Critical Care Hesi Review
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125 Terms
A 56-year-old female client is receiving intracavitary radiation vis a radium implant. Which nurse should be assigned to care for this client?
A. The nurse who is caring for another client receiving intracavitary radiation.
B. A nurse with Marfan’s syndrome who is postmenopausal.
C. A nurse with oncology experience who may be pregnant.
D. The nurse who is caring for another client who has Clostridium difficile.
Answer: B - A nurse with Marfan’s syndrome who is postmenopausal.
A client who has active tuberculosis (TB) is admitted to the medical unit. What action is most important for the nurse to implement?
A. Fit the client with a respirator mask.
B. Assign the client to a negative air-flow room.
C. Don a clean gown for client care.
D. Place an isolation cart in the hallway
Answer: B. Assign the client to a negative air-flow room
A client is receiving atenolol (Tenormin) 25 mg PO after a myocardial infarction. The nurse determines the client's apical pulse is 65 beats per minute. What action should the nurse implement next?
A. Measure the blood pressure.
B. Reassess the apical pulse.
C. Notify the healthcare provider.
D. Administer the medication.
Answer: D. Administer the medication.
The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation?
A. Hypothyroidism
B. Thyroid Cyst
C. Thyroid Cancer
D. Hyperthyroidism
Answer: D. Hyperthyroidism
A 6-year-old child is alert but quiet when brought to the emergency center with periorbital ecchymosis and ecchymosis behind the ears. The nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture. What assessment finding would be consistent with a basilar skull fracture?
A. Hematemesis and abdominal distention.
B. Asymmetry of the face and eye movements.
C. Rhinorrhoea or otorrhoea with Halo sign.
D. Abnormal position and movement of the arm.
Answer: C. Rhinorrhoea or otorrhoea with Halo sign.
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent with which disorder?
A. Grave's disease.
B. Multiple sclerosis.
C. Addison's disease.
D. Cushing syndrome.
Answer: A. Grave's disease.
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
A. A nystagmus on the left.
B. Exophthalmos on the right.
C. Ptosis on the left eyelid
D. Astigmatism on the right
Answer: C. Ptosis on the left eyelid
The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse take?
A. Question the type and quantity of foods eaten in a typical day.
B. Encourage giving two additional snacks each day to the child.
C. Recommend a daily intake of at least four glasses of whole milk.
D. Assess for signs of poor nutrition, such as a pale appearance
Answer: A. Question the type and quantity of foods eaten in a typical day.
A child is receiving maintenance intravenous (IV) fluids at the rate of 1000 ml for the first 10 kg of body weight, plus 50 ml/kg per day for each kilogram between 10 and 20. How many milliliters per hour should the nurse program the infusion pump for a child who weighs 19.5 kg? (Enter numeric value only. If rounding is required, round to the nearest whole number.)
A. 24
B. 61
C. 73
D. 58
Answer: B. 61
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?
A. Withhold the medication and contact the healthcare provider.
B. Give the medication dosage as scheduled.
C. Assess respiratory rate for one minute next.
D. Wait 30 minutes and give half of the dosage of medication
Answer: A. Withhold the medication and contact the healthcare provider.
The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?
A. Wear the brace over a T-shirt 23 hours per day.
B. Dress with the brace over regular clothing.
C. Shower with the brace directly against the skin.
D. Remove the brace just before going to bed.
Answer: A. Wear the brace over a T-shirt 23 hours per day.
A client with asthma receives a prescription for high blood pressure during a clinic visit. Which prescription should the nurse anticipate the client to receive that is least likely to exacerbate asthma?
A. Carteolol (Ocupress).
B. Propranolol hydrochloride (Inderal).
C. Pindolol (Visken).
D. Metoprolol tartrate (Lopressor)
Answer: D. Metoprolol tartrate (Lopressor)
A male client who has been taking propranolol (Inderal) for 18 months tells the nurse that the healthcare provider discontinued the medication because his blood pressure has been normal for the past three months. Which instruction should the nurse provide?
