disease? Join a group weight loss program. 85. An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? Decreased abdominal girth. 86. A male client tells the nurse that he is “very nervous” about the surgery he is scheduled to have in the morning. Which action should the nurse implement first? Explore the client’s perception of the impending surgery. 87. During an annual exam at the clinic, a 70-year-old female client reports that she is more fatigued than she has been in the last couple of months. Based on the normal aging process, which of this client’s diagnostic study results should the nurse review? (Select all that apply). Thyroid stimulating hormone, complete blood count (CBC), serum electrolytes. 88. An older client with chronic obstructive lung disease (COPD) who is being admitted to an assisted living facility reports chronic constipation. Which action should the nurse implement to promote normal bowel evacuation? Increase intake of fresh fruits and vegetables. 89. To maintain muscle tone and joint mobility of a client with right-side paralysis, which intervention is best for the nurse to implement? Perform range of motion exercises on all extremities. 90. The nurse assesses a client who is newly diagnosed with hyperthyroidism and observes that the client’s eyeballs are protuberant, causing a wide-eyed appearance and eye discomfort. Based on this finding, which action should the nurse include in the client’s plan of care? Obtain a prescription for artificial tear drops. 91. An older adult woman is seen in the clinic 3 months following her diagnosis of type 2 diabetes mellitus (DM). She tells the nurse that she has had a difficult time keeping her blood sugar in control. The nurse reviews the client’s current fingerstick and daily log of blood glucose. Which intervention is most important for the nurse to implement? Review the client’s glycosylated hemoglobin (A1C) level. 92. Following a transurethral resection of the prostate (TURP), a client is discharged from the hospital with an indwelling urinary catheter. Which instruction is most important for the nurse to include in the discharge teaching plan? Avoid driving a car for 2 weeks. 93. A client with a history of chronic renal failure (CRF) has distended neck veins and bibasilar crackles. The nurse and unlicensed assistive personnel (UAP) reposition the client to complete a skin assessment. Which assessment finding warrants immediate intervention by the nurse? Rapid, irregular breathing pattern. 94. The nurse is teaching a client with allergic rhinitis about avoidance of allergens. Which is an important point that should be included in the teaching plans? Ensure air conditioning vents in bedroom remain open. 95. The nurse who works in a long-term care facility applies Erikson’s theory of developmental stages when developing a plan of care for an older female resident with a diagnosis of osteoarthritis. Which nursing intervention should the nurse include to assist the resident to achieve Erikson’s developmental task? Facilitate the resident’s participation in group social activities. 96. The nurse is working with a client who has a new cast for a fractured elbow. Which outcome is the priority? Experiences no peripheral neurovascular dysfunction. 97. A client who had an appendectomy returns to the postoperative unit following recovery from general anesthesia. Two hours after being re-admitted to the unit, the client reports of abdominal pain. Which intervention should the nurse implement at this time? Assess respirations and time of last pain medication. 98. A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid. The client develops a rigid abdomen with rebound tenderness. Which action should the nurse take? Obtain vital sign measurements. 1. The nurse is caring for adult clients on an acute care medical unit. Which assessment warrants immediate intervention by the nurse? Expectoration of pink, frothy sputum in a client diagnosed with heart failure. 2. A client diagnosed with pancreatitis is complaining of severe epigastric pain and intense nausea. After the nurse administers a narcotic and an antiemetic, the client insists on sitting up and leaning forward. Which action should the nurse implement? Position bedside table for client to lean across. 3. After returning to the telemetry unit following a cardiac catheterization, a male client asks the nurse if he can walk because his right foot is asleep. Which action should the nurse take? Observe femoral puncture site for hematoma formation. 4. A client with a right ulnar fracture and cast placement reports an increase in arm pain. Which action should the nurse take next? Assess right radial pulse volume. 5. The nurse encourages ambulation in a postoperative client to reduce the risk for which early postoperative complication? Atelectasis. 6. A client with diabetes mellitus has orthostatic hypotension and syncope secondary to cardiovascular autonomic neuropathy. Which instruction should the nurse give the unlicensed assistive personnel (UAP) to address these problems? Follow fall risk precautions. 7. The nurse receives a report that a male client with Alzheimer’s disease who resides in an assisted living center often becomes agitated and wanders outside. In managing this recurring problem, which action should the nurse take first? Remove the client from the stimulus that is causing agitation. 8. When preparing a client for a bone scan, which nursing action is indicated? Inform the client that following the procedure it will be important to increase the intake of fluids. 