HESI V4 EXIT EXAM PN 2018110 QUESTION AND ANSWER( Complete Solution Rated A)

2018 HESI PN V4 EXIT EXAM 110 QUESTION AND ANSWER(S) 1. Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for ...

2018 HESI PN V4 EXIT EXAM 110 QUESTION AND ANSWER(S) 1. Assessment by the home health nurse of an older client who lives alone indicates that client has chronic constipations. Daily medications include furosemide for hypertension and heart failure and laxatives. To manage the client’s constipation, which suggestions should the nurse provide? (Select all that apply)  Decrease laxative use to every other day, and use oil retention enemas as needed.  Include oatmeal with stewed pruned for breakfast as often as possible.  Increase fluid intake by keeping water glass next to recliner.  Recommend seeking help with regular shopping and meal preparation.  Report constipation to healthcare provider related to cardiac medication side effects.  Rational: older adult are at higher risk for chronic constipation due to decreased gastrointestinal muscle tone leading to reduce motility. Oatmeal with prunes increases dietary fiber and bowel stimulation, thereby decreasing need for laxatives. Increased fluid intake also decreases constipations. Assistance with food preparation might help the client eat more fresh fruits and vegetables and result on less reliance on microwaved and fast foods, which are usually high in sodium and fat with little fiber. Laxatives can be reduced gradually by improving the diet, without resorting to using enemas. 2. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and which action should the nurse implement next?  Report the incident to the local child protective services.  Find a home health agency that specializes in brain injuries.  Determine the mother’s basic skill level in providing care.  Consult the ethics committee to determine how to proceed.  Rational: Although the mother states she is a capable caregiver, the client is manifesting disuse syndrome complications, and the mother’s skill in providing basic care should be determined. Further assessment is needed before implementing other nursing actions. 3. After the risk and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart heating during the procedure. What action should the nurse take?  Explain the procedure again in detail and clarify any misconceptions.  Notify the healthcare provider of the client’s lack of understanding.  Call the client’s next of kin and have them provide verbal consent.  Postpone the procedure until the client understands the risk and benefits.  Rational: the nurse is only witnessing the signature, and is not responsible for the client’s understanding of the procedure. The healthcare provider needs to clarify any questions and misconceptions. Explaining the procedure again is the healthcare provider’s legal responsibility. The other options are not indicated. 4. In assessing a client at 34-weeks’ gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?  Elevated thyroid hormone level.  Hematocrit of 28%.  Heart rate of 92 beats per minute.  Systolic murmur.  Rational: although physiologic anemia is expected in pregnancy, a hematocrit of 28% is below pregnant norms and could signify iron-deficiency anemia. Other options are normal finding pregnancy 5. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory values requires intervention by the nurse?  Total calcium 9 mg/dl (2.25 mmol/L SI)  Creatinine 4 mg/dl (354 micromol/L SI)  Phosphate 4 mg/dl (1.293 mmol/L SI)  Fasting glucose 95 mg/dl (5.3 mmol/L SI) 6. A clinical trial is recommended for a client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client’s son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond?  Ask the client with her children present if she fully understands the decision she has made.  Discuss success of clinical trials and ask the client to consider participating for one month.  Explain to the family that they must accept their mother’s decision.  Explore the client’s decision to refuse treatment and offer support  Rationale: as long as the client is alert, oriented and aware of the disease prognosis, the healthcare team must abide by her decisions. Exploring the decision with the client and offering support provides a therapeutic interaction and allows the client to express her fears and concerns about her quality of life. Other options are essentially arguing with the client’s decisions regarding her end of life treatment or diminish the opportunity for the client to discuss her feelings 7. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran one year ago, his spouse states that the client no longer runs, bur sits and watches television most of the day. Which is most important for the nurse to include in this client’s plan of care for today?  Assist client in identifying goals for the day.  Encourage client to participate for one hour in a team sport.  Schedule client for a group that focuses on self-esteem.  Help client to develop a list of daily affirmations.  Rationale: clients with severe depression have low energy and benefit from structured activities because concentration is decreased. The client participate in care by identifying goals for the day is the most important intervention for the client’s first day at the unit. Other options can be implemented over time, as the depression decreases. 8. An adult who is 5 feet 5 inches (165.1 cm) tall and weighs 90 lb. (40.8 Kg) is admitted with a diagnosis of chronic anorexia. The client receives a regular diet for 2 days, and the client’s medical records indicates that 100% of the diet provided has been consumed. However the client’s weight on the third day morning after admission is 89 lb. (40.4 Kg). What action should the nurse implement?  Examine the client’s room for hidden food.  Assign staff to monitor what the client eats.  Ask the client if the food provided is being eaten or discarded.  Provide the client with a high calorie diet.  Rationale: clients with an eating disorder have an unhealthy obsession with food. The client’s continued weight loss, despites indication that the client has consumed 100% of the diet, should raise questions about the client’s intake of the food provided, so the client should be observed during meals to prevent hiding or throwing away food. Other options may be accurate but ineffective and unnecessary. 9. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?  Conversion of the client’s PPD test from negative to positive.  Length of time of the exposure to tuberculosis.  Current diagnosis of hepatitis B.  History of intravenous drug abuse.  Rationale: prophylactic treatment of tuberculosis with isoniazid is contraindicated for persons with liver disease because it may cause liver damage. The nurse should withhold the prescribed dose and contact the healthcare provider. Other options do not provide data indicating the need to question or withhold the prescribed treatment. 10. The nurse walks into a client’s room and notices bright red blood on the sheets and on the floor by the IV pole. Which action should the nurse take first?  Clean up the spilled blood to reduce infection transmission.  Notify the healthcare provider that the client appears to be bleeding.  Apply direct pressure to the client’s IV site.  Identify the source and amount of bleeding.  Rationale: the nursed should first assess the client to determine the action that should be taken. Patient safety is the priority; other options are not priority. 11. During a routine clinic visit, an older female adult tells the nurse that she is concerned that the flu season is coming soon, but is reluctant to obtain the vaccination. What action should the nurse take first?  Determine when the client last had an influenza vaccination.  Discuss the concerns expressed by the client about the vaccination.  Ask about any recent exposure to persons with the flu or other viruses.  Review the informed consent form for the vaccination with the client.  