A. Obtain another antihypertensive prescription to avoid withdrawal symptoms.
B. Stop the medication and keep an accurate record of blood pressure
C. Report any uncomfortable symptoms after stopping the medication.
D. Ask the healthcare provider about tapering the drug dose over the next week.
Answer: D. Ask the healthcare provider about tapering the drug dose over the next week.
A client who is taking clonidine (Catapres, Duraclon) reports drowsiness. Which additional assessment should the nurse make?
A. Has the client experienced constipation recently?
B. Did the client miss any doses of the medication?
C. How long has the client been taking the medication?
D. Does the client use any tobacco products?
Answer: C. How long has the client been taking the medication?
The nurse is preparing to administer atropine, an anticholinergic, to a client who is scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide?
A. Provide a more rapid induction of anesthesia.
B. Induce relaxation before induction of anesthesia.
C. Decrease the risk of bradycardia during surgery.
D. Minimize the amount of analgesia needed postoperatively.
Answer: C. Decrease the risk of bradycardia during surgery.
An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?
A. Antacids.
B. Tricyclic antidepressants.
C. Nonsteroidal anti-inflammatory agents.
D. Insulin.
Answer: B. Tricyclic antidepressants.
A client with osteoarthritis is given a new prescription for a nonsteroidal anti-inflammatory drug (NSAID). The client asks the nurse, "How is this medication different from the acetaminophen I have been taking?" Which information about the therapeutic action of NSAIDs should the nurse provide?
A. Are less expensive.
B. Provide anti-inflammatory response.
C. Increase hepatotoxic side effects
D. Cause gastrointestinal Bleeding
Answer: B. Provide anti-inflammatory response.
A client with cancer has a history of alcohol abuse and is taking acetaminophen (Tylenol) for pain. Which organ function is most important for the nurse to monitor?
A. Cardiorespiratory.
B. Liver.
C. Sensory.
D. Kidney.
Answer: B. Liver.
The nurse obtains a heart rate of 92 and a blood pressure of 110/76 prior to administering a scheduled dose of verapamil (Calan) for a client with atrial flutter. Which action should the nurse implement?
A. Give intravenous (IV) calcium gluconate.
B. Withhold the drug and notify the healthcare provider.
C. Administer the dose as prescribed.
D. Recheck the vital signs in 30 minutes and then administer the dose.
Answer: C. Administer the dose as prescribed.
Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
A. Stimulate contraction of the uterus.
B. Initiate the lactation process.
C. Facilitate maternal-infant bonding.
D. Prevent neonatal hypoglycemia.
Answer: A. Stimulate contraction of the uterus.
A client is admitted to the hospital with a diagnosis of Type 2 diabetes mellitus and influenza. Which categories of illness should the nurse develop goals for the client's plan of care?
A. One chronic and one acute illness.
B. Two acute illnesses.
C. One acute and one infectious illness.
D. Two chronic illnesses.
Answer: A. One chronic and one acute illness.
Which intervention should the nurse include in the plan of care for a female client with severe postpartum depression who is admitted to the inpatient psychiatric unit?
A. Restrict visitors who irritate the client.
B. Full rooming-in for the infant and mother
C. Supervised and guided visits with infant.
D. Daily visits with her significant other.
Answer: C. Supervised and guided visits with infant.
A 16-year-old male client is admitted to the hospital after falling off a bike and sustaining a fractured bone. The healthcare provider explains the surgery needed to immobilize the fracture. Which action should be implemented to obtain a valid informed consent?
A. Obtain the permission of the custodial parent for the surgery.
B. Notify the non-custodial parent to also sign a consent form.
C. Instruct the client sign the consent before giving medications.
D. Obtain the signature of the client's stepfather for the surgery.
Answer: A. Obtain the permission of the custodial parent for the surgery.
During a client assessment, the client says, "I can't walk very well." Which action should the nurse implement first?
A. Predict the likelihood of the outcome.
B. Consider alternatives.
C. Choose the most successful approach.
D. Identify the problem.
Answer: D. Identify the problem.
