HESI RN EXIT EXAM V4 160 Questions & answers fall 2020,100% CORRECT

HESI RN EXIT EXAM V4 160 Questions & answers fall 2020 1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full strength fee ...

HESI RN EXIT EXAM V4 160 Questions & answers fall 2020 1. A client is receiving a continuous half strength tube feeding at 50ml/hour. To prepare enough of the solution for eight hours, how many ml of full strength feeding will the nurse need? (Enter numeric value only.) 200ml . 25 ml of full strength feeding mixed with 25ml of water provided 50ml of half strength. 25ml × 8 hours= 200m 2. An elderly male client is experiencing urinary incontinence. What is the best initial nursing action? Apply an external condom catheter 3. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication, stating he cannot allow fluids to enter his body once he is cleansed for prayer. What action should the nurse implement? Reschedule administration of the antibiotic until after he completes his prayers 4. UAP using a hand sanitzers that is alcohol for 2 minutes- tell that hand sanitizer use is less > 2min 5.A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child weighs 44 pounds. How many mg of the medication should the nurse administer. Answer: 800 Rationale: First, convert the child’s weight to kg: 44 pounds divided by 2.2pound/kg = 20 kg. Next calculate the mg/kg/dose, 40 mg x 20 kg = 800mg 6. While assisting a postpartum client with perineal care, the nurse notes that her vaginal bleeding spurts rather than trickles from the vagina. The uterine fundus is firm and the client’s vital signs are pulse 88 beats/minute; respiratory rate, 21 breaths/minute; and blood pressure, 104/68 mmHg. What action should the nurse take next? Compare current vital signs with previous vital signs 7. A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? Have the parent take the child for emergency help 8. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of “Altered thought processes, secondary to” what condition? Postpartum psychosis 9. The nurse identifies a priority diagnosis of, “Altered comfort related to menstrual cramps” for a 25-year-old female client. Which self-care activity should the nurse emphasize in the client’s teaching plan? Regular aerobic exercise. 10. Psych/Alcohol/Tylenol overdose antidote – Give Mucomyst 11. Medical Surgical/Laxative abuses – Patient -taking Milk of Magnesium 12. Spiritual/Documentation- Native American – Allow pt’s family to stay in the room 13. Leadership- Interpreter informed consent – Pt should sign the consent 14. Geriatrics/Emergency Rib fractures fall – Pulmonary embolism 15. A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client’s family? Involve the client in usual at home activities 16. Upon assessment, the nurse discovers that a postpartum client has persistent red lochia. Which of the following does this assessment finding suggest to the nurse? Coagulation disorders 17. The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is drained. What action should the nurse complete first? Assess vital signs. 18. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? Clamp the tube 19. The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.; Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What should the nurse implement? Determine if Client B has two units of packed cells available in the blood bank. 20. Triage question with a train wreck The psychiatric nurse is called to a train derailment that was likely caused by a terrorist bomb. In triaging those in need of immediate care, what is the priority ranking for these cases? (arrange these cases in order or priority with the top item requiring the most immediate care and the bottom item requiring the least priority care) A mother and father have just arrived on the . A crying child being held by another passenger. A woman sitting on the ground with a blanket. A middle-aged man who is wandering around 21. (arrange in order) = middle age woman bleeding- woman w/ blanket- child crying- mother and father. (Mine didn’t have a middle age woman bleeding, instead it had an old man wandering and correct order is: wandering old man, woman w/blanket, man holding baby, and mother & father) 22. The nurse in the emergency department is using the simple triage and rapid transport (START) system to assess victims of a hurricane. Which statement correctly describes a yellow disaster tag? A yellow disaster tag means critical injuries and require immediate intervention. 23. What makes a baby frontal bulge or rises= crying 24. Which of the following is a nursing intervention for a 3-year-old client who is going in for sugery in 8 hours that has an order for fluid restriction? Do not allow the child to drink fluids 25. The ear, where do u pull to give a ear drop= it a picture so look it up online (KNOW CHILD & ADULT) (pull the pinnae top side of ear; u can look at a picture to see exactly where pinnae is) (Mine had a picture of ear and put it on the lobule of the pinnae it is the ear lobe). The eye picture asked to find the macula or the fovea centralis (there are 2 prominent spots on the eye – choose the DARK spot to the left not the spot where the light is) 26. Know your serum levels? K- 3.5-5.1, Na – 135-145, Ca 9-11, BUN – 10-20 27. When to use drug for motion sickness drug question – Take Zofran 4 hours before going on trip via sea. 28. Pt with DM= she states that she has to eat lunch rite after the gets her insulin to prevent going to hypoglycemia 29. Electrical burn pt= put him in a cardiac telemetry monitor 30. Which discharge instruction has the greatest priority for the mother of a 6-year-old who was diagnosed with Type 1 diabetes mellitus one week ago? “Always carry a quick source of sugar 31. A nurse working on a mental health unit where a diagnosis of bulimia nervosa is being admitted. Which of the following symptoms would the nurse most likely NOT expect to find with this client? severe over-or under-weight 32. 12yrs pt coming for surgery= have a tour of the OR with the a week before with the family 33. The charge nurse is developing the nursing guidelines for a coronary care unit. Which references is likely to be the most useful in developing these guidelines? The Scope of Standards of Practice from the American Nurses Association 34. Which assessment finding indicates a client's readiness to leave the nursing unit for a Bronchoscopy? On-call sedation administered. 35. A nurse-manager is preparing an annual budget for the unit. Nursing salaries should be included in which component of the budget? Operating budget 36. The nurse has not finished administering routine oral medication because on e client experienced chest pain and another rectal bleeding. It is now dinner time and two clients must be fed. The unlicensed assistive personnel (UAP) is filling water pitchers and the practical nurse (PN) is charting vital signs. Which change in assignments is best for the team leader to make? UAP feed the two clients, PN finish oral medications and RN monitor clients with chest pain and rectal bleeding 37. What is manntiol drug used for? To promote diuresis in prevention and treatment of oliguric phase of renal failure, ICP, IOP, edema in CHF. 38. The nurse is caring for a 42 year old male client who is excreting less sodium than he is consuming. If this condition continues, what complication can the nurse expect this client to exhibit? Edema 39. A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months ago. Because of secondary complications often associated with this illness the nurse plans to carefully assess for signs of what condition? Anemia 40. A pt on a trachea/endotrach with gurgling sound= always pick suctioning 41. Know how the chest tube vac machine works – there is a picture of a chest tube vac machine. Answer this q is very easy just mark the spot on the tube for the amount of 125 ml of drainage 42. Child w/ hemophila= have parent pad the corners of the furniture due to bleeding. 43. You are preparing a plan of care for a client who is a Jehovah's Witness.The client has been told that surgery is necessary. With consideration to the client's religious preferences in development of the plan of care, you would document what? The administration of blood and blood products is forbidden 44. A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for what? Drug toxicity 45. A 68-year-old male has been admitted to the hospital with abdominal pain, anemia and bloody stools. He complains of feeling weak and dizzy. He has rectal pressure and needs to urinate and move his bowels. The nurse should help him onto the bedpan/with the urinal. 46. Nurse writes on the chart of Bob Miller that his nurse, Nurse Smith did not take great care of Mr. Miller. Nurse Jones has committed which of the following? Libel. 47. A client is prescribed Zolpidem (Ambien). Which of the following side effects should be monitored while the client is taking this medication? Daytime drowsiness 48. Translator is working with the nurse who is giving discharge instructions to a non-English client. When the translator restates what the nurse is saying it appears that he is saying much more than what the nurse said. What action should the nurse take? Ask the translator if there is a reason for the lengthiness of the translation 49. Who is at risk for rib fracture - Elderly pt. 50. Splint- Chest compression or chest splint after surgery – they used it for comfort 51. Metabolic syndrome - high cholesterol & high BP (cardiac strip) 52. Know how to prevent SIDS death- Instruct parents to have a firm mattress and avoid laying infant in prone position. 53. Hypertension Diet Teaching- presented with a list of menu choices, the best choice was Baked pork chops, applesauce,etc 54. Teenager attempted suicide and during group session became upset and left group- Go to client room and ask what happened. 55. Client has rapid speech, flight of ideas, 3hrs of sleep- client experiencing high levels Depakote 56. New RN to Unit- best client to assign is client 4 days post MI 57. Incorrect Delegation - LVN/LPN to remove staples from abdominal wound 58. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? Withdraw the nasogastric tube 59. One week after client received above the knee amputation, client experiences phantom pain in left foot, what to do- Review causes and sensations of phantom pain 60. The nurse-manager of a perinatal units is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? A 35-year-old with lupus erythematosus 61. Decerebrate Positioning – Extension of the upper and lower extremity. 62. Four clients arrive at the labor and delivery nurses’ station at the same time. Which pt should the nurse assess first? A 38-week multigravida with biophysical profile score of 4 out of 8 63. Teenagers Teaching for Diabetic diet – Teach to look out for restaurant that have healthy food. 64. Pyelonephritis symptoms - elevates temperature 65. Leg cast Assessment – Compartment syndrome 66. Diagnosis of breast cancer – Needle aspiration or biopsy. 67. Risk Osteoarthritis - seen in long distance runner since high school client 68. Client skin integrity for client with chronic venous insufficiency – around the ankle with little pain. 69. IV Line - Flush line before and after compatible IV solution 70. Teaching - Carafate given before and after meal 71. Nurse given a change in drug orders via phone from physician for a client headed to radiology, place in order what steps the nurse should take first to last? (Place in order) 1- read order back 2-enter verbal prescription 3- administer prn meds 4- prepare client for x-ray procedure 72. Heparin - Hematoma assessment 73. When the nurse auscultates the anterior chest just above the right nipple moderate, pitched breath sounds are heard that are equal on inspiration and expiration. Which statement best describes this finding? Bronchovesicular breath sounds that are normal in that location 74. Priority pt - Ruptured spleen life threatening 75. Magnesium – Alcohol pt (Magnesium 1.5 to 2.5) 76. Endotrach has slipped into right main bronchus of no breath sounds are heard (Audio/Visual) Pleaurvac, know how to set vac at 850 77. Chron’s disease- decrease intestinal activity 78. Dialysis- educate client of the reality of condition 79. Acute Pancreatitis- withhold food and fluid intake 80. 39 to 48 Glucose- Notify healthcare provider of client’s status 81. Ankle brachial index- ensure that you provide meticulous foot care to client 82. Anterior Cruciate Ligament injury - crutches 83. (Select all that apply) Mantoux test-select all except 45-degree angle 84. Late decelerations- nurse should turn off the Pitocin infusion first 85. Crohn’s Disease – Which has lowest Na+- choose Horseradish (choices are ketchup, steak sauce, pickle relish, horseradish) 86. Disseminated intravascular coagulation (DIC)- best test to diagnose, D-Dimer 87. Septic shock-best class of medicine to give are –Anti infectives 88. Adolescents and drug abuse at 13yrs old- mostly likely to use, Paint thinners 89. A female client who has been taking the corticosteroid methylprenisolone (Solu-Medrol) for three weeks reports to the nurse that she has gained ten pounds since starting the medication, and she wants to stop taking it. What is the best response by the nurse? The medication must be disconnected gradually, tapering the dose each day. 90. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse? An elderly client with Alzheimer’s disease complicated by dysphagia. 91. A 6-year old boy was hit with a bat while playing at school. He has a splinter of wood imbedded in his eye. Which action should the school nurse take? Have the parent take the child for emergency help 92. A nurse who is new to the pediatric unit is positioning a 6 month-old for an injection of penicillin V (Pen V) in the dorsogluteal muscle. Which action should the nurse-manager who is supervising this nurse take first? Instruct the nurse to select another injection site. 93. After diagnosis and initial treatment of a 3-year-old child with cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child’s mother indicates that she understands home care treatment to promote pulmonary function? “Cough suppressants can be used four times a day.” 94. Within four weeks of childbirth, a client is admitted to the hospital for disorganized speech bizarre behavior, and strange thoughts about her infant being possessed by demons. The nurse identifies a nursing diagnosis of “Altered thought processes, secondary to” what condition? Postpartum psychosis 95. The nurse is caring for a client who was admitted two hours ago with confusion, Kussmaul respirations, and warm, flushed skin. The healthcare provider determines the client is in acute renal failure (ARF). Which intervention is most important for the nurse to include in this clients plan of care? Hourly neurological assessments. 96. The nurse observes a 2cm area of non-blanchable erythema on the sacrum of an immobile client. What documentation of this finding is best for the nurse to enter into the client’s record? Stage 1 pressure ulcer on sacrum. 97. A client diagnosed with major depression is being allowed a weekend pass from the psychiatric unit. Which instruction should the nurse provide to the client’s family? Involve the client in usual at home activities 98. A 14-year-old male client arrives at the emergency room in status epilepticus. He was diagnosed with a seizure disorder in childhood. What is the most likely cause of his present condition? Acute withdrawal from anticonvulsant medication. 99. A client with gestational diabetes at 39-weeks gestation is in the second stage of labor. After delivery of the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first? Assist the client to sharply flex her thighs up against the abdomen 100. The nurse is teaching a childbirth education class t prospective parents and describing possible signs of labor. Class participants should be taught that which sign should be reported to the healthcare provider immediately? Leaking of fluid from the vagina 101. During the first trimester of pregnancy, a client who was treated for genital herpes with acyclovir (Zovirax) prior to this pregnancy tells the nurse that she is experiencing an episode of genital herpes. Which nursing intervention has the highest priority? The highest priority in this situation is to determine if the client has taken the drug Zoviarax, because Acyclovir has been associated with birth defects. 102. The nurse is obtaining a medication history for a client with a new prescription for paroxetine (Paxil). The client reports current use of the MAO inhibitor isocarboxazid (Marplan). What intervention is most important for the nurse to implement? Notify the healthcare provider that the client is currently taking Marplan. 103. After administering a medication through a nasogastric tube connected to suction, what action should the nurse take first? Clamp the tube 104. What action should the nurse implement first when delegating nursing activities to an unlicensed assistive personnel (UAP)? Evaluate the experience of the UAP. 105. The nurse is caring for four clients: Client A 94% o2 saturation, Client B, hemoglobin of 8.; Client C, potassium level of 3.8 and Client D appendectomy who has a white blood cell count of 15,000. What should the nurse implement? =Determine if Client B has two units of packed cells available in the blood bank. 106. A 40-year-old client with type 1 diabetes developed chronic kidney (CKD) disease 6 months ago. Because of secondary complications often associated with this illness the nurse plans to carefully assess for signs of what condition? Anemia 107. A client diagnosed with acute epididymitis secondary to a sexually transmitted disease receives a prescription for ceftriaxone (Rocephin). Prior to administering the prescription, which question should the nurse ask the client? “Have you ever had an allergic reaction to any other antibiotics?” 108. A client at 38 weeks gestation is in active labor, and a vaginal birth after Cesarean section (VBAC) is planned. Vaginal exam indicates that the client is 6cm dilated, 90% effaced, and the station 0 with intact membranes. As the client’s contraction become stronger, the fetal heart rate decelerates during the contraction but returns to baseline. What action should be taken? Continue to monitor the client’s labor progress. 109. An elderly client with limited mobility reports frequent episodes of nocturia. To reduce the risk for urinary incontinence, what action should the nurse implement? Keep the call bell button within the client’s reach. 110. Which diagnosis tests are most important for the nurse to monitor when providing care for a client with a bowel movement? Serum electrolytes. 111. While assessing a client with wrist restraints the nurse first slides two fingers under the restraints and then notes that the ties are secured to the side rail using a quick-release tie. What action should the nurse implement? Reposition the restraints ties, securing them to the bed frame 112. After administering the first dose of newly prescribed medications to four clients within a thirty minute time frame, the nurse evaluates each client for therapeutic responses or any adverse reactions. Which medication should the nurse evaluate first? Hydromorphone (Dilaudid) 113. What is the most important symptom the nurse should monitor the client for while assisting with the insertion of a subclavian central venous catheter? Shortness of breath. 114. A client admitted to the hospital is suspected of having meningitis. The nurse should plan to prepare the client for which diagnostic test? Lumbar puncture 115. The nurse is performing an intake interview at a prenatal clinic. Which planned activities described by the client who is at 6 weeks gestations will the nurse investigate first? Supervision of the renovation of an old house the family just purchased due to teratogen defect. 116. The nurse notes that a postoperative adult client’s respiratory rate is 10 breaths/minute. Which factor in the client’s history is the most likely explanation for this finding? The PCA pump containing morphine sulfate was discontinued 15 minutes before vital signs were taken. 117. The nurse is assessing a client with hypothyroidism and knows that these clients are at risk for myxedema coma. What symptoms indicate that the client is developing this condition? Hypothermia, decreased cardiac output, and decreased respiratory functioning 118. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? Withdraw the nasogastric tube 119. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? Perform fundal massage until firm 120. The nurse-manager of a perinatal units is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit? A 35-year-old with lupus erythematosus 121. Who is at risk for rib fracture - Elderly pt. 122. The nurse is assessing a client with hypothyroidism and knows that these clients are at risk for myxedema coma. What symptoms indicate that the client is developing this condition? Hypothermia, decreased cardiac output, and decreased respiratory functioning 123. A client is receiving a continuous infusion of normal saline at 125ml per hour. The nurse prepares to change the primary IV tubing and hang a new bag of normal saline to maintain the prescription. In which sequence should the nurse implement the procedure? (Arrange with first on top and last on bottom.) Spike a new bag- open the clamp-close the clamp-place the pumpattach the distal end-open all tubing clamps 124. A client who is wheelchair-bound demonstrates a positive Thomas test after admission to the rehabilitation unit. The health care provider prescribes positioning the client prone for 30minutes three times each day to prevent further contractures. Based on this finding, what change in the client’s plan of care should the nurse expect? There may be a delay in the rehabilitation process. 125. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? Withdraw the nasogastric tube 126. A client with a general anxiety disorder is pacing the hallway. The client tells the nurse, “My heart is just racing and sometimes it feels like it’s fluttering. I’m feeling short of breath and dizzy.” What action should the nurse implement first? Obtain the clients vital signs. 127. Translator is working with the nurse who is giving discharge instructions to a non-English client. When the translator restates what the nurse is saying it appears that he is saying much more than what the nurse said. What action should the nurse take? Ask the translator if there is a reason for the lengthiness of the translation 128. An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the bathroom what should the nurse implement? provide a raised toilet seat. 129. The nurse tests a client’s visual acuity and determines that the uncorrected vision is 20/100 in the right eye and 20/80 in the left eye. What does this finding indicate? Difficulty visualizing objects at a distance also known as myopia. 130. Client has a Lithium Rx level of 0.54 (know Lithium ranges- Low, so the answer is to ask client if they have been taking their medication everyday 131. (Select all that apply) Determining pain level for 3mo old infant- infant will clinch fists, increase pulse, restlessness, increased respiratory effort 132. 5yr old burn victim has pot of hot liquid fall on him, what should nurse tell mother to do first- nurse should tell mother to remove clothing and place in cool bath 133. The Nurse recognizes that the primary purpose of recommending a yearly digital rectal examination (DRE) for all men over the age of 40 is to help detect the early stages of which type of cancer? Prostate cancer. 134. A client with carpal tunnel syndrome is in the out-patient surgical unit after an endoscopic carpal tunnel release. What instructions should the nurse provide the client regarding postoperative care? After carpel tunnel release, measure to promote circulation, comfort, and to prevent complications should include positioning the hand above the heart to reduce edema. 135. Which client should the nurse assist first? An inguinal hernia who has developed abdominal distention and fever in the last 8 hours. 136. A client with a chest tube develops sepsis and dyspnea. Based on findings in the client’s medical record, which prescription should the nurse implement first? (Click on each chart tab for additional Information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the clients medical record) 137. The nurse is teaching a client with COPD about health promotioin activities. What is the most important advice the nurse should give this client? “If you have not already done so, quit smoking” 138. A client at 38-weeks gestation complains of abdominal pain. The nurse notes that her abdomen is rigid. What is the probable cause of these findings? 139. 39 to 48 Glucose- Notify healthcare provider of client’s status 140. Family members of a client who is in hospice care discuss with the nurse their fears that their loved one’s death will be painful. Which intervention should the nurse implement? Although the client may or may not experience pain as death approaches, the nurse should provide teaching that pain control methods will be used, and are helpful in managing pain that may occur. 141. Which nurse’s behavior is a breach of clients confidentiality according to the Health Insurance Portable Accountability Act (HIPAA) regulations? Take home a daily report sheet with the information of the team’s client. 142. A male client with cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures. The nurse notes that the client’s admission prescription include radiation therapy. What action should the nurse implement? Consult with the client about his expected goals for his hospitalization and current treatment plan 143. An Elderly man is having trouble urinating and unsteady he uses a wheelchair to walk to the bathroom what should the nurse implement? provide a raised toilet seat. 144. The nurse completes the Leopold maneuvers for a primipara who is admitted in active labor and determines that the fetus is in the right sacral anterior (RSA) position. On which quadrant should the nurse place the external fetal heart transducer? (Click the chosen location. To change, click on the new location.) 145. The nurse is caring for a 5 year-old child with Reye’s syndrome. What goal has the highest priority in caring for this child? Reduce cerebral edema and lower intracranial pressure. 146. The nurse is preparing a discharge plan for an older client who was recently diagnosed with Alzheimer’s disease. Which intervention should the nurse suggest to the spouse if the client becomes uncooperative at home? Ensure a calm and predictable environment. 147. A mother brings her 15-month old son and 6 year-old daughter to the clinic for immunizations. Both children are fretful and obviously have upper respiratory infections. The mother tells the nurse that the younger child ran a fever of 100.2ºF following his last immunization. What plan is best for the nurse to implement? Administer the boosters and instruct the mother to call the clinic if either child’s temperature exceeds 101ºF. 148. Pregnancy Induced Hypertension high blood pressure, blurred vision, headache, Proteinuria, Abdominal pain 149. A client with endometrial carcinoma is receiving brachytherapy and has radioactive Cesium (Cs) loaded in a vaginal applicator. What action should the nurse implement? Wear a dosimeter film badge when in the client’s room 150. A client who has localized eczematous eruptions on both hands is diagnosed as having contact dermatitis. What instructions should the nurse include on the clients discharge teaching plan? Take prescribed antihistamine near bedtime. 151. The community health nurse is attempting to address the issue of child abuse in a large metropolitan area. A primary prevention program for child abuse might include which program? High school child development and parenting classes. 152. Risk management: pt fell while using some equipment… charge nurse trying to find out what happened- how? - hospital polices 153. A client has a history of chronic atrial fibrillation. Which instruction should the nurse include in the teaching plan for this client? Be sure to take the prescribed daily aspirin. 154. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother’s vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? Perform fundal massage until firm 155. It is most important for the nurse to use an IV pump and/or Buretrol, an in-line volumecontrol device, when initiating IV therapy for a client following which surgical procedure? Craniotomy. 156. Which strategy is most important for the nurse to use when assisting a client with myasthenia gravis to devise a daily routine? Female with a head injury whose pupils are fixed and dilated. 157. A male infant born at 30-weeks gestation at an outlying hospital is being prepared for transport to a level IV neonatal facility. His respirations are 90/min, and his heart rate is 150 beats per min. Which drug is the transport team most likely to administer to the infant? Beractant (SURVANTA) 100mg/kg per endotracheal tube. 158. A 60 year-old female client takes NPH insulin each morning. What would necessitate holding this clients usual morning NPH insulin dose? The client is NPO for surgical debridement of a leg ulcer at 11.00am. 159. Which finding should the nurse expect a client to exhibit who is newly diagnosed with fibromyalgia? Disrupt in sleep patherns. 160. Chest tube disconnect ( Put the end of the tube in a sterile bottle fill with Normal saline and connect back to patient)