9. Which nursing problem has the highest priority when planning care for a client with osteomalacia? Risk for injury. 10. A client who is receiving general anesthesia begins to demonstrate symptoms of malignant hyperthermia. Which intervention should the postoperative nurse prepare to implement first? Prepare for cessation of the anesthesia and the surgical procedure. 11. A young adult client with osteoarthritis of both knees tells the nurse the desire to continue daily walks in the park with friends. How should the nurse respond? Encourage continued maintenance of the walking routine. 12. The nurse is assessing a client who is one-day post parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider, the nurse should prepare for which procedure? Tracheostomy placement. 13. A client experiences residual effects following an acute attack of Meniere’s disease and receives a new prescription for an antihistamine. Which assessment finding indicates that the medication is effective? Ambulates easily without vertigo. 14. An older male with right hemiplegia, dysphagia, and aphasia is admitted to the rehabilitation care facility after experiencing a left cerebral infarct 4 weeks ago. Which is the priority action that the nurse should include in the client’s plan of care? Ensure oral suction equipment is available during meals. 15. A client is receiving a secondary infusion of erythromycin 1 gram in 100 mL dextrose 5% in water (D5W) to be infused in 45 minutes. How many mL/hour should the nurse program the infusion pump? Round to whole number. 133 mL/hr. 16. The nurse administers isophane insulin 1B units subcutaneous at 1630 to a client with diabetes. Which intervention is most important for the nurse to implement? Ensure that the client eats the bedtime snack provided by dietary. 17. When using a Yankauer oral-tip catheter to suction a client’s oropharynx, which action should the nurse take before inserting the catheter into the oropharynx? Turn on the continuous suction device. 18. The nurse observes that a client with Parkinson’s disease (PD) has a mask-like face. Which follow-up assessment is most important for the nurse to implement? Determine ability to chew and swallow. 19. Which laboratory test result is most important for the nurse to report to the surgeon prior to a client’s scheduled abdominal surgery? Serum creatinine of 5 mg/dL. SEEN ON RECENT 2020 HESI 20. Patient is 2 hours from surgery what is the most important thing for preop checklist – answer is surgical consent form is not signed. 21. GERD teaching – answer is bed blocks. 22. Blood pressure drops after abdominal surgery what do you do first? – answer is check the incision. 23. Recently married couple, woman keeps getting UTIs, what do you want to access? – answer is ask about after sex hygiene. 24. Metastatic cancer 10/10 what should you do? – answer is administer analgesics on a fixed and continuous schedule. 25. Aplastic anemia teaching (SALA) – answer is soft toothbrush, monitor for bleeding, transfusion of blood products. 26. Signs of bowel obstruction (SALA) – answer is distended abdomen, high pitch sounds, peristalsis waves. 27. Herpes zoster question, what do you want to ask? – answer is has everyone at home had varicella? 28. Patient with hypernatremia has flank pain what should you implement – answer is strain all the urine. 29. Chemo side effect that warrants intervention – answer is ascites. 30. AKI patient has weight gain of 4.4lbs in 24hrs, what do you want to assess for? – answer is assess pitting edema. 31. What is normal finding for AV fistula? – answer is big vein. 32. Which is a low iron food? – answer is orange or orange juice. 33. A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Acute pain related to biliary spasm. 34. Howshouldthepatient’swifecopewithchangestothislifestyle?Askwhatshe wantsandhowshewouldparticipateinherhusband’scare. 35. TheUAPhasloweredtheheadofthebedforaclientontubefe ding.Whatis thenurse’spriorityaction?Priorityinterventionistoensureclient’sbedis elevatedtoreducetheriskforaspiration. 36. Whatshouldthenurseputontheclientbeforesuctioningtheoralcavity? -Protectivegearshouldbeworn. 37. Howshouldthenurseassessforagagreflex?Placetonguebladeonbackhalf ofthetongue. 38. Whichpositionreducetheriskforinjurytotheclient?Fe tpositioneddirectlyon theflo rinfrontofwhe lchair. 39. Whichmaskisused?Thetopedgeofasurgicalmaskshouldbesecured. 40.Aclientisap roachingneardeath.Whatisthebestresponse?Listenandhelp goalspreservesenseofhopelessness. 41. Whatassessmentforpatient’sgaitandpostureADLs?Assessactivitytolerance beforedeterminingabilitytoperform ADLs. 42. Whatisthemostherapeuticresponsewhenherboyfriendisvisiting?Broad openingthatencouragestotalk. 43. Beforeadministeringpainmedication,whatassessmentisused?Painlevel scale. 44. Apatientisatriskformetabolicsyndromeassociatedwithobesityandphysical inactivityMeasurementofwaistcircumference(skildonebyPN). 45. Whatmaycontraindicatefunction? Significantdecreaseinneurosensory function. 46. Patientwithobstructivesle papneasyndrome(OSAS).Whichteachingis effective?Advicepatientoavoidalcoholicbeverages3hourspriortobedtime. 47. Whatisthefirstcomponentofthecriticalthinkingmodel?Knowledgebase. 48.NasalCan ula-SkinBreakdown?Assessforskindamagethatmayocur. 49.Clientsinabilitytocontroltheurinarysphincterwhentheurgetourinateisfelt. Bedsidecommode2-hourtotrainblad er. 50.Navahopeople?Directeyecontactinterviewisrespect. 51.Patientusesacessorymusclestobreathe.Whatdoesthismean?Indicates increaserespiratoryeffortbytheclient. 52.Whatshouldthenursetalkdofirstwhenspeakingwithpatient?Askfamily memberstoleavethero m. 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