The nurse identifies a client's needs and formulates the nursing problem of, "Imbalanced nutrition: less than body requirements, related to mental impairment and decreased intake, as evidenced by increasing confusion and weight loss of more than 30 pounds over the last 6 months." Which short-term goal is best for this client?
A. Verbalize understanding of plan and of intention to eat meals.
B. Eat 50% of six small meals each day by the end of one week.
C. Meals prepared during hospitalization will be fed by the nurse
D. Demonstrate progressive weight gain toward the ideal weight.
Answer: B. Eat 50% of six small meals each day by the end of one week.
A male client is angry and is leaving the hospital against medical advice (AMA). The client demands to take his chart with him and states the chart is "his" and he doesn' t want any more contact with the hospital. How should the nurse respond?
A. This hospital does not need to keep it if you are leaving and not returning here.
B. Because you are leaving against medical advice, you may not have your chart.
C. The information in your chart is confidential and cannot leave this facility legally.
D. The chart is the property of the hospital but I will see that a copy is made for you.
Answer: D. The chart is the property of the hospital but I will see that a copy is made for you.
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
A. Tracheostomy tube suctioning.
B. Medication administration.
C. Colostomy care instruction.
D. Client personal hygiene.
Answer: B. Medication administration.
What nursing delivery of care provides the nurse to plan and direct care of a group of clients over a 24-hour period?
A. Case management.
B. Team nursing.
C. Primary nursing.
D. Functional nursing.
Answer: C. Primary nursing.
Two unlicensed assistive personnel (UAP) are arguing on the unit about who deserves to take a break first. What is the most important basic guideline that the nurse should follow in resolving the conflict?
A. Require the UAPs to reach a compromise.
B. Weigh the consequences of each possible solution.
C. Encourage the two to view the humor of the conflict.
D. Deal with issues and not personalities
Answer: D. Deal with issues and not personalities
The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 0700 and 1530. Which client response should the nurse document that indicates successful outcome?
A. Demonstrates adequate fluid intake and output.
B. Verbalizes abdominal comfort without pressure.
C. Drinks 240 mL of fluid five times during the shift.
D. Voids at least 1000 mL between 7 am and 3 pm
Answer: C. Drinks 240 mL of fluid five times during the shift.
The nurse plans a teaching session with a client but postpones the planned session based on which nursing problem?
A. Knowledge deficit regarding impending surgery.
B. Ineffective management of treatment regimen.
C. Activity intolerance related to postoperative pain.
D. Noncompliance with prescribed exercise plan.
Answer: C. Activity intolerance related to postoperative pain.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to wear a gown and mask when you are in my room?" How should the nurse respond?
A. "To protect you because you can get an infection very easily."
B. "Your condition could be spread to staff and other clients in the hospital."
C. “There are many forms of bacteria and germs in the hospital.”
D. “After taking medication for 24 hours a gown and mask won’t be needed.”
Answer: A. "To protect you because you can get an infection very easily."
The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which statement by a parent indicates understanding of phototherapy?
A. "I should leave the baby under the light all of the time."
B. "I should dress the baby in light clothing when the baby is under the light."
C. "I need to change the baby's position every four hours."
D. "I will keep the baby's eyes covered when the baby is under the light."
Answer: D. "I will keep the baby's eyes covered when the baby is under the light."
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry mouth. Which action should the nurse implement?
A. Apply a water soluble lubricant to the lips, oral mucosa and nares.
B. Put petroleum jelly on the lips and around the nasogastric tube.
C. Offer the client ice chips and instruct client to spit out the water.
D. Allow the client to drink water and record on the I an O record.
Answer: A. Apply a water soluble lubricant to the lips, oral mucosa and nares.
The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings are consistent with this client's clinical picture?
A. Hemoglobin of 10 g and hypophosphatemia.
B. Cloudy, amber urine with sediment, specific gravity of 1.040.
C. Serum potassium of 5.5 mEq and total calcium of 6 mg/dl.
D. Blood urea nitrogen 40 m and creatinine 1.0.
Answer: C. Serum potassium of 5.5 mEq and total calcium of 6 mg/dl.