Rationale: the nurse should first address the concerns identified by the client, before taking other actions, such as obtaining information about past vaccinations, exposure to the flu, or reviewing the informed consent form. 12. A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs q2 hours. Which finding should the nurse report immediately to the healthcare provider?  Confusion and tremors  Yellowing and itching of skin.  Abdominal pain and vomiting  Anorexia and abdominal distention  Rationale: daily alcohol is the likely etiology for the client’s pancreatitis. Abrupt cessation of alcohol can result in delirium tremens (DT) causing confusion and tremors, which can precipitate cardiovascular complications and should be reported immediately to avoid life-threatening complications. The other options are expected findings in those with liver dysfunction or pancreatitis, but do not require immediate action. 13. The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using medela haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple’s elongated tip in the back of the oral cavity. What instructions should the nurse provide the mother about feedings?  Squeeze the nipple base to introduce milk into the mouth  Position the baby in the left lateral position after feeding  Alternate milk with water during feeding  Hold the newborn in an upright position  Rationale: the mother should be instructed to hold the infant during feedings in a sitting or upright position to prevent aspiration. Impaired sucking is compensated by the use of special feeding appliances and nipples such as the haberman feeder that prevents aspiration by adjusting the flow of mild according to the effort of the neonate. Squeezing the nipple base may introduce a volume that is greater than the neonate can coordinate swallowing. The preferred positon of an infant after feeding is on the right side to facilitate stomach emptying. Sucking difficulty impedes the neonate’s intake of adequate nutrient needed for weight gain and water should be provided after the feeding to cleanse the oral cavity and not fill up the neonate’s stomach. 14. Following and gunshot wound, an adult client a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of type A Rh negative, reporting that there is not type AB negative blood currently available. Which intervention should the nurse implement?  Transfuse Type A negative blood until type AB negative is available.  Recheck the client’s hemoglobin, blood type and Rh factor.  Administer normal saline solution until type AB negative is available  Obtain additional consent for administration of type A negative blood  Rationale: those who have type AB blood are considered universal recipients using A or B blood types that is the same Rh factor. The client’s hemoglobin is critically low and the client should receive a unit of blood that is type A, which must be Rh negative blood. Other options are not indicated in this situation. 15. A young adult female college student visits the health clinic in early winter to obtain birth control pills. The clinic nurse asks if the student has received an influenza vaccination. The student stated she did not receive vaccination because she has asthma. How should the nurse respond?  Offer to provide the influenza vaccination to the student while she is at the clinic  Encourage the student to obtain a vaccination prior to the next influenza season.  Confirm that a history of asthma can increase risks associated with the vaccine.  Advise the student that the nasal spray vaccine reduces side effects for people with asthma.  Rationale: person with asthma are at increased risk related to influenza and should receive the influenza vaccination prior to or during influenza season. Waiting until the start of the next season places the student at risk for the current season. The vaccination does not increase risk for persons with asthma but the nasal spray may result in increased wheezing after receiving that form of the vaccination. 16. A client with eczema is experiencing severe pruritus. Which PRN prescriptions should the nurse administer? (Select all that apply)  Topical corticosteroid.  Topical scabicide.  Topical alcohol rub.  Transdermal analgesic.  Oral antihistamine  Rationale: anti-inflammatory actions of topical corticosteroids and oral antihistamines provide relief from severe pruritus (itching). Other options are not indicated. 17. The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning am prepping this client, rank the actions in the sequence they should be implemented. (Place to first action on the top on the last action on the bottom.)  Correct : ODCP  1. Open the sterile catheter kit close to the client’s perineum.  2. Don sterile gloves and prepare to sterile field  3. Cleanse the urinary meatus using the solution, swabs, and forceps provided  4. Place distal end of the catheter in sterile specimen cup and insert catheter into meatus  Rationale: First the kit should be open near the clients to minimize the risk of contamination during the collection of the sterile specimen. Once the kit is opened, sterile gloves should be donned to prepare the sterile field. Then the clients’ meatus should be cleansed, and the catheter inserted while to distal end of the catheter drains urine into the sterile specimen cup or receptacle. 18. An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies. What is the best response by the nurse?  Explain that the client will start to lose consciousness and his body system will slow down  Reassure the spouse that the healthcare provider will let her know when to call the children  Offer to discuss the client’s health status with each of the adult children  Gather information regarding how long it will take for the children to arrive  Rationale: Expected signs of approaching death include noticeable changes in the client’s level of consciousness and a slowing down of body systems. The nurse should answer the spouse’s questions about the signs of imminent death rather than offering reassurance that may or may not be true. Other options listed may be implemented but the nurse should first answer the spouse’s question directly. 19. When should intimate partner violence (IPV) screening occur?  As soon as the clinician suspects a problem  Only when a client presents with an unexplained injury  As a routine part of each healthcare encounter  Once the clinician confirms a history of abuse  Rationale: Universal screening for IPV is a vital means to identify victims of abuse in relationship. The suspicious of different clinicians vary greatly, so screening would not be implemented consistently. The client should be screened regardless of the presence of injury. Although history of abuse is difficult to confirm, screening should occur regardless, and this incident may know may be initial case of abuse. 20. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?  Instructions about how much fluid the child should drink daily  information about non-pharmaceutical pain reliever measures  Referral for social services for the child and family  Signs of addiction to opioid and medications  Rationale: It is essential that the child and family understands the importance of adequate hydration in preventing the stasis-thrombosis-ischemia cycle of a crisis that has a specific plan for hydration is developed so that a crisis can be delayed. Other choices listed are not the most important topics to include in the discharge teaching. 21. What action should the school nurse implement to provide secondary prevention to a schoolage children?  Collaborate with a science teacher to prepare a health lesson  Prepare a presentation on how to prevent the spread of lice  Initiate a hearing and vision screening program for first-graders  Observe a person with type 1 diabetes self-administer a dose of insulin  Rationale: Community care occurs at primary, secondary, and tertiary levels of prevention. Primary prevention involves interventions to reduce the incidence of disease. Secondary prevention includes screening programs to detect disease. Tertiary prevention provides treatment directed toward clinically apparent disease. Secondary prevention focuses on screaming children for a specific disease processes such as hearing and vision screening. The other options are not examples of secondary prevention. 22. While assisting a client who recently had a hip replacement into a bed pan, the nurse notices that there is a small amount of bloody drainage on the surgical dressing, the client’s skin is warm to the touch, and there is a strong odor from the urine. Which action should the nurse take?  Obtain a urine sample from the bed pan  Remove dressing and assess surgical site  Insert an indwelling urinary catheter  Measure the client’s oral temperature  Rationale: The strong odor from the urine and skin that is warm to the touch may indicate that the client has a urinary tract infection. Assessing the client’s temperature provides objective information regarding infection that can be reported to the healthcare provider. Urine should be obtained via a clean catch, not the bed pan where it has been contaminated. The drainage on the dressing is normal and does not require direct conservation at this time. An indwelling catheter should be avoided if possible because it increases the risk of infection. 23. While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side-table. The client is currently receiving at 2 litters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?  Assist the client to lie back in bed  Call for an Ambu resuscitating bag  Increase oxygen to 6 litters/minute  Administer a nebulizer Treatment  Rationale: The client needs an immediate medicated nebulizer treatment. Sitting in an upright position with head and arms resting on the over-bed table is an ideal position to promote breathing because it promotes lung expansion. Other actions me be accurate but not yet indicated. 24. A client with emphysema is being discharged from the hospital. The nurse enters the client’s room to complete discharge teaching. The client reports feeling a little short of breath and is anxious about going home. What is the best course of action?  Postpone discharge instructions at this time and offer to contact the client by phone in a few days  Invite the client to return to the unit for discharge teaching in a few days, when there is less anxiety  Provide only necessary information in short, simple explanations with written instructions to take home  Give detailed instructions speaking slowly and clearly while looking directly at the client when speaking  Rationale: Simple, short explanations should be provided. Information is not retained when the recipient is anxious, and too much information can increase worry. Ethically, discharge instructions may not be postponed. 25. An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He is found wandering into another client’s room and is return to his room by the unlicensed assistive personnel (UAP). What actions should the nurse take? (Select all that apply).  Apply soft upper limb restrains and raise all four bed rails  Report mental status change to the healthcare provider  Assess the client’s breath sounds and oxygen saturation  Assign the UAP to re-assess the client’s risk for falls  Review the client’s most recent serum electrolyte values  Rationale: The healthcare provider should be informed of changes in the client’s condition (B) because this behavior may indicate a postoperative complication. Diminished oxygenation (C) and electrolyte imbalance (E) may cause increased confusion in the older adult. Raising all four bed rails (A) may lead to further injury if the client climbs over the rails and falls and restrains should not be applied until other measures such as re-orientation are implemented. The nurse should assess the client’s increased risk for falls, rather than assigning this to the UAP (D). 26. A client is admitted to a medical unit with the diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administered to prevent the development of Wernicke's syndrome?  Lorazepam (Ativan)  Famotidine (Pepcid)  Thiamine (Vitamin B1)  Atenolol (Tenormin)  Rationale: Thiamine replacement is critical in preventing the onset of Wernickes encephalopathy, an acute triad of confusion, ataxia, and abnormal extraocular movements, such as nystagmus related to excessive alcohol abuse. Other medications are not indicated. 27. When conducting diet teaching for a client who was diagnosed with nutritional anemia in pregnancy, which foods should the nurse encourage the client to eat? (Select all that apply)  Seeds, spices, lettuce  Consomme, celery, carrot  Oranges, orange juice, bananas  Fortified whole wheat cereals, whole-grain pasta, brown rice  Spinach, kale, dried raisins and apricots  Rationale: Nutritional anemia in pregnancy should be supplemented with additional iron in the diet. Foods that are high in iron content are often protein based, whole grains (D), green leafy vegetables and dried fruits (E). (A, B, and C) are not iron rich sources 28. A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply)  Check urine for ketones  Measure blood glucose  Monitor vital signs  Assessed level of consciousness  Obtain culture of wound  Rationale: Blood glucose greater than 600 mg/dl (33.3 mmol/L SI), vital sign changes in mental awareness are indicators of possible HHNS. Urine ketones are monitored in diabetic ketoacidosis. Wound culture is performed prior to treating the wound infection but is not useful in monitoring for HHNS. 29. An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)  0.4  Rationale: Calsulate using the formula, desired dose (220,000 units) over dose on hand (600,000 units) x the volume of the available dose (1 ml). 220,000 / 600,000 x 1 ml = 0.36 = 0.4 ml 30. After receiving report, the nurse can most safely plan to assess which client last? The client with…  A rectal tube draining clear, pale red liquid drainage  A distended abdomen and no drainage from the nasogastric tube  No postoperative drainage in the Jackson-Pratt drain with the bulb compressed  Dark red drainage on a postoperative dressing, but no drainage in the Hemovac®.  Rationale: The most stable client is the one with a functioning drainage device and no drainage. This client can most safely be assesses last. Other clients are either actively bleeding, have an obstruction in the nasogastric tube which may result in vomiting, or may be bleeding and / or may have a malfunction in the Hemovac® drain. 31. The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized elderly client with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the UAP to take each time the client is turned?  Empty the urinary drainage bag  Feed the client a snack  Offer the client oral fluids  Assess the breath sounds  Rationale: Increasing oral fluid intake reduces the risk of problems associated with immobility, so the UAP should be instructed to offer the client oral fluids every two hours, or whenever turning he client. It is not necessary to empty the urinary bag or feed the client every two hours. Assessment is a nursing function, and UAPs do not have the expertise to perform assessment of breath sounds. 32. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply)  Inspect skin for redness  Use a residual limb shrinker  Apply alcohol to the stump after bathing  Wash the stump with soap and water  Avoid range of motion exercises  Rationale: Several actions are recommended for home care following an amputation. The skin should be inspected regularly for abnormalities such as redness, blistering, or abrasions. A residual limb shrinker should be applied over the stump to protect it and reduce edema. The stump should be washed daily with a mild soap and carefully rinse and dried. The client should avoid cleansing with alcohol because it can dry and crack the skin. Range of motion should be done daily. 33. When assessing the surgical dressing of a client who had abdominal surgery the previous day, the nurse observes that a small amount of drainage is present on the dressing and the wound’s Hemovac suction device is empty with the plug open. How should the nurse respond?  Replace the dressing and remove the drainage device  Reposition the drainage device and keep the plug open  Notify the healthcare provider that the drain is not working  Recompress the wound suction device and secure to plug  Rationale: The plug of a wound suction device, such as a Hemovac, should be closed after compressing the device to apply gentle suction in a closed surgical wound to facilitate the evacuation of subcutaneous fluids into the device. Compressing the device and securing the plug should restore function of the closed wound device. A small amount of drainage should be marked on the dressing, but replacing the dressing is not necessary and the nurse should not remove the device. Other options are not indicated. 34. A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child’s hernia. Which explanations should the nurse provide?  This hernia is a normal variation that resolves without treatment.  Restrictive clothing will be adequate to help the hernia go away.  An abdominal binder can be worn daily to reduce the protrusion.  The quarter should be secured with an elastic bandage wrap.  Rational: an umbilical hernia is a normal variation in infants that occurs due to an incomplete fusion of the abdominal musculature through the umbilical ring that usually resolves spontaneously as the child learns to walk. Other choices are ineffective and unnecessary. 35. A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?  Patch one eye.  Reorient often.  Range of motion.  Evaluate swallow  Rational: Osmotic demyelination, also known as central pontine myelinolysis, is nerve damage caused by the destruction of the myelin sheath covering nerve cells in the brainstem. The most common cause is a rapid, drastic change in sodium levels when a client is being treated for hyponatremia, a common occurrence in SIADH. Difficulty swallowing due to brainstem nerve damage should be care, but determining the client’s risk for aspiration is most important. 36. A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement?  Collect a clean catch urine specimen.  Instruct the client to empty the bladder.  Obtain vital signs and breath sounds.  No specific nursing action is required  Rational: the client’s baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds associated with pulmonary edema, the administration of the fluid challenge should be terminate. Other options would not assure a safe administration of the medication. 37. A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?  “I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best”  “ I never use the inhaler unless I am feeling really short of breath”  I always shake the inhaler several times before I start”  “After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away” 38. A nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. What information is most important for the nurse to include?  Ensure that the infant’s crib mattress is firm 39. A 6 -years-old who has asthma is demonstrating a prolonged expiratory phase and wheezing, and has 35% personal best peak expiratory flow rate (PEFR). Based on these finding, which action should the nurse implement first?  Administer a prescribed bronchodilator.  Report finding to the healthcare provider.  Encourage the child to cough and deep breath  Determine what trigger precipitated this attack.  Rationale: If the PEFR is below 50% in as asthmatic child, there is severe narrowing of the airway, and a bronchodilator should be administered immediately. Be should be implemented after A. C will not alleviate the symptoms and D is not a priority. 40. A client is receiving lactulose (Portalac) for signs of hepatic encephalopathy. To evaluate the client’s therapeutic response to this medication, which assessment should the nurse obtain?  Level of consciousness  Percussion of abdomen  Serum electrolytes  Blood glucose.  Rationale: Colonic bacteria digest lactulose to create a drug-induces acidic and hyperosmotic environment that draws water and blood ammonia into the colon and coverts ammonia to ammonium, which is trapped in the intestines and cannot be reabsorbed into the systemic circulation. This therapeutic action of lactulose is to reduce serum ammonia levels, which improves the client’s level of consciousness and metal status. 41. When administering an immunization in an adult client, the nurse palpates and administer the injection one inch below the acromion process into the center of the muscle mass. The nurse should document that the vaccine was administered at what site?  Rectus femenis  Ventrogluteous  Vastus lateralis  Deltoid  Rationale: The acromion process is a parameter identified for the deltoid site. 42. A primigravida a 40-weeks gestation with preeclampsia is admitted after having a seizure in the hot tub at a midwife’s birthing center. Based on documentation in the medical record, which action should the nurse implement? (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 client’s medical record.)  Continue to monitor the client’s blood pressure hourly 43. A female nurse who took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the nurse has asked administration to allow her to return to work. When the nurse administrator approaches the charge nurse with the impaired nurse request, which action is best for the charge nurse to take?  Since treatment is completed, assign the nurse to the route RN responsibilities  Ask to meet with impaired nurse’s therapist before allowing her back on the unit.  Allow the impaired nurse to return to work and monitor medication administration  Meet with staff to assess their feelings about the impaired nurse’s return to the unit.  Rationale: provides essential monitoring and helps ensure nurse compliance and promote client safety. 44. In making client care assignment, which client is best to assign to the practical nurse (PN) working on the unit with the nurse?  An immobile client receiving low molecular weight heparin q12 h.  A client who is receiving a continuous infusion of heparin and gets out of bed BID  A client who is being titrated off heparin infusion and started on PO warfarin (Coumadin)  An ambulatory client receiving warfarin (Coumadin) with INR of 5 second.  Rationale: A describe the most stable client. The other ones are at high risk for bleeding problems and require the assessment skills. 45. A client who is admitted to the intensive care unit with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasingly anxious and complain of difficulty breathing. The nurse determine the client is tachypneic with absent breath sounds in the client’s right lungs fields. Which additional finding indicates that the client has developed a tension pneumothorax?  Continuous bubbling in the water seal chamber  Decrease bright red blood drainage  Tachypnea and difficulty breathing  Tracheal deviation toward the left lung.  Rationale: Tracheal deviation toward the unaffected left lung with absent breath sounds over the affected right lung are classic late signs of a tension pneumothorax. 46. A low-risk primigravida at 28-weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?  Pulse increase of 10 beats/minute  Proteinuria  Glucosuria  Fundal height 0f 22 centimeters 47. The nurse discovers that an elderly client with no history of cardiac or renal disease has an elevated serum magnesium level. To further investigate the cause of this electrolyte imbalance, what information is most important for the nurse to obtain from the client’s medical history?  Frequency of laxative use for chronic constipation 48. Which action should the nurse implement with auscultating anterior breath sounds? (Place the first action on top and last action on the bottom)  Correct order: (PADD) 1. Place stethoscope in suprasternal area to auscultate for bronchial sounds 2. Auscultate bronchovesicular sounds from side to side the first and second intercostal spaces 3. Displace female breast tissue and apply stethoscope directly on chest wall to hear vesicular sounds 4. Document normal breath sounds and location of adventitious breath sounds 49. A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client?  Cheddar cheese and crackers.  Carrot and celery sticks.  Beef bologna sausage slices.  Dry roasted almonds.  Rational: alcoholism promotes inadequate food intake and gastrointestinal loss of magnesium include green leafy vegetables and nuts and seeds. Other snacks listed provide much lower amounts of magnesium per serving. 50. The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. What expected outcome has the highest priority for this client?  Identifies 2 treatments for constipation due to immobility.  Names 3 home safety hazards to be resolve immediately.  State 4 risk factors for the development of osteoporosis.  Lists 5 calcium-rich foods to be added to her daily diet.  Rational: a major teaching goal for an elderly client with osteoporosis is maintenance of safety to prevent falls. Injury due to a fall, usually resulting in a hip fracture, can result in reduced mobility and associated complications. Other goals are also important when teaching clients who have osteoporosis, but they do not have the priority of preventing falls, which relates to safety. 51. The nurse is teaching a male adolescent recently diagnosed with type 1diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate do you effectiveness of the teaching?  Ask the adolescent to describe his level of comfort with injecting himself with insulin.  Observe him as he demonstrates self-injection technique in another diabetic adolescent  Have the adolescent list the procedural steps for safe insulin administration.  Review his glycosylated hemoglobin level 3 months after the teaching session.  Rational: watching the adolescent perform the procedure with another adolescent provides peer support the most information regarding his skill with self-injection. Other options do not provide information about the effectiveness of nurse’s teaching. 52. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?  Explain that counseling will be provided to give her information about her cancer risk  Gather additional information about the client’s family history for all types of cancer.  Offer assurance that there are a variety of effective treatments for breast cancer.  Provide information about survival rates for women who have this genetic mutation.  Rational: BRACA1or BRACA2 genetic mutation indicates an increased risk for developing breast or ovarian cancer and genetic counseling should be provided to explain the increased risk (A)to the client along with options for increased screening or preventative measures. (B) Is completed by the genetic counselor before the client undergoes genetic testing. a positive BRACA1test is not an indicator of the presence of cancer and (C and D) are not appropriate responses prior to genetic counseling. 53. A mother runs into the emergency department with s toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?  Call poison control emergency number.  Determine type of chemical exposure.  Obtain equipment for gastric lavage.  Assess child for altered sensorium.  Rational: once the type of chemical is determined, poison control should be called even if the chemical is unknown. If lavage is recommended by poison control, intubation and nasogastric tube may be needed as directed by poison control. Altered sensorium, such as lethargy, may occur if hydrocarbons are ingested 54. The nurse assigned unlicensed assistive personnel (UAP) to apply antiembolism stockings to a client. The nurse and UAP enters the room, the nurse observes the stockings that were applying by the UAP. The UAP states that the client requested application of the stockings as seen on the picture, for increased comfort. What action should the nurse take?  Ask the client if the stocking feel comfortable.  Supervise the UAP in the removal of the stockings.  Place a cover over the client’s toes to keep them warm.  Discussed effective use of the stockings with the client on UAP  Rational: antiembolism stockings are designed to fit securely and should be applied so that there are no bands of the fabric constricting venous return. The nurse should discuss the need for correct and effective use of the stockings with both the client and UAP to improve compliance. Other options do not correct the incorrect application of the stockings. 55. Nurses working on a surgical unit are concerned about the physicians treatment of clients during invasive procedures, such as dressing changes and insertion of IV lines. Clients are often crying during the procedures, and the physician is usually unconcerned or annoyed by the client’s response. To resolve this problem, what actions should the nurses take? (Arrange from the first action on the top of the list on the bottom) 1. Talk to the physician as a group in a non-confrontational manner. 2. Document concerns and report them to the charge nurse. 3. Submit a written report to the director of nursing. 4. Contact the hospital’s chief of medical services. 5. File a formal complaint with the state medical board.  Rational: nurses have both an ethical and legal responsibility to advocate for clients’ physical and emotional safety. Talking with the physician in a nonconfrontational manner is the first step in conflict resolution. If this is not effective, the organizational chain of ineffective, a formal complaint with the state medical board should be implemented. 56. While changing a client’s chest tube dressing, the nurse notes a crackling sensation when gentle pressure is applied to the skin at the insertion site. What is the best action for the nurse to take?  Apply a pressure dressing around the chest tube insertion site.  Assess the client for allergies to topical cleaning agents.  Measure the area of swelling and crackling.  Administer an oral antihistamine per PRN protocol.  Rational: a crackling sensation, or crepitus, indicates subcutaneous emphysema, or air leaking into the skin. This area should be measured and the finding documented. Other options are not indicated for crepitus. 57. To prevent infection by auto contamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?  Dress each wound separately.  Avoid sharing equipment between multiple clients.  Use gown, mask and gloves with dressing change.  Implement protective isolation.  Rational: each wound should be dressed separately using a new pair of sterile glove to avoid auto contamination (the transfer of microorganisms form one infected wound to a non-infected wound). The other choices do not prevent auto contamination. 58. The nurse is preparing an intravenous (IV) fluid infusion using an IV pump. Within 30 seconds of turning on the machine, the pump’s alarm beeps “occlusion”. What action should the nurse implement first?  Flush the vein with 3 ml of sterile normal saline.  Assess the IV catheter insertion site for infiltration.  Verify the threading of the tubing through the IV pump.  Determine if the clamp on the IV tubing is released  Rational: When the pump immediately beeps, it is often because the IV tubing clamp is occluding the flow, so the clamp should be checked first to ensure that it is open. If the alarm is not eliminated after the tubing clamp is released, flushing the IV site with saline is a common practice to clean the needle or to identify resistance due to another source. Local signs of infiltration may indicate the need to select another vein, but the pump’s beeping-this early in the procedure is likely due to a mechanical problem. If beeping continues after verifying that the clamp is released the placement or threading of the tubing through the pump should be verified. 59. A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?  Sed rate (ESR)  Hemoglobin  Calcium  Osmolality.  Rational: naproxen can cause gastric bleeding, so the nurse should monitor the client’s hemoglobin to assess for possible bleeding. Other options are not likely to be affected by the used of naproxen and are not related to the client’s current symptoms. 60. The nurse assesses a child in 90-90 traction. Where should did nurse assess for signs of compartment syndrome?  Rationale: compartment syndrome is the result of swelling and subsequent reduction in circulation to the area distal to the compartment. This can be a complication of traumatic injury and cast administration, so it is important to assess circulation distal to the casted prolonged capillary refill. 61. After receiving the Braden scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize the skin care for which client?  An older adult who is unable to communicate elimination needs.  An older man whose sheets are damped each time he is turned.  A woman with osteoporosis who is unable to bear weight.  A poorly nourished client who requires liquid supplement.  Rational: a Braden score of less than 18 indicates a risk for skin breakdown, and clients with such score require intensive nursing care. Constant moisture places the client at a high risk for skin breakdown, and interventions should be implemented to pull moisture away from the client’s skin. Other options may be risk factors but do not have as high a risk as constant exposure to moisture. 62. A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes Mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is the most important for the nurse to include in this client’s plan of care?  Monitor the client’s cardiac activity via telemetry.  Maintain venous access with an infusion of normal saline.  Assess glucose via fingerstick q4 to 6 hours.  Evaluate hourly urine output for return of normal renal function.  Rational: as insulin lowers the blood glucose of a client with diabetic ketoacidosis (DKA), potassium returns to the cell but may not impact hyperkalemia related to acute renal failure. The priority is to monitor the client for cardiac dysrhythmias related to abnormal serum potassium levels. IV access, assessment of glucose level, and monitoring urine output are important interventions, but do not have the priority of monitoring cardiac function. 63. A client with C-6 spinal cord injury rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or “goosebumps”. The nurse should asses for which trigger?  Loud hallway noise.  Fever  Full bladder  Frequent cough.  Rational: a pounding headache is a sign of autonomic hyperreflexia, an acute emergency that occurs because of an exaggerated sympathetic response in a client with a high level spinal cord injury. Any stimulus below the level of injury can trigger autonomic hyperreflexia, but the most common cause is an overly distended bladder. The other options are unlikely to produce the manifestation of autonomic hyperreflexia. 64. A nurse working on an endocrine unit should see which client first?  An adolescent male with diabetes who is arguing about his insulin dose.  An older client with Addison’s disease whose current blood sugar level is 62mg/dl (3.44 mmol/l).  An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour.  A client taking corticosteroids who has become disoriented in the last two hours.  Rational: meeting the client’s need for safety is a priority intervention. Mania and psychosis can occur during corticosteroids therapy, places the client at risk for injury, so the patient taking corticosteroids should be seen first. 65. A client is receiving and oral antibiotic suspension labeled 250 mg/2ml. The healthcare provider prescribes 200mg every 6 hours. How many ml should the nurse administer at each dose? (Enter numerical value only. If rounding is required, round to the nearest tenth)  Answer: 1.6  Rational: using the formula D/H x Q  200mg/250 mg x 2ml = 200/250 = 1.6 ml 66. Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. What action should the nurse take?  Reposition the transdermal patch to the client’s trunk.  Remove the transdermal patch until the vomiting subsides.  Notify the healthcare provider of the vomiting.  Explain that this is a side effect of the medication in the patch.  Rational: transdermal scopolamine is used to prevent nausea and vomiting from anesthesia and surgery. The nurse should notify the healthcare provider if the medication is ineffective. The patch should be applied behind the ear and should remain in place to reduce the nausea and vomiting. Nausea and vomiting are no side effects of the medication. 67. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and elevated BP for a client with chronic kidney disease. Which is the most important action for the nurse to take?  Monitor daily sodium intake.  Record usual eating patterns.  Measure ankle circumference.  Auscultate for irregular heart rate.  Rational: Chronic kidney failure (CKF) is a progressive, irreversible loss of kidney functions, decreasing glomerular filtration rate (GFR), and the kidney’s inability to excrete metabolic waste products and water, resulting in fluid overload, elevated pulse, elevated BP and electrolytes imbalances. The most important action for the nurse to implement is to auscultate for irregular heart rate (D) due to the decreased excretion of potassium by the kidneys. (A, B, and C) are not as important as monitoring for fatal cardiac dysrhythmias related to hyperkalemia. 68. A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond?  Determine if the sensation feels uncomfortable.  Decrease the strength of the electrical signals.  Remove electrodes and observe for skin redness.  Check the amount of gel coating on the electrodes.  Rational: electronic stimulators, such as a transelectrical nerve stimulator (TENS) unit, have been found to be effective in reducing low back pain by “closing the gate” to pain stimuli. A tingling sensation should be felt when the power is turned on, and the nurse should assess whether the sensation is too strong, causing discomfort or muscle twitching. Decreasing the electrical signal may be indicated if the sensation is too strong. Other options are not necessary because the tingling sensation is expected. 69. A female client is extremely anxious after being informed that her mammogram was abnormal and needs to be repeated. Client is tearful and tells the nurse her mother died of breast cancer. What action should the nurse take?  Provide the client with information about treatment options for breast cancer.  Reassure the client that the final diagnosis has not been made.  Encourage the client to continue expressing her fears and concerns.  Suggest to the client that she seek a second opinion.  Rational: the nurse should show support for the client by encouraging her to continue expressing her concerns. A diagnosis has not yet been made, so it is too early to discuss treatment options. Other options dismiss the client’s feelings or are premature given that the diagnosis is not yet made. 70. The psychiatric nurse is talking to a newly admitted client when a male client diagnosed with antisocial behavior intrudes on the conversation and tells the nurse, “I have to talk to you right now! It is very important!” how should the nurse respond to this client?  Put his behavior on extinction and continue talking with the newly admitted.  Inform him that the nurse is busy admitting a new client and will talk to him later.  Encourage him to go to the nurse’s station and talk with another nurse.  Introduce him to the newly admitted client and ask him to him to join in the conversation.  Rational: the psychiatric nurse must set limits with antisocial behavior so that appropriate behavior is demonstrated. Interrupting a conversation is rude and inappropriate, so telling the client that they can talk later is the best course of action. Other options may cause the client to become angry and they do not address the client’s behavior. The nurse should not involve this client with newly admitted client’s admission procedure. 71. The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?  A 64 year old client who had a total hip replacement the previous day.  A 75 year old client with renal calculi who requires urine straining.  An adolescent with multiple contusions due to a fall that occurred 2 days ago.  A 30 year old depressed client who admits to suicide ideation.  RATIONALE: A client who is suicidal requires psychological assessment, therapeutic communication and knowledge beyond the educational level of a practical nurse (RN). Other clients could be cared for by the PN or the UAP, with supervision by the registered nurse. 72. A female client presents in the Emergency Department and tells the nurse that she was raped last night. Which question is most important for the nurse to ask?  Does she knows the person who raped her?  Has she taken a bath since the raped occurred?  Is the place where she lived a safe place?  Did she report the rape to the police Department?  RATIONALE: The priority action is collected the forensic evidence, so asking if the has taken a bath since the rape occurred is the most important information to obtain. Other options are used by law enforcement to determine the perpetrator and are not vital in providing client care at this time. 73. While caring for a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s laboratory values?  Serum albumin  Creatinine level  Culture for sensitive organisms.  Serum blood glucose (BG) level  RATIONALE: A client who has a postoperative dressing with purulent drainage from the wound is experiencing an infection. The nurse should review the client’s laboratory culture for sensitive organisms (C) before reporting to the healthcare provider. (A, B and D) are not indicated at this time. 74. The nurse is demonstrating correct transfer procedures to the unlicensed assisted personnel (UAP) working on a rehabilitation unit. The UAPs ask the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommended?  Hold the client at arm’s length while transferring to better distribute the body weight.  Apply the gait belt around the client’s waits once standing position has been assumed.  Place a client’s locked wheelchair on the client’s strong side next to the bed.  Pull the client into position by reaching from the opposite side of the bed.  RATIONALE: Placing the wheelchair on the client’s strong side offers the greatest stability for the transfer. Holding the client arm’s length or pulling from the opposite site of the bed reflect poor body mechanism. Using a gait belt offers additional safety for the client, but should be done after the wheelchair has be put into the proper place and the wheels have been locked and before the client has assumed a standing position. 75. A client who is experiencing musculoskeletal pain receives a prescription for ketorolac 15mg IM q6 hours. The medication is depended in a 39mg/ml pre-filled syringe. Which action should the nurse implement when giving the medication?  Administer the entire pre-filled syringe deep in the dorsogluteal site.  Use a separate syringe to remove 15mg from the pre-filled syringe and give in the back of the arm.  Waste 0.5 ml from the pre-filled syringe and inject the medication in the ventrogluteal site.  Call the healthcare provider to request a prescription change to match the dispensed 30mg dose.  RATIONALE: The pre-filled contain 30mg /1ml, so 0.5ml should be wasted to obtain the correct dosage of 15mg for administration in the preferred IM ventrogluteal site. The nurse is responsible for calculating and preparing the prescribed dose using the available concentration, so other options are not indicated. 76. A client with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO q 12hours. When the client request an afternoon snack, which dietary choice should the nurse provide?  Vanilla-flavored yogurt  Low fat chocolate milk.  Calcium fortified juice  Cinnamon applesauce  RATIONALE: Dairy products and calcium fortified dairy products decrease the absorption of ciprofloxacin. Cinnamon applesauce contains no calcium, so this is the best snack selection. Since other options contains calcium, these snack should be avoided by a client who is taking ciprofloxacin. 77. The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection would indicate to the nurse the client understands they prescribed diet?  Roasted turkey canned vegetables  Baked potatoes with skin raw carrots  Pancakes whole-grain cereal's  Roast pork fresh strawberries  Rationale: Foods allowed on a low-fiber diet includes roasted or baked turkey and canned vegetables the foods in the other options are not low in fiber 78. An adult client with schizophrenia begin treatment three days ago with the Antipsychotic risperidone. The client also received prescription for trazodone as needed for sleep and clonazepam as needed for severe anxiety. When the client reports difficulty with swallowing, what action should the nurse take?  Obtain a prescription for an anticholinergic medication  Determine how many hours declined slept last night  Administer the PRN prescription for severe anxiety  Watch the thyroid cartilage move while the client swallows  Rationale: Antipsychotic medications have an extrapyramidal side effects one of which is difficult to swallowing the nurse should obtain a prescription for an anticholinergic medication which is used for the treatment of extrapyramidal symptoms. Other options are not warranted actions based on the symptoms presented. 79. One year after being discharged from the burn trauma unit, a client with a history of 40% full-thickness burns is admitted with bone pain and muscle weakness. Which intervention should the nurse include in the clients plan of care?  Encourage Progressive active range of motion  Teach need for dietary and supplementary vitamin D3  Explain the need for skin exposure to sunlight without sunscreen  Instruct the client to use of muscle strengthening exercises  Rationale: Burn injury results in the acute loss of bone as well as the development of progressive vitamin D deficiency because burn scar tissue and adjacent normalappearing skin cannot convert normal quantities of the precursors for vitamin D3 that is synthesized from ultraviolet sun rays which is needed for strong bones. Clients with a history of full thickness burns should increase their dietary resources of vitamin D and supplemental D3 (B). range of motion (A) and muscle strengthening exercises (D) do not treat he underlying causes of the bone pain and weakness unprotected sunlight (C) should be avoided. 80. When teaching a group of school-age children how to reduce the risk of Lyme disease which instruction should the camp nurse include?  Wash hands frequently  Avoid drinking lake water  Wear long sleeves and pants  Do not share personal products  Rationale: Lyme disease is it tick bone disorder and is transmitted to a child via a tick bite. Keeping the skin covered reduces the risk of being bitten by a tick. Other options are not reduce the risk for tick bites. 81. A native-American male client diagnosed with pneumonia, states that in addition to his prescribed medical treatment of IV antibiotics he wishes to have a spiritual cleaning performed. Which outcome statement indicates that the best plan of care was followed?  Identifies his ethnocentric values and behaviors  States an understanding of the medical treatment  Participated actively in all treatments regimens  Expresses a desire for cultural assimilation  Rationale: indicates active participation by the client, which is required for treatment to be successful. The best plan of care should incorporate the valued and treatments of both cultures and in this case there is no apparent cultural clash between the two forms of treatment. The client has already identify he's cultural values (A). (B) Only considers one of the two treatment modalities desired by the client the client has already chosen how he wishes to assimilate his cultural values with the prescribed medical treatment (D). 82. A male client with cancer is admired 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?  Ask the client about his expected goals for the hospitalization  Explain the palliative care measures can be provided at home  Notify do radiation department to withhold the treatment for now  Determine if the client wishes to cancel further radiation treatment  Rationale: Palliative care measures provide relief or control of symptoms, so it is important for the nurse to determine the client’s goals for symptom control while receiving treatment in the hospital. Although home care is available the client may not be legible for palliative care at home. Radiation therapy is an effective positive care measure used to manage symptoms and would be appropriate unless the radiation conflicts with the client goals. 83. A client with myasthenia Gravis (MG) is receiving immunosuppressive therapy. Review recent laboratory test results show that the client’s serum magnesium level has decreased below the normal range. In addition to contacting the healthcare provider, what nursing action is most important?  Check the visual difficulties  Note most recent hemoglobin level  Assessed for he and Hand joint pain  Observe rhythm on telemetry monitor  Rationale: If not treated a low little Serum magnesium level can affect myocardial depolarization leading to a lethal arrhythmia, and the nurse should assess for dysrhythmias before contacting the healthcare provider. Other choices are common in MG but do not contribute the Safety risk of low magnesium levels. 84. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider?  Pain scale rating at 9 on a 0-10 scale  Last menstrual period was 7 weeks ago  Reports white curdy vaginal discharge  History of irritable bowel syndrome IBS  Rationale: Acute lower abdominal pain in A young adult female can be indicative of an ectopic pregnancy, which can be life threatening. Since the clients last menstrual period was seven weeks ago a pregnancy test to be obtained to ruled out ectopic pregnancy, which can result in intra-abdominal hemorrhage caused by a ruptured Fallopian tube. Although the severity of pain requires treatment, the most significant finding is the clients last menstrual period. Other options are not the most important concerns. 85. A 154 pound client with diabetic ketoacidosis is receiving an IV of normal saline 100 ML with regular insulin 100 units. The healthcare provider prescribes a rate of 0.1 units/kg/hour. To deliver the correct dosage, the nurse should set the infusion pump to Infuse how many ml/hour? enter numeric value only  7  Rationale: Convert the client’s weight to kg, 2.2 pound: 1 kg:: 154 pounds: x kg = 154/2.2 = 70kg. Calculate the client infusion rate, 0.1 x 70 kg = 7 units/hour. Using the formula, D/H x Q = 7 units/hour / 100 units x 100 ml = 7ml / hour 86. The nurse is assessing a postpartum client who is 36 hours post-delivery. Which finding should the nurse report to the healthcare provider?  White blood count of 19,000 mm3  Oral temperature of 100.6 F  Fundus deviated to the right side  Breasts are firm when palpated  Rationale: A temperature greater than 100.4 F (38 C) (B), which is indicative of endometriosis (infection of the lining of the uterus), should be reported to the health care provider. (A and D) are findings that are within normal limits in the postpartum period. Fundal deviation to one side (C) is an expected finding related to a full bladder, so the nurse should encourage the client to void. 87. A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presented with which symptoms requires the most immediate intervention by the nurse?  Low-grade fever, headache, and malaise for the past 72 hours  Unable to bear weight on the left foot, with the swelling and bruising  Chest discomfort one hour after consuming a large, spicy meal  One-inch bleeding laceration on the chain of the crying five-year-old  Rationale: Emergency triage involves quick assessment to prioritize the need for further evaluation and care. Those with trauma, chest pain, respiratory distress, or acute neurological changes are priority. In this example, while clients with other conditions require attention, the client with chest discomfort is at greatest risk and is a priority. 88. The nurse is planning to assess a client's oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below-the-knee amputation and pedal pulses that are weak and threaty. What action should the nurse take?  Document that an accurate oxygen saturation reading cannot be obtained  Elevate to client's hands for five minutes prior to obtaining a reading from the finger  Increase the oxygen based on the clients breathing patterns and lung sounds  Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading  Rationale: Pulse oximeter clips can be attached to the earlobe to obtain an accurate measurement of oxygen saturation. Other options will not provide the needed assessment. 89. A young adult male who is being seen at the employee health care clinic for an annual assessment tell the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficulty indeed. Which response is best for the nurse to provide?  Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.  Encourage the client to seek genetic counseling to determine his risk for mental illness.  Informed the client that his mother schizophrenic has affected his psychological development.  Tell the client that mental illness has a familial predisposition so he should see a psychiatrist. 90. A client on a long-term mental health unit repeatedly takes own pulse regardless of the circumstance. What action should the nurse implement?  Overlook the client’s behavior.  Distract client to interfere with the ritual.  Ask why the client checks the pulse.  Hold client’s hand to stop the behavior. 91. A client is discharged with automated peritoneal dialysis (PD) to be used nightly…which instructions should the nurse include?  Wash hands before cleaning exit site  Keep the head of the bed flat at night  Feel for a thrill and a distal pulse nightly  Do not get up if fluid is left in the abdomen 92. The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse?  Opening the package  Picking up the second glove  Picking up the first glove  Positioning of the table 93. A male client reports to the clinic nurse that he has been feeling well and is often “dizzy” his blood pressure is elevated. Based on this findings, this client is at a greatest risk for which pathophysiological condition?  Stroke  Renal failure  Left ventricular hypertrophy  Pulmonary hypertension 94. The nurse ask the parent to stay during the examination of a male toddler’s genital area. Which intervention should the nurse implement?  Examine the genitalia as the last part of the total exam.  Use soothing statements to facilitate cooperation  Allow the child to keep underpants on to examine genitalia  Work slowly and methodically so not to stress the child 95. The nurse is changing a client’s IV tubing and closes the roller clamp on the new tubing setup when the bag of solution is….which action should the nurse take to ensure adequate filling of the drip chamber?  Lower the IV bag to a flat surface  Compress the drip chamber  Open the roller clamp  Squeeze the bag of IV solution 96. …An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar…in addition to the client’s glucose, which laboratory value is most important for the nurse to monitor?  Serum potassium  Urine ketones  Urine albumin  Serum protein 97. A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?  Altered consciousness within the first 24 hours after injury.  Cushing reflex and cerebral edema after 24 hours  Fever, nuchal rigidity and opisthotonos within hours  Headache and pupillary changes 48 hours after a head injury 98. In planning strategies to reduce a client's risk for complications following orthopedic surgery, the nurse recognizes which pathology as the underlying cause of osteomyelitis?  infectious process  metastatic process  autoimmune disorder  inflammatory disorder 99. A client with bipolar disorder began taking valproic acid (Depakote) 250 mg PO three times daily two months ago. Which finding provides the best indication that the medication regimen is effective?  The family reports a great reduction in client’s maniac behavior 100. Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client’s arm?  Assess IV site frequently for signs of extravasation