(RN PROCTORED) THE NURSING CARE OF ADULTS WITH MEDICAL AND SURGICAL HEALTH PROBLEMS Q&A.; With Rationales >RATED A.

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1. 1.ID: 9476872990 A registered nurse (RN) on the 7 a.m.–3 p.m. shift is planning client assignments for the day. Which clients would be appropriate for the RN to assign to the licensed practical... nurse (LPN)? Select all that apply. A. A client who had a mastectomy 2 days ago Correct B. A client with type 1 diabetes mellitus who has a foot ulcer Correct C. A client with left­side weakness who will need assistance with personal care Correct D. A newly admitted client with chronic obstructive pulmonary disease (COPD) E. A client being transferred in from the intensive care unit with a deep vein thrombosis and a heparin drip Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. The client with COPD who was admitted during the night will need close monitoring of the respiratory status. An LPN may not administer most high­risk intravenous medications, including heparin. The client who has had a mastectomy and the client with a foot ulcer will likely require dressing changes, an activity that is within the scope of practice of the LPN. The client with left­side weakness requiring personal care assistance could also be assigned to the LPN. Test­Taking Strategy: Use the process of elimination, focusing on the subject, assignment to the LPN. Recalling that an LPN may not administer high­risk intravenous medications will assist you in eliminating this option. Eliminate the newly admitted client with COPD, noting that this client will require a higher level of monitoring. Review the principles of delegating tasks if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Zerwekh, J., & Zerwekh, A. (2015). Nursing today: Transition and trends (8th ed., pp. 305, 308). St. Louis: Elsevier Awarded 3.0 points out of 3.0 possible points. 2. 2.ID: 9476871061 A home care nurse is assigned to visit a prenatal client with a diagnosis of hyperemesis gravidarum (HEG). During physical assessment of the client, the nurse should first: A. Weigh the client Incorrect B. Assess the client’s intake and output Correct C. Encourage the client to verbalize her feelings about the diagnosis D. Review the results of the hemoglobin and hematocrit determinations Rationale: HEG is persistent, uncontrolled vomiting that begins before the 20th week of pregnancy. It can have serious consequence, including loss of 5% of prepregnancy weight, dehydration, ketosis, acid­base imbalance, and electrolyte imbalances. Physical assessment begins with determining the client’s intake and output, because these data provide information regarding hydration and the nutritional status of the client. The client’s weight would be obtained and the baseline value compared with previous and subsequent values. Additionally, the nurse would instruct the client in how to accurately check and monitor her weight. Laboratory data may need to be evaluated; increased hemoglobin and hematocrit values may occur as a result of dehydration. Encouraging the client to verbalize her feelings about the diagnosis is a component of the plan of care but is not the first intervention during physical assessment. Test­Taking Strategy: Note the strategic word “first.” Use Maslow’s Hierarchy of Needs theory to eliminate the option that indicates encouraging the client to verbalize her feelings, recalling that physiological needs are the priority. To select from the remaining options, recall the description of HEG; this will direct you to the correct option. Review the priority physical assessment techniques in this disorder if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Assessment Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Nutrition HESI Concepts: Collaboration/Managing Care – Care Coordination, Nutrition Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal­child nursing (4th ed., pp. 589­590). St. Louis: Elsevier. Awarded 0.0 points out of 1.0 possible points. 3. 3.ID: 9476869315 A registered nurse (RN) on the night shift has a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP)on the team and is planning the client assignments for the night. Which client does the RN assign to the LPN? Select all that apply. A. A client who undergoing a 24­hour urine collection Incorrect B. A client with a nasogastric tube who underwent bowel resection 2 days ago Correct C. A client with urinary frequency who needs assistance in getting to the bathroom D. A client scheduled for renal dialysis in the morning who needs assistance with hygiene E. A client who has been fitted with skeletal traction of the right leg after an open reduction measures Correct Rationale: When a nurse delegates aspects of a client’s care to another staff member, the nurse assigning the task is responsible for ensuring that each task is appropriately assigned on the basis of the educational level and competency of the staff member. An LPN may perform certain invasive procedures. A client with a nasogastric tube who underwent bowel resection 2 days ago and a client in skeletal traction to the right leg after open reduction may safely be assigned to the LPN, because the LPN is capable of performing the nasogastric tube care, dressing changes, and monitoring for postoperative complications that the clients will require. Interventions such as assisting clients with ambulation and hygiene measures and performing noninvasive procedures — the types of tasks identified in the other options — may be assigned to a nursing assistant. Test­Taking Strategy: Use the process of elimination, focusing on the subject, assignment to an LPN. Eliminate the options that are comparable or alike in that they are noninvasive procedures. Also note that the remaining options involve routine care of the postoperative client and activities that are within the scope of practice for the LPN. Review the principles of delegation if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., pp. 262, 281­283). St. Louis: Mosby. Awarded 1.0 points out of 2.0 possible points. 4. 4.ID: 9476867243 A nurse is monitoring a client with preeclampsia who is receiving intravenous magnesium sulfate to prevent seizures. The nurse notes that the client’s respiratory rate is 10 breaths/min. On the basis of this finding, the nurse first: A. Takes the client’s vital signs health care provider B. Contacts the health care provider Incorrect C. Discontinues the magnesium sulfate Correct D. Checks the most recent serum magnesium sulfate level Awarded 0.0 points out of 1.0 possible points. 5. 5.ID: 9476864338 A client who has just undergone abdominal surgery calls the nurse and states, “I feel as if I just split open.” The nurse checks the abdominal incision and finds wound evisceration. The nurse immediately: A. Documents the findings B. Notifies the operating room C. Takes the client’s vital signs D. Contacts the health care provider Correct Awarded 1.0 points out of 1.0 possible points. 6. 6.ID: 9476874711 A client is receiving an intravenous (IV) infusion of 1000 mL of normal saline solution at a rate of 125 mL/hr. The client suddenly complains of shortness of breath, and the nurse notes the presence of dependent edema and puffiness around the client’s eyes. The nurse suspects circulatory overload and immediately: A. Slows the IV rate Correct B. Administers a diuretic C. Contacts the health care provider D. Places the client in a supine position Awarded 1.0 points out of 1.0 possible points. 7. 7.ID: 9476864386 A nurse is performing closed suctioning through a tracheostomy for a ventilator­dependent client. During the procedure, the alarm on the cardiac monitor sounds and the nurse notes severe bradycardia. The nurse stops suctioning the client and immediately: A. Contacts the respiratory therapist B. Rechecks all ventilator connections C. Oxygenates the client manually with 100% oxygen Correct D. Increases the degree of PEEP the client is receiving Awarded 1.0 points out of 1.0 possible points. 8. 8.ID: 9476867288 Inner maxillary fixation (IMF) is performed on a client who sustained a mandibular fracture in a motor vehicle crash. During an assessment, the client begins to vomit. The nurse suctions the client but is unsuccessful, and the client exhibits signs of hypoxia. The nurse immediately: A. Cuts the mouth wires Correct B. Administers an antiemetic C. Contacts the anesthesiologist D. Places the client is a supine position Awarded 1.0 points out of 1.0 possible points. 9. 9.ID: 9476869352 A child arrives at the emergency department experiencing anaphylaxis after being stung by a bee on the right arm. The nurse should first: A. Call a code B. Start an intravenous (IV) line C. Initiate cardiopulmonary resuscitation (CPR) D. Place a tourniquet proximal to the site of the insect sting Correct Awarded 1.0 points out of 1.0 possible points. 10. 10.ID: 9476869370 A nurse is preparing to care for a child being admitted to the hospital with infectious gastroenteritis. The priority nursing intervention is: A. Obtaining a stool sample for culture Incorrect B. Administering prescribed antimicrobials C. Starting an intravenous (IV) line as prescribed Correct D. Instructing the parents in home care measures to prevent infection Awarded 0.0 points out of 1.0 possible points. 11. 11.ID: 9476874738 A nurse is caring for a client after tonsillectomy and adenoidectomy. The nurse notes that the client has become restless and is swallowing frequently. List in order of priority the actions that the nurse should take in this situation, with number 1 as the first action. Incorrect A. Notifying the surgeon B. Inspecting the client’s throat C. Checking the client’s vital signs D. Maintaining NPO status The correct order is: E. Inspecting the client’s throat F. Checking the client’s vital signs G. Notifying the surgeon H. Maintaining NPO status Rationale: Bleeding is a potential complication after tonsillectomy and adenoidectomy. If the client becomes restless and is swallowing frequently, the nurse should suspect bleeding. The nurse would first inspect the throat for the presence of bleeding and then check the client’s vital signs for indications of hypovolemia. The surgeon would be notified. Because recauterization is the treatment of choice when bleeding is uncontrolled, the client would be maintained on nothing­by­mouth (NPO) status in anticipation of a return to surgery. Test­Taking Strategy: Focus on the data in the question and use your prioritizing skills. Noting the strategic words “swallowing frequently” will direct you to assessment of the client for bleeding as the first action. The next step is checking the vital signs next to detect signs of shock and to have the data that the health care provider will need. Although food or fluids would not be given to the client during this episode anyway, keeping the client on NPO status would be the fourth priority. Review the nursing actions to be taken immediately when bleeding occurs after tonsillectomy and adenoidectomy if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Perfusion HESI Concepts: Collaboration/Managing Care – Care Coordination, Perfusion/Clotting Reference: Ignatavicius, D., & Workman, M. (2013). Medical­surgical nursing: Patient­centered collaborative care. (7th ed., p. 644). St. Louis: Saunders. Awarded 0.0 points out of 1.0 possible points. 2. 12.ID: 9476876993 A nurse is caring for a client with a diagnosis of endocarditis when the client suddenly begins to experience chest pain, dyspnea, and tachypnea. The nurse suspects that the client has a pulmonary embolism. List in order of priority the actions that the nurse would take in this situation, with number 1 as the first action. Incorrect A. Notifying the health care provider B. Placing a nasal oxygen cannula on the client C. Ensuring that the intravenous (IV) line is patent D. Preparing an IV heparin sodium infusion E. Preparing the client for a computerized tomography (CT) scan The correct order is: F. Placing a nasal oxygen cannula on the client G. Notifying the health care provider H. Ensuring that the intravenous (IV) line is patent I. Preparing an IV heparin sodium infusion J. Preparing the client for a computerized tomography (CT) scan Rationale: Pulmonary embolism is a life­threatening emergency. Stabilizing the cardiopulmonary system is the first priority. Nasal oxygen is administered immediately to relieve hypoxemia, respiratory distress, and central cyanosis. The health care provider is notified. Because IV infusion lines are needed to administer fluids to treat the hypotension and to administer medications, the nurse ensures that the client has patent IV lines. Anticipating that IV anticoagulant therapy will be started, the nurse next prepares an administration set. Finally, because a CT scan or other diagnostic test may be performed to confirm the diagnosis, client preparations for testing are begun. Test­Taking Strategy: Focus on the client’s diagnosis and use the skills of prioritizing. Recalling that stabilizing the cardiopulmonary system is the priority will direct you to the administration of oxygen. Recognizing the immediacy of the situation will then direct you to notification of the health care provider. Next, visualize the situation to determine the order of the remaining options. Review the nursing actions to be taken immediately in the event of pulmonary embolism if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Perfusion HESI Concepts: Collaboration/Managing Care – Care Coordination, Perfusion/Clotting Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 552). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. 3. 13.ID: 9476867298 A client is brought to the emergency department after a motor vehicle crash in which the client sustained a blunt chest injury when his chest struck the steering wheel. The client is complaining of sharp pain on inspiration and dyspnea. The nurse notes the absence of breath sounds on the affected side. The nurse would immediately: A. Obtain a chest x­ray B. Notify the health care provider C. Place the client in a semi­Fowler position Correct D. Prepare a thoracentesis tray and chest drainage equipment Incorrect Awarded 0.0 points out of 1.0 possible points. B. 14.ID: 9476864343 A registered nurse (RN) is planning assignments for six clients on a nursing unit. The RN has an RN, a licensed practical nurse (LPN), and an unlicensed assistive personnel (UAP) on the nursing team. Which clients should the nurse assign to the RN? Select all that apply A. A client who requires tap water enemas until clear B. A client with newly diagnosed type 1 diabetes mellitus Correct C. A client requiring complete assistance with personal care D. A client with gastrointestinal bleeding and a hemoglobin of 7.3 mg/dL (73 g/L) Correct E. A client who was admitted during the night after an acute asthma attack Correct F. A client who has undergone amputation of the right leg amputation and a dressing change Incorrect Awarded 1.0 points out of 3.0 possible points. C. 15.ID: 9476879575 A registered nurse (RN) is planning the client assignments for the day. To which nurse does the RN appropriately assign care of a woman undergoing brachytherapy with a sealed radiation source for cervical cancer? A. A pregnant nurse who has special expertise in oncology B. A nurse who has worked with clients undergoing brachytherapy in the past Correct C. A male nurse who has never worked with a client undergoing brachytherapy D. A nurse who is also assigned to provide care to another client undergoing brachytherapy Awarded 1.0 points out of 1.0 possible points. D. 16.ID: 9476864326 A client is complaining of chest pain, and the nurse notes that the client’s skin is cool and clammy. The client is receiving oxygen at a rate of 2 L/min, and the pulse oximetry reading is 84%. Which action should the nurse take first? A. Administering nitroglycerin Incorrect B. Taking the client’s vital signs C. Increasing the oxygen to 3 L/min Correct D. Obtaining an arterial blood gas (ABG) specimen Awarded 0.0 points out of 1.0 possible points. E. 17.ID: 9476878102 A nurse is assigned to care for a client with a closed chest drainage system that was inserted 1 day ago after the client sustained a stab wound to the chest. List in order of priority the actions that the nurse would take in caring for the client, with number 1 the first action. Incorrect A. Assessing the client’s level of discomfort B. Assessing patency and function of the chest tube C. Checking the client’s vital signs D. Asking the client to cough and deep­breathe The correct order is: E. Assessing patency and function of the chest tube F. Checking the client’s vital signs G. Assessing the client’s level of discomfort H. Asking the client to cough and deep­breathe Awarded 0.0 points out of 1.0 possible points. 2. 18.ID: 9476876931 An emergency department (ED) nurse receives a telephone call and is informed that several victims from a train accident will be brought to the ED. The nurse who received the telephone call must first: A. Activate the agency disaster plan Correct B. Empty all available rooms in the ED C. Ensure that the triage rooms are stocked with additional dressing supplies D. Call the intensive care unit (ICU) and asks for nurses to assist with the victims Awarded 1.0 points out of 1.0 possible points. B. 19.ID: 9476880352 A home health nurse is assigned to three client visits today. One client requires twice­daily irrigation of an abdominal wound. Another client was discharged from the hospital yesterday after cardiac catheterization and will require an admission assessment and assistance with the scheduling of medications. The last client has diabetes mellitus and requires a blood specimen for serum glucose testing to be drawn. The nurse will schedule the assignment by visiting: A. The client with diabetes mellitus first, the client with the wound irrigation second, and the client requiring admission last Correct B. The client needing wound irrigation first, the client with diabetes mellitus second, and the client requiring admission last C. The client requiring admission first, the client with diabetes mellitus second, and the client needing wound irrigation last D. The client with diabetes mellitus first, the client requiring admission second, and the client needing wound irrigation last Awarded 1.0 points out of 1.0 possible points. C. 20.ID: 9476871009 A registered nurse is planning client assignments for the day. Which clients should the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply. A. A client scheduled for colonoscopy B. A client who underwent mastectomy 2 days ago C. A client scheduled for discharge after cardiac catheterization D. A client with diarrhea who requires assistance with hygiene care Correct E. A client on strict bed rest who requires range­of­motion exercises every 2 hours Correct Awarded 2.0 points out of 2.0 possible points. D. 21.ID: 9476867256 A registered nurse (RN) must determine how best to assign an RN and a licensed practical nurse (LPN) to provide care to a group of clients. Which is the appropriate assignment? A. Assigning the RN to care for a woman with newly diagnosed metastatic carcinoma who has two school­aged children Correct B. Assigning the RN to care for a woman, hospitalized for chest pain, who is being discharged home today with no medications C. Assigning the LPN to care for a client who has undergone craniotomy and was transferred from the intensive care unit (ICU) this morning D. Assigning the LPN to provide initial discharge teaching about cardiac medications to a client who has undergone a coronary artery bypass graft Awarded 1.0 points out of 1.0 possible points. E. 22.ID: 9476869332 A nurse is monitoring a postoperative client on an hourly basis. The nurse notes that the client’s urine output for the past hour is 20 mL. On the basis of this finding, the nurse should first: A. Call the health care provider B. Increase the rate of the IV infusion Incorrect C. Check the client’s overall intake and output record Correct D. Administer a 250­mL bolus of normal saline solution (0.9%) Awarded 0.0 points out of 1.0 possible points. F. 23.ID: 9476876956 A nurse is delegating tasks to the nursing staff. Which tasks are appropriate for the unlicensed assistive personnel (UAP? Select all that apply. A. Feeding a newly admitted client with dysphagia after a stroke B. Obtaining frequent oral temperatures from a client who is receiving a blood transfusion Correct C. Accompanying a man being discharged home to his transportation at the hospital entrance Correct D. Obtaining a 24­hour dietary recall from a client admitted to the hospital with anorexia nervosa E. Obtaining a clean­catch urine specimen from a client who is complaining of urgency and frequency Correct Awarded 3.0 points out of 3.0 possible points. G. 24.ID: 9476864306 A nurse on the day shift (7 a.m.–3 p.m.) is assigned to care for four clients. In planning care, which client does the nurse assess first? A. A client scheduled for a barium enema at 9 a.m. B. A client requiring a daily dressing change on an amputation stump C. A client with emphysema who is receiving oxygen at a rate of 2 L/min Correct D. A client who has undergone angioplasty and is preparing to be discharged at 10 a.m. Awarded 1.0 points out of 1.0 possible points. H. 25.ID: 9476880322 A nurse is planning client assignments for the shift. Which clients would the nurse assign to the unlicensed assistive personnel (UAP)? Select all that apply. A. A client receiving blood transfusions B. A client who needs to be ambulated with a walker twice a day Correct C. A client with incontinence who requires a bladder scan after each void Correct D. A client with diabetes mellitus who requires blood glucose testing every 2 hours E. A client on a bowel management program who requires a daily rectal suppository Incorrect Rationale: Assignment of tasks must be implemented on the basis of the job description of the UAP, the UAPs level of clinical competence, and state law. A client who is receiving blood transfusions, one in a bowel­management program who requires a rectal suppository daily, and one with diabetes mellitus who requires blood glucose monitoring all require the skill of a licensed nurse, because these are invasive procedures. A client receiving blood must be monitored closely for transfusion reactions. A rectal suppository must be administered by a licensed nurse. Blood glucose monitoring needs to be performed by a licensed nurse. A client with incontinence requiring a bladder scan after each void and a client who needs to be ambulated with a walker twice a day are the most appropriate assignments for the UAP. Test­Taking Strategy: Use the process of elimination and your knowledge regarding tasks that may be safely delegated to a nursing assistant. A UAP is trained to perform a bladder scan and ambulate a client with a walker, and these are both noncritical, noninvasive tasks. Review the principles of delegation and assignment­making if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Safety HESI Concepts: Collaboration/Managing Care – Care Coordination, Safety Reference: Huber, D. (2014). Leadership and nursing care management (5th ed., pp. 147­148). St. Louis: Saunders. Awarded 1.0 points out of 2.0 possible points. I. 26.ID: 9476864335 A registered nurse is in charge of the emergency department on the night shift when a client is brought for treatment after being sexually assaulted. The nurse has never cared for anyone after a sexual assault. To determine the interventions that the client requires, the nurse would first: A. Call the police department B. Call the nursing supervisor C. Call the nurse in charge of the day shift D. Check unit policy regarding the protocol for care to clients who have been sexually assaulted Correct Awarded 1.0 points out of 1.0 possible points. J. 27.ID: 9476864375 A client with a spinal cord injury suddenly experiences a severe headache and nasal stuffiness. The client is also diaphoretic, hypertensive, and bradycardic. The nurse determines that the client is experiencing autonomic dysreflexia and immediately: A. Notifies the health care provider B. Checks the bladder and catheterizes the client C. Raises the head of the bed to a high Fowler position Correct D. Performs a rectal examination to check for a fecal impaction Awarded 1.0 points out of 1.0 possible points. K. 28.ID: 9476869341 A client calls the nurse at the emergency department (ED), says that he thinks that he came in contact with poison ivy while working in his yard, and asks the nurse for advice. The nurse tells the client immediately to: A. Take a shower Correct B. Come to the ED C. Soak in a warm oatmeal bath D. Apply hydrocortisone cream to the areas that may have been in contact with the poison ivy Awarded 1.0 points out of 1.0 possible points. L. 29.ID: 9476872971 A nurse notes that the site of a client’s peripheral intravenous (IV) catheter is red and inflamed and feels hard on palpation. On the basis of this assessment, the nurse should first: A. Remove the IV catheter Correct B. Slow the rate of infusion C. Notify the health care provider D. Place warm compresses on the IV site Awarded 1.0 points out of 1.0 possible points. M. 30.ID: 9476869308 A nurse assesses a client at the beginning of the shift and notes an intravenous (IV) infusion is running at 100 mL/hr and that 800 mL of fluid remains in the IV bag. Thirty minutes later, the client calls the nurse and complains of shortness of breath. The nurse sees that 400 mL of IV solution remains in the IV bag. The nurse immediately: A. Administers oxygen B. Elevates the head of the bed C. Notifies the health care provider D. Stops the rate of the IV infusion Correct Awarded 1.0 points out of 1.0 possible points. N. 31.ID: 9476874758 A client complains of pain at the site of an intravenous (IV) catheter. On assessment, the nurse notes that the site appears bruised and concludes that the client has a hematoma. The nurse first: A. Applies ice to the IV site B. Removes the IV catheter Correct C. Applies pressure to the site D. Notifies the health care provider Awarded 1.0 points out of 1.0 possible points. O. 32.ID: 9476872942 A nurse suspects that a client receiving a unit of packed red blood cells (RBCs) is experiencing a transfusion reaction. List in order of priority the actions that the nurse should take in this situation, with 1 as the first action. Correct A. Discontinuing the infusion B. Keeping the IV line open with 0.9% normal saline solution C. Notifying the health care provider D. Notifying the blood bank E. Sending the blood bag and tubing to the blood bank Awarded 1.0 points out of 1.0 possible points. 2. 33.ID: 9476864353 A nurse is caring for a client with a central venous catheter. The client suddenly complains of chest pain and dyspnea. During assessment of the client, the nurse notes hypotension, tachycardia, and a loud churning sound over the pericardium on auscultation. The nurse suspects an air embolism and immediately: A. Obtains an electrocardiogram B. Clamps the central line catheter Correct C. Places the client in a high Fowler position D. Connects a syringe to the line and aspirates as much fluid as possible Rationale: An air embolism occurs when air enters the central venous system. Signs and symptoms include chest pain, dyspnea, hypoxia, anxiety, tachycardia, hypotension, and a loud churning sound over the pericardium on auscultation. Air may be introduced into the central venous system during insertion of the catheter, tubing changes, or breakage of the catheter. The nurse immediately clamps the catheter, places the client in a lateral Trendelenburg position on the left side to trap the air in the right atrium, and contacts the health care provider. The health care provider may order an electrocardiogram, chest x­ray, and arterial blood gas determinations. Placing the client in a high Fowler position and connecting a syringe to the line and aspirating as much fluid as possible are both incorrect. Test­Taking Strategy: Use the process of elimination and note the strategic word “immediately.” Note that the nurse suspects an air embolism. Recalling the danger of an air embolism if it travels to the lungs will help you identify the correct option. Review care of the client with an air embolism originating from a central line infusion if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Clotting HESI Concepts: Collaboration/Managing Care – Care Coordination, Perfusion/Clotting Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 798). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. B. 34.ID: 9476882006 A nurse responds to a disaster call in which a building collapsed and several victims were seriously injured. Which victim will the nurse attend to first? A. A victim with an amputated arm Correct B. A victim with a closed fracture of the leg C. A victim with a sprained ankle and a minor laceration on the head D. A victim with massive head trauma who is in cardiopulmonary arrest Rationale: A triage system identifies and categorizes victims so that those with the most critical but treatable injuries or illnesses are treated first. In one common system, red denotes priority I, yellow is priority II, green is priority III, and black is priority 0. Priority I includes life­threatening problems that need immediate attention such as trauma, chest pain, respiratory distress, chemicals in the eyes, arm or leg amputation, and shock. Priority II includes victims in need of treatment within 20 minutes to 2 hours — for example, a victim with a simple fracture. Priority III is assigned to victims who can wait for treatment, such as people who have sustained sprains or minor lacerations. Priority 0 denotes a victim who is dying or dead, who has sustained massive head trauma, or who is in cardiopulmonary arrest. Test­Taking Strategy: Use the process of elimination and note the strategic word “first,” then note the extent of the victims’ injuries. A victim with a closed fracture of the leg and one with a sprained ankle and a minor laceration on the head are not seriously injured, so eliminate these options. Of the remaining options, select the amputation victim, because this person will be bleeding profusely and will require lifesaving measures. It is less likely that the victim who has sustained a massive head injury will survive. Review triage systems if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Disasters Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision­Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 328). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. C. 35.ID: 9476879560 A mother rushes into the emergency department with her child and tells the nurse that the child has drunk bleach from a bottle that the mother was using to clean bathrooms. The nurse notes that child is alert but sees areas of irritation around his mouth. Which intervention does the nurse immediately begin preparing for? A. Insertion of a nasogastric tube B. Administration of syrup of ipecac to induce vomiting C. Dilution of the corrosive substance with water or milk Correct D. Administration of an agent to neutralize the corrosive substance Awarded 1.0 points out of 1.0 possible points. D. 36.ID: 9476876947 A nurse in a postanesthesia care unit (PACU) receives a client who is being transferred from the operating room after abdominal surgery. The PACU nurse ensures that the client has a patent airway and that the respiratory pattern is adequate. Which interventions should the PACU nurse perform next? A. Orienting the client to the surroundings Incorrect B. Checking the Foley catheter for urine output C. Assessing he abdominal dressing for drainage D. Checking the client’s pulse oximetry readings Correct Awarded 0.0 points out of 1.0 possible points. E. 37.ID: 9476882031 A nurse notes that a client who is attached to a cardiac monitor has suddenly began exhibiting the following rhythm. After contacting the health care provider, which intervention does the nurse prepare the client for? A. Administration of adenosine Correct B. Administration of heparin sodium C. Insertion of a permanent pacemaker D. Transesophageal echocardiography (TEE) Awarded 1.0 points out of 1.0 possible points. F. 38.ID: 9476878126 A client who experienced ventricular fibrillation has undergone defibrillation three times, without success. The nurse would next: A. Increase the IV flow rate B. Perform defibrillation one last time C. Assess the client’s level of consciousness D. Continue cardiopulmonary resuscitation (CPR) Correct Awarded 1.0 points out of 1.0 possible points. G. 39.ID: 9476880300 A nurse in the ambulatory care unit is caring for a client after cataract extraction. The client suddenly complains of severe pain in the affected eye. The nurse must immediately: A. Notify the surgeon Correct B. Place the client in a supine position C. Administer the prescribed pain medication D. Tell the client that this is to be expected after surgery Awarded 1.0 points out of 1.0 possible points. H. 40.ID: 9476867272 A client arrives at the emergency department after experiencing a traumatic blow to the eye, and a hyphema is diagnosed. The nurse should first: A. Place a patch and shield on the eye B. Administer prescribed cycloplegic eye drops C. Ensure that the client is placed in a semi­Fowler position Correct D. Tell the client that reading and watching television are restricted Awarded 1.0 points out of 1.0 possible points. I. 41.ID: 9476867283 A client comes to the emergency department after being hit in the eye with a hockey puck. Which action does the nurse, seeing that the client has periorbital ecchymosis, implement immediately? A. Applying ice to the affected eye Correct B. Irrigating the affected eye with cool water C. Placing a pressure dressing on the affected eye D. Applying a warm saline compress to the affected eye Awarded 1.0 points out of 1.0 possible points. J. 42.ID: 9476867215 A client arrives in the emergency department complaining of feeling “something in my eye” and reports that some dust blew into the eye. The nurse would first: A. Apply a patch to the eye B. Assess the client’s vision Correct C. Examine the eye, using fluorescein D. Irrigate the eye with sterile normal saline solution Incorrect Awarded 0.0 points out of 1.0 possible points. K. 43.ID: 9476864396 A client who has been bitten on the right arm by a snake arrives at the emergency department. The nurse immediately: A. Applies ice to the site of the bite B. Prepares to administer tetanus prophylaxis C. Immobilizes the affected arm at heart level Correct D. Places a tourniquet above the site of the bite Awarded 1.0 points out of 1.0 possible points. L. 44.ID: 9476876924 A client arrives in the emergency department and reports that an acid solution was splashed into his eye. The nurse immediately: A. Performs visual acuity tests B. Applies litmus paper to the conjunctiva C. Swabs the eye with a corticosteroid ointment D. Irrigates the eye with copious amounts of sterile normal saline solution Correct Awarded 1.0 points out of 1.0 possible points. M. 45.ID: 9476878112 A nurse assessing a client with a closed chest tube drainage system notes constant bubbling in the water seal chamber. The nurse assesses the system for air leaks but is unable to locate a visible leak. Based on this finding, the nurse next: A. Milks the chest tube B. Clamps the chest tube Incorrect C. Replaces the drainage system Correct D. Reduces the degree of suction being delivered Rationale: Constant bubbling in the water seal chamber of a closed chest tube drainage system may indicate the presence of an air leak. The nurse would assess the chest tube system for the presence of an air leak if constant bubbling were noted in this chamber. If an air leak cannot be located, the nurse next replaces the drainage system. If continuous bubbling in the water seal chamber continues, the health care provider is notified, because an air leak may be present in the pleural space, and leakage and trapping of air in the pleural space may result in a tension pneumothorax. Reducing the degree of suction being delivered will not affect the bubbling in the water seal chamber and could be a harmful. Clamping and milking the chest tube are both incorrect. Additionally, a chest tube is not clamped or milked unless specifically prescribed and the procedure is an approved intervention as stated in the agency’s policies and procedures. Test­Taking Strategy: Use the process of elimination and your knowledge regarding priority actions in the care of a client with a chest tube drainage system. Recalling that a chest tube is not milked or clamped unless agency policies and procedures specifically prescribe these interventions will assist you in eliminating these options. To select from the remaining options, focus on the subject, the inability of the nurse to locate a leak, to identify the correct option. Review the nursing actions to be taken immediately in response to of a chest tube drainage system if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Gas Exchange HESI Concepts: Clinical Decision­Making/Clinical Judgment, Oxygenation/Gas Exchange Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 546). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. N. 46.ID: 9476880397 A nurse is caring for a client who has just experienced a pulmonary embolism. List, in order of priority, the actions that the nurse would take in this situation, with 1 as the first action. Incorrect A. Notifying the health care provider B. Elevating the head of the bed C. Applying low­flow oxygen by way of nasal cannula D. Preparing an intravenous (IV) heparin solution The correct order is: E. Elevating the head of the bed F. Applying low­flow oxygen by way of nasal cannula G. Notifying the health care provider H. Preparing an intravenous (IV) heparin solution Awarded 0.0 points out of 1.0 possible points. 2. 47.ID: 9476864314 A client who has sustained a severe burn injury is brought to the emergency department (ED). Which action does the ED nurse implement immediately? A. Cleansing the burn wounds B. Administering tetanus prophylaxis C. Covering the client with a warm blanket D. Administering 100% oxygen by way of face mask Correct Awarded 1.0 points out of 1.0 possible points. B. 48.ID: 9476874784 A registered nurse (RN) on the day shift has been assigned to care for four clients. Once the nurse has made initial rounds and checked all of the assigned clients, which client will the RN care for first? A. A client who is scheduled for surgery at 1 p.m. Correct B. A client who is scheduled for occupational therapy at 10 a.m. C. A client with metastatic carcinoma who has just received pain medication D. A client scheduled for an ultrasound at 11 a.m. who is on nothing­by­mouth (NPO) status Incorrect Awarded 0.0 points out of 1.0 possible points. C. 49.ID: 9476874722 A nurse is assigned to care for four clients. Which client would the nurse would assess first during initial rounds? A. A client with pneumonia Correct B. A client who is in Buck’s traction C. A client with chronic renal failure D. A client with a diagnosis of cirrhosis Awarded 1.0 points out of 1.0 possible points. D. 50.ID: 9476871098 A nurse is changing a client’s central intravenous (IV) catheter dressing. During the procedure, the unit secretary calls the nurse over the handheld radio and says that a health care provider has telephoned and is asking to speak to the nurse. The nurse should: A. Have the unit secretary transfer the call to the nurse’s handheld radio B. Place a sterile towel over the client’s catheter site and answer the call C. Ask the unit secretary to place the health care provider on a telephone hold until the dressing change is complete D. Ask the unit secretary to inform the health care provider that the call will be returned after the dressing change has been completed Correct Awarded 1.0 points out of 1.0 possible points. E. 51.ID: 9476872954 A man calls a nurse in the emergency department (ED) and tells the nurse that his wife “just got a bloody nose.” The man then asks the nurse what to do to stop the bleeding. The nurse tells the man immediately to: A. Bring his wife to the ED B. Place a cool compress on the back of the woman’s neck C. Place a cotton ball or tampon in the nostril that is bleeding D. Place the spouse in a sitting position, leaning forward with the head tipped downward Correct Awarded 1.0 points out of 1.0 possible points. F. 52.ID: 9476864316 A client arrives in the nursing unit after internal maxillary fixation (IMF) surgery. The nurse immediately: A. Administers an antiemetic to prevent vomiting B. Places suction equipment and wire cutters at the bedside C. Positions the client on one side with the head slightly elevated Correct D. Connects the nasogastric (NG) tube to low intermittent suction Awarded 1.0 points out of 1.0 possible points. G. 53.ID: 9476878160 A postanesthesia care unit (PACU) nurse is assessing a newly admitted client. The client’s blood pressure is 78/52 mm Hg and the pulse rate is 120 beats/min. List in order of priority the actions that the nurse should take in this situation, with 1 indicating the first action. Correct A. Making certain that the airway is patent and administering oxygen B. Elevating the client’s feet and legs C. Increasing the intravenous (IV) fluid infusion rate in accordance with unit protocol D. Notifying the anesthesia care provider and the surgeon E. Checking the client’s Foley catheter for urine output Rationale: The client is exhibiting signs of shock and requires emergency intervention. The nurse would immediately take steps to ensure a patent airway and administer oxygen. The nurse would next elevate the client’s feet and legs, keeping the head flat or elevated to a 30­degree angle. In the PACU, the nurse would be able to increase the rate of the IV fluids in accordance with unit protocol. The anesthesia care provider and the surgeon must also be notified. The nurse would then continue to assess the client, including checking urine output and reassessing vital signs. Test­Taking Strategy: Use your knowledge of the ABCs (airway, breathing, and circulation) to determine the order of priorities. Making sure the airway is patent and administering oxygen are interventions focused on the client’s immediate need, maintaining optimal respiratory status. Elevating the client’s feet and legs and increasing the IV fluid infusion rate in accordance with unit protocol both address the client’s circulatory status. Once immediate interventions have been carried out quickly, the healthcare provider is notified. Review the interventions to be undertaken immediately by the nurse when postoperative shock occurs if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Clotting HESI Concepts: Collaboration/Managing Care – Care Coordination, Perfusion/Clotting References: Hammond, B., & Zimmermann, P. (2013) Sheehy’s Manual of Emergency Care (7th ed., p. 217). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points. 2. 54.ID: 9476872934 A nurse assessing a peripheral intravenous (IV) site notes blanching, coolness, and edema at the site. What should the nurse do first? A. Remove the IV catheter Correct B. Measure the area of infiltration C. Apply a warm compress to the site D. Check for blood return from the IV site Awarded 1.0 points out of 1.0 possible points. B. 55.ID: 9476880369 A nurse monitoring a client who has just undergone cardiac catheterization notes the presence of a hematoma at the catheter insertion site. The nurse immediately: A. Places ice on the insertion site B. Applies a pressure dressing to the insertion site C. Assesses the client’s blood pressure and radial pulse D. Checks the peripheral pulse in the affected extremity Correct Awarded 1.0 points out of 1.0 possible points. C. 56.ID: 9476872916 A nurse is preparing to care for a client who is undergoing cardioversion. Once the procedure is complete, the nurse ensures that the client has a patent airway and administers oxygen to the client, then: A. Checks the client’s vital signs Correct B. Provides emotional support to the client C. Administers antidysrhythmic medication Incorrect D. Checks the client’s chest for paddle burns Awarded 0.0 points out of 1.0 possible points. D. 57.ID: 9476878181 A mother brings her child to the emergency department because an insect has flown into the child’s ear and the child is complaining of a buzzing sound. The nurse uses a flashlight in an attempt to coax the insect out of the ear, but this intervention is unsuccessful. Which action should the nurse take next? A. Placing diluted alcohol in the ear Correct B. Irrigating the ear with sterile water Incorrect C. Placing cotton in the ear to stop the buzzing sensation D. Using an otoscope and ear forceps to remove the insect Awarded 0.0 points out of 1.0 possible points. E. 58.ID: 9476876901 An emergency department nurse is conducting an assessment of a client who has sustained a circumferential burn to the right arm. What should the nurse assess first? A. Heart rate B. Radial pulse Correct C. Temperature D. Blood pressure (BP) Awarded 1.0 points out of 1.0 possible points. F. 59.ID: 9476876937 A nurse is caring for a client who is receiving intermittent feedings by way of a nasogastric tube. Before feeding the client, the nurse checks tube placement and determines correct placement, then: A. Checks the residual volume Correct B. Warms the feeding to 100° F (37.8°C) C. Irrigates the nasogastric tube with tap water D. Raises the head of the client’s bed 15 degrees Awarded 1.0 points out of 1.0 possible points. G. 60.ID: 9476876979 A health care provider places an intestinal tube in a client. After insertion, the nurse immediately: A. Initiates a tube feeding B. Positions the client on the right side Correct C. Secures the tube to the client’s face with tape D. Documents the insertion and the client’s tolerance of the procedure Awarded 1.0 points out of 1.0 possible points. H. 61.ID: 9476880363 A client is admitted to the emergency department with a complaint of severe crushing chest pain that radiate down both arms. The client is dyspneic, and the nurse immediately places a cannula on the client to deliver oxygen at 4 L/min and inserts an intravenous (IV) catheter. The health care provider orders an immediate troponin determination, a chest x­ray, a 12­lead electrocardiogram (ECG), and morphine sulfate 2 mg IV. What will the nurse do first? A. Obtain a 12­lead ECG B. Administer the IV morphine sulfate Correct C. Call radiology to set up the chest x­ray D. Draw blood for the troponin determination Rationale: Pain control is a priority, because the chest pain indicates cardiac ischemia. Pain also stimulates the autonomic nervous system and increases preload, resulting in increased myocardial demand and further cardiac damage. The nurse would administer oxygen to the client and administer morphine sulfate. Once the morphine sulfate has been administered, the nurse can obtain the ECG, which may provide evidence of cardiac damage and the location of myocardial ischemia. Although an evaluation of the client’s troponin level may be of use in the choice of treatment, this is an assessment, and the situation requires action. Although the chest x­ray might show cardiac enlargement, having the chest x­ray would not influence immediate treatment, so is not the priority. Test­Taking Strategy: Use the process of elimination, noting the strategic word “first.” Remember that pain can increase myocardial demand and further cardiac damage. The only option that will relieve the pain is the administration of IV morphine sulfate. If you had difficulty with this question, review the immediate intervention for a client with chest pain. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Clinical Judgment HESI Concepts: Clinical Decision­Making/Clinical Judgment, Collaboration/Managing Care – Care Coordination Reference: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., p. 750). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. I. 62.ID: 9476879540 A nurse is monitoring a client in the active stage of labor who is receiving oxytocin . The nurse checks the fetal monitor and sees this: The nurse immediately places an oxygen cannula on the mother and then: A. Documents the findings B. Stops the oxytocin infusion Correct C. Places the mother in a supine position D. Transports the client to the delivery room Awarded 1.0 points out of 1.0 possible points. J. 63.ID: 9476871071 A client is brought to the labor unit, and, as the nurse is attaching the fetal heart monitor, the client’s membranes rupture spontaneously. The nurse immediately assesses the fetal heart rate, then: A. Checks the client’s temperature B. Checks the character of the amniotic fluid Correct C. Prepares the client for immediate delivery D. Documents the spontaneous rupture of the client’s membranes Awarded 1.0 points out of 1.0 possible points. K. 64.ID: 9476867231 A client who has sustained an open pneumothorax as a result of a gunshot wound is brought to the emergency department (ED) with an occlusive dressing, placed by a paramedic, over the wound. The ED nurse assesses the client and notes extreme respiratory distress and distended jugular neck veins. On the basis of these assessment findings, the nurse should first: A. Contact the health care provider B. Remove the occlusive dressing Correct C. Assess the client’s blood pressure Incorrect D. Check the client’s pulse oximetry readings Awarded 0.0 points out of 1.0 possible points. L. 65.ID: 9476874793 A client who sustained serious rib fractures in a motor vehicle accident is exhibiting signs of flail chest. With which immediate treatment measure does the nurse prepare to assist? A. Inserting a chest tube B. Splinting the ribs with a rib strap C. Administering an opioid analgesic for pain D. Endotracheal intubation with mechanical ventilation Correct Awarded 1.0 points out of 1.0 possible points. M. 66.ID: 9476876968 A client with pneumonia is admitted to the hospital, and the health care provider writes prescriptions for the client. Place the health care provider’s prescriptions in order of priority for the nurse, with 1 as the first action. Correct A. Administering oxygen at 3 L/min by way of nasal cannula B. Obtaining sputum specimens for a Gram stain and culture and sensitivity C. Administering a prescribed antibiotic by way of the intravenous (IV) route D. Obtaining a chest x­ray Awarded 1.0 points out of 1.0 possible points. 2. 67.ID: 9476872908 A nurse conducting a postpartum assessment notes that the client’s uterus is not firmly contracted. The nurse would first: A. Massage the uterine fundus Correct B. Check the client’s vital signs C. Contact the health care provider D. Prepare to administer a rapid infusion of dilute oxytocin Awarded 1.0 points out of 1.0 possible points. B. 68.ID: 9476882022 A client who has just undergone surgery is receiving continuous intravenous (IV) morphine sulfate for pain control. On assessment of the client, what does the nurse check first? A. Temperature B. Respiration Correct C. Urine output D. Surgical incision Awarded 1.0 points out of 1.0 possible points. C. 69.ID: 9476874768 A nurse monitoring a client undergoing peritoneal dialysis notes that the client is experiencing problems with inflow of the dialysate. The nurse first: A. Repositions the client B. Milks the peritoneal dialysis tube C. Places the client in a supine low Fowler position Incorrect D. Asks the client about recent problems with constipation Correct Awarded 0.0 points out of 1.0 possible points. D. 70.ID: 9476872929 A nurse is caring for a client undergoing peritoneal dialysis. The nurse checks the client and notes that the drainage from the outflow catheter is cloudy. The nurse first: A. Increases the flow of peritoneal dialysis B. Adds heparin sodium to the dialysate solution C. Adds antibiotics to the next several dialysis bags D. Checks the client’s white blood cell (WBC) count Correct Awarded 1.0 points out of 1.0 possible points. E. 71.ID: 9476876916 A nurse in charge of an emergency department (ED) arrives at work at 11 p.m. and is told that four registered nurses scheduled to work will not be reporting to work because they are ill. Every trauma room is busy, and emergency medical services has just called to report that several victims of a fire will be brought to the ED. The nurse in charge immediately: A. Closes the ED temporarily to incoming clients B. Calls the nursing supervisor to discuss activation of the disaster plan Correct C. Tells emergency medical services to take the victims to another hospital D. Demands that the nurses from the evening shift stay until all of the victims have been treated Awarded 1.0 points out of 1.0 possible points. F. 72.ID: 9476867208 A woman is brought to the emergency department (ED) in a severe state of anxiety after witnessing a child’s drowning. The nurse assigned to care for the client would first: A. Teach the client relaxation techniques B. Take the client to a quiet room with minimal stimulation Correct C. Encourage the client to describe the events of the accident Incorrect D. Provide the client with a gross motor activity to drain some tension Awarded 0.0 points out of 1.0 possible points. G. 73.ID: 9476876911 A nurse reviews the laboratory values of a client with bipolar disorder who is taking lithium carbonate (Lithobod) and notes that the serum lithium level is 2.0 mEq/L (2.0 mmol/L). On the basis of this laboratory value, the nurse first: A. Calls the health care provider Correct B. Places the client in the seclusion room C. Administers the prescribed dose of lithium carbonate D. Documents the laboratory report in the client’s record Awarded 1.0 points out of 1.0 possible points. H. 74.ID: 9476878144 A nurse on the surgical nursing unit is assessing a postoperative client who is experiencing tachycardia and tachypnea. The client’s blood pressure is 88/60 mm Hg and the pulse rate is 100 beats/min. The client is receiving oxygen at 2 L/min by way of nasal cannula, and the pulse oximetry reading is 92%. Once it has been determined that the airway is patent, what should the nurse do next? A. Notify the surgeon B. Check the client’s dressing for bleeding Incorrect C. Prepare a blood transfusion administration set D. Elevate the client’s feet and legs above heart level Correct Rationale: The client is exhibiting signs of shock and requires emergency intervention. When shock is suspected, the nurse immediately takes steps to ensure a patent airway and administers oxygen. In this case, the client is already receiving oxygen and the nurse has determined that the airway is patent. The nurse would next elevate the client’s feet and legs, keeping his or her head flat or elevated 30 degrees. The nurse should assess the dressing for any bleeding and, if bleeding is noted, apply direct pressure. The surgeon would be notified. The surgeon may prescribe an increase in intravenous fluids or a blood transfusion; however, preparing a transfusion administration set at this time is not indicated. Test­Taking Strategy: Note the strategic word “next” and use your knowledge of the ABCs (airway, breathing, and circulation). Because the nurse has already determined that the client has a patent airway and is breathing, you must choose the option that addresses the client’s circulatory status. Review the immediate nursing interventions in the event of postoperative shock if you had difficulty with this question. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Fluid and Electrolytes HESI Concepts: Clinical Decision­Making/Clinical Judgment, Fluids and Electrolytes Reference: Ignatavicius, D., & Workman, M. (2013). Medical­surgical nursing: Patient­centered collaborative care. (7th ed., p. 818). St. Louis: Saunders. Awarded 0.0 points out of 1.0 possible points. I. 75.ID: 9476864380 A nurse is assigned to care for a client in the fourth stage of labor. What does the nurse plan to do first? A. Provide oral fluids B. Assess the uterine fundus Correct C. Place an ice pack on the perineal area D. Allow the father and grandparents to visit and hold the newborn Rationale: The fourth stage of labor is the stage of physical recovery for the mother and infant. It lasts from the delivery of the placenta through the first 1 to 4 hours after birth. One potential complication after delivery is hemorrhage, and the most significant source of bleeding is the site where the placenta is attached. Therefore the nurse should first assess the client’s uterine fundus to ensure that it is firm. The nurse must also check the client’s vital signs. Once these interventions have been performed, the nurse checks lochial flow, assesses the episiotomy site, places ice on the perineal area to promote comfort, and provides the mother with oral fluids. Once physiological needs have been met, the nurse may allow visitors to see the mother and newborn. Test­Taking Strategy: Use the steps of the nursing process to answer the question. The correct option is the only one that addresses assessment, the first step. Additionally, use your knowledge of the ABCs (airway, breathing, and circulation). Assessing the uterine fundus provides information about blood loss and circulatory status. Review priority nursing assessments in the fourth stage of labor if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Care Coordination, Reproduction HESI Concepts: Collaboration/Managing Care – Care Coordination, Reproduction Reference: McKinney, E., James, S., Murray, S., Nelson, K. & Ashwill, J. (2013). Maternal­child nursing (4th ed., pp. 333, 335). St. Louis: Elsevier. Awarded 1.0 points out of 1.0 possible points. J. 76.ID: 9476867237 A labor nurse is caring for a client with a known history of sickle cell anemia. Which action does the nurse implement as a priority to help prevent sickle cell crisis? A. Providing continuous fetal monitoring B. Administering intravenous (IV) fluids as prescribed Correct C. Maintaining strict asepsis when performing procedures Incorrect D. Administering oxygen only if the client complains of shortness of breath Awarded 0.0 points out of 1.0 possible points. K. 77.ID: 9476864368 A nurse is caring for a client who sustained a serious burn injury 24 hours ago. On assessment, the nurse finds that the client’s urine output is 0.3 mL/kg/hr, blood pressure is 88/60 mm Hg, and heart rate is 110 beats/min. The nurse would immediately: A. Notify the health care provider Correct B. Cover the client with a warm blanket C. Increase the intravenous (IV) flow rate D. Make a note to reassess the client in 30 minutes Awarded 1.0 points out of 1.0 possible points. L. 78.ID: 9476871053 A nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action should the nurse take first? A. Contacting the health care provider B. Checking the client’s apical heart rate C. Calling for assistance in getting the client out of bed D. Lowering the head of bed slowly until the dizziness passes Correct Awarded 1.0 points out of 1.0 possible points. M. 79.ID: 9476869389 A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain that radiates to the jaw. List in order of priority the actions that the nurse should take in this situation, with 1 as the first action. Correct A. Administering a nitroglycerin tablet sublingually B. Assisting the client to back to bed C. Contacting the health care provider D. Obtaining a 12­lead electrocardiogram Awarded 1.0 points out of 1.0 possible points. 2. 80.ID: 9476864321 A client arrives at the emergency department with an episode of status asthmaticus. The nurse first: A. Obtains a set of vital signs B. Starts an intravenous (IV) line C. Places the client in a high Fowler position Correct D. Administers oxygen at 21% by way of a Venti mask Incorrect Awarded 0.0 points out of 1.0 possible points. B. 81.ID: 9476871088 A nurse teaches a client with urolithiasis about the signs of urinary obstruction and the interventions to be taken if obstruction is suspected. The nurse tells the client that if signs of urinary obstruction occur, the client should immediately: A. Drink 1500 mL of water B. Check the pH of the urine C. Perform a self­catheterization D. Call the health care provider Correct Awarded 1.0 points out of 1.0 possible points. C. 82.ID: 9476869362 A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client’s skin is warm and flushed and the pulse and respiratory rate are increased from the client’s baseline. The nurse would first: A. Give the client 4 oz (120 ml) of orange juice B. Administer a bolus dose of 50% dextrose C. Check the client’s capillary blood glucose Correct D. Prepare an intravenous (IV) insulin infusion Awarded 1.0 points out of 1.0 possible points. D. 83.ID: 9476869396 A client undergoing mechanical ventilation pulls out the endotracheal tube. The nurse would immediately: A. Call a code B. Suction the client C. Prepare for re­intubation Correct D. Call x­ray to obtain a chest x­ray Awarded 1.0 points out of 1.0 possible points. E. 84.ID: 9476879509 A nurse is monitoring a client with an oral endotracheal tube inserted that is attached to mechanical ventilation. The nurse assesses the client and notes that the client has unequal breath sounds. On the basis of this assessment finding, the nurse would first: A. Suction the endotracheal tube B. Contact the health care provider C. Apply humidified oxygen to the client D. Check the depth marking at the client’s lips Correct Awarded 1.0 points out of 1.0 possible points. F. 85.ID: 9476872979 A cardiac monitor alarm sounds, and the nurse notes an erratic rhythm on the screen. The immediate nursing action is to: A. Call a code B. Assess the client Correct C. Obtain a rhythm strip for evaluation D. Check the cardiac electrodes attached to the client Incorrect Awarded 0.0 points out of 1.0 possible points. G. 86.ID: 9476880383 A nurse assesses the closed chest tube drainage system of a client who underwent pulmonary wedge resection 12 hours ago. The nurse notes that there has been no chest tube drainage for the past hour. The nurse first: A. Strips the chest tube B. Assesses the client’s heart rate C. Checks for an air leak in the system D. Checks for obstructions or kinks in the chest drainage system Correct Awarded 1.0 points out of 1.0 possible points. H. 87.ID: 9476879521 A nurse is suctioning an adult client undergoing mechanical ventilation through a tracheostomy tube. During the procedure, the nurse notes that the client’s oxygen saturation on pulse oximetry has dropped to 89%. The nurse would: A. Stop and oxygenate the client with 100% oxygen Correct B. Call respiratory therapy to check the pulse oximeter C. Increase the suction pressure and continue suctioning D. Obtain a pediatric suction catheter and suction the client Awarded 1.0 points out of 1.0 possible points. I. 88.ID: 9476882013 A nurse is caring for a client with a closed chest tube drainage system. When the client is repositioned, the chest tube is disconnected. The nurse immediately: A. Notifies the health care provider B. Instructs the client to perform a Valsalva maneuver C. Submerges the end of the tube in a bottle of sterile water Correct D. Clamps the chest tube as close to the insertion site as possible Awarded 1.0 points out of 1.0 possible points. J. 89.ID: 9476867201 A ventilator’s high­pressure alarm sounds. The nurse rushes to the client’s room and assesses the client but is unable to determine the cause of the alarm. The nurse immediately: A. Calls the respiratory therapist B. Inserts an oral airway into the client C. Ventilates the client manually with the use of a resuscitation bag Correct D. Silences the alarm and continues trying to determine the cause of the alarm Awarded 1.0 points out of 1.0 possible points. K. 90.ID: 9476864324 A nurse performing nasopharyngeal suctioning and suddenly notes the presence of bloody secretions in the catheter. The nurse should immediately: A. Contact the health care provider B. Suction more vigorously to remove the blood C. Check the degree of suction pressure being applied Correct D. Encourage the client to cough out the bloody secretions Rationale: Bloody secretions are an unexpected outcome of suctioning. If they are noted, the nurse first assesses the client and then checks the degree of suction pressure being applied. The degree of suction pressure may need to be decreased. The nurse must also ensure that intermittent suction and catheter rotation are being performed during suctioning. Continuing with the suctioning or suctioning more vigorously will cause increased trauma and therefore increased bleeding. Suctioning is normally performed in clients who are unable to expectorate secretions. Therefore it is unlikely that the client would be able to cough out the bloody secretions. The health care provider may need to be notified, but this is not the first action. Test­Taking Strategy: Use the process of elimination. Realizing that it is unlikely that the client would be able to cough out the bloody secretions will assist you in eliminating this option. Next eliminate the option including the word “vigorously.” To select from the remaining options, focus on the subject, the presence of bloody secretions, to identify the correct option. Review immediate nursing actions in the event of complications during suctioning if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Implementation Content Area: Delegating/Prioritizing Giddens Concepts: Clinical Judgment, Safety HESI Concepts: Clinical Decision­Making/Clinical Judgment, Safety Reference: Perry, A., Potter, P., & Ostendorf, W. (2014). Clinical nursing skills & techniques (8th ed., p. 637). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. L. 91.ID: 9476867248 A client with a fracture of the left arm that has been set in a cast complains of severe, diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the pulse distal to the site of injury has weakened and that the tissue is pale. On the basis of these assessment findings, the nurse first: A. Elevates the extremity B. Contacts the health care provider Correct C. Continue to assess the client’s pain level D. Checks to see whether it is time for more pain medication Awarded 1.0 points out of 1.0 possible points. M. 92.ID: 9476871042 A nurse who is caring for a client with a tracheostomy tube notes heavy bleeding from the stoma and sees that the tracheostomy tube pulsates with the client’s heartbeat. Suspecting that a trachea– innominate artery fistula has developed, the nurse immediately removes the tracheotomy tube. The next nursing action is: A. Transporting the client to surgery Incorrect B. Initiating an intravenous (IV) line C. Inserting a smaller tracheostomy tube D. Applying direct pressure to the innominate artery at the stoma site Correct Awarded 0.0 points out of 1.0 possible points. N. 93.ID: 9476864362 A nurse is caring for a client who had a tracheostomy tube inserted 24 hours ago. The client begins to cough vigorously, accidentally decannulating (dislodging) the tube. The nurse immediately: A. Calls respiratory therapy B. Calls the health care provider C. Replaces the tracheostomy tube D. Ventilates the client with the use of a manual resuscitation bag and face mask Correct Awarded 1.0 points out of 1.0 possible points. O. 94.ID: 9476878194 A nurse determines that a client with type 1 diabetes mellitus is having a mild hypoglycemic reaction. The nurse immediately gives the client: A. 6 oz (180 ml) of diet soda Incorrect B. A graham cracker C. A full­size candy bar D. 1 tablespoon of honey Correct Awarded 0.0 points out of 1.0 possible points. P. 95.ID: 9476867223 The mother of a 6­year­old calls a nurse who lives in the neighborhood and reports that her child has accidentally splashed alcohol into her eyes. The nurse tells the mother immediately to: A. Darken the room B. Have the child rest with the eyes closed C. Have the child wipe the eyes with a wet towel D. Hold the child’s head with the eyes under running lukewarm tap water for 20 minutes Correct Awarded 1.0 points out of 1.0 possible points. Q. 96.ID: 9476871079 A nurse notes that a client who has just been given a diagnosis of AIDS appears anxious and is reluctant to ask questions. Which initial action by the nurse is the best way to deal with the observation? A. Allowing the client time to be alone Incorrect B. Asking a family member to be present when caring for the client C. Asking the client direct questions regarding feelings about having the disease D. Identifying common fears and questions expressed by other clients with the same diagnosis Correct Rationale: Identifying common fears and questions expressed by other clients often encourages the client to ask questions that he or she has thought of but not verbalized. The nurse should plan to spend additional time with the client. Requesting that a family member be present could reduce the client’s anxiety and may be tried after the nurse has talked to the client. However, communication with the client is needed to determine the source of the anxiety. Asking the client direct questions is initially a nontherapeutic communication technique. The client may not be able to explain or discuss his or her feelings about having the disease. Test­Taking Strategy: Use your knowledge of therapeutic communication techniques, noting the strategic word “initial” in the query of the question. Eliminate the options that do not address the client’s feelings. To select from the remaining options, note the words “direct questions,” which will assist you in eliminating this option. Review therapeutic communication techniques if you had difficulty with this question. Level of Cognitive Ability: Applying Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Delegating/PrioritizingGiddens Concepts: Anxiety, Communication HESI Concepts: Communication, Mood and Affect – Anxiety References: Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical­surgical nursing: Assessment and management of clinical problems (9th ed., pp. 242­243). St. Louis: Mosby. Potter, P., Perry, A. G., Stockert, P. A., & Hall, A. M. (2013). Fundamentals of nursing. (8th ed., p. 321). St. Louis: Mosby. Awarded 0.0 points out of 1.0 possible points. R. 97.ID: 9476878117 A client who is receiving a blood transfusion suddenly experiences chills, a high fever, vomiting, and diarrhea and complains of abdominal cramping. The nurse, noting that the client’s blood pressure has dropped significantly, suspects that the client is experiencing a bacterial sepsis reaction to the transfusion. The nurse immediately stops the blood transfusion, hangs an intravenous (IV) bag of normal saline solution to be infused at a keep­vein­open rate, and contacts the health care provider, who prescribes several interventions. Which prescription will the nurse implement first? A. Contacting the blood bank B. Obtaining blood for cultures Correct C. Administering the prescribed IV corticosteroid Incorrect D. Administering the prescribed IV broad­spectrum antibiotic Awarded 0.0 points out of 1.0 possible points. S. 98.ID: 9476867265 A client returns from the operating room after the application of skeletal traction to treat a fractured femur. Which action would the nurse implement first in the care of the client? A. Checking the client’s temperature B. Asking the client about the presence of pain C. Instructing the client in the use of the trapeze Incorrect D. Assessing the neurovascular status of the affected extremity Correct Awarded 0.0 points out of 1.0 possible points. T. 99.ID: 9476872964 A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. Which health care provider’s prescriptions does the nurse implement first? A. Obtaining a pulse oximetry reading Correct B. Encouraging the intake of oral fluids C. Administering the prescribed antibiotic D. Administering pertussis immune globulin Incorrect Awarded 0.0 points out of 1.0 possible points. U. 100.ID: 9476876986 A home care nurse is assigned to visit a client who lives alone. The client was recently discharged from the hospital after cardiac catheterization and placement of two stents in the right main coronary artery. The client tells the nurse that she has been experiencing chest pain and has taken 3 sublingual nitroglycerin tablets, with no relief. What immediate action should the nurse take? A. Call an ambulance to take the client to the ED Correct B. Drive the client to the emergency department (ED) Incorrect C. Inform the home healthcare agency of the situation D. Call a family member to come and stay with the client Awarded 0.0 points out of 1.0 possible points. [Show More]

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