Which information should the nurse give a client with chronic kidney disease (CKD)?
A. Obtain monthly B12 injections.
B. Restrict calcium-rich foods.
C. Avoid salt substitutes.
D. Increase daily intake of fiber.
Answer: C. Avoid salt substitutes.
A nurse is answering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to explain the use of tamoxifen (Nolvadex). Which response should the nurse provide?
A. Part of a combination of chemotherapeutic agents used to treat tumors.
B. An used to reduce the risk of breast cancer for all women.
C. Low doses of tamoxifen prevent menopausal hot flashes.
D. This anti-estrogen drug inhibits malignancy growth.
Answer: D. This anti-estrogen drug inhibits malignancy growth.
Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer?
A. Use condoms for sexual intercourse during the next week.
B. Notify the healthcare provider if heavy vaginal discharge occurs.
C. Use a sanitary napkin instead of a tampon.
D. Flat subclinical mucosal lesions are a common harmless side effect.
Answer: C. Use a sanitary napkin instead of a tampon.
Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between healthcare providers?
A. Case manager.
B. Nurse-manager.
C. Discharge manager.
D. Quality manager.
Answer: A. Case manager.
The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the healthcare provider?
A. Expresses fear about the surgical procedure.
B. Reports a history of hives after eating shellfish.
C. States has a history of post-operative nausea.
D. Recalls drinking a glass of juice after midnight
Answer: D. Recalls drinking a glass of juice after midnight
The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to "grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing behaviors. Which information is best for the nurse to provide?
A. Rebelliousness requires consequences to prevent socially deviant behavior.
B. The parents should consider hospitalization to prevent self-injury.
C. Adolescents who demonstrate labile behaviors are at risk for self-injury.
D. Early adolescence is a developmental stage of normal experimentation.
Answer: D. Early adolescence is a developmental stage of normal experimentation.
The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the questions for the client. Which action is best for the nurse to implement?
A. Direct the questions to the spouse whenever possible.
B. Ask another nurse to complete the interview.
C. Ask the spouse to step out for a few minutes.
D. Repeat each question and tell the client to speak up.
Answer: C. Ask the spouse to step out for a few minutes.
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor should the nurse include in the nursing problem "Imbalanced nutrition: more than body requirements"?
A. Marked obese.
B. Inadequate lifestyle changes in diet and exercise.
C. Morbidly obese.
D. Increased morbidity and mortality risks.
Answer: B. Inadequate lifestyle changes in diet and exercise.
The nurse is assessing a client and identifies the presence of petechiae. Which documentation best describes this finding?
A. Purplish-red pinpoint lesions of the skin
B. Generalized reddish discoloration of an area of skin.
C. Small circumscribed elevations containing purulent fluid.
D. Purple to bluish discoloration of the skin.
Answer: A. Purplish-red pinpoint lesions of the skin
The nurse is inspecting the external eye structures for a client. Which finding is a normal racial variation?
A. A Hispanic client may have inward-turned eyelashes.
B. A Caucasian client may have a slightly protruding eyeball.
C. An African-American client may have slightly yellow sclerae.
D. An Asian client may have a horizontal palpebrale fissure.
Answer: C. An African-American client may have slightly yellow sclerae.
During the physical assessment, which finding should the nurse recognize as a normal finding?
A. Jugular venous pressure palpable with the client in an upright position.
B. Point of maximal impulse at the third intercostal space in the right midclavicular line.
C. Apical pulse noted over an area 4 to 5 centimeters with a duration of 2 seconds.
D. Regular pulsation at the epigastric area when the client is supine.
Answer: D. Regular pulsation at the epigastric area when the client is supine.
The nurse is monitoring neurological vital signs for a male client who lost consciousness after falling and hitting his head. Which assessment finding is the earliest and most sensitive indication of altered cerebral function?
A. Loss of central reflexes.
B. Unequal pupils.
C. Inability to open the eyes.
D. Change in level of consciousness.
Answer: D. Change in level of consciousness.
When documenting assessment data, which statement should the nurse record in the narrative nursing notes?
A. Slight tenderness in the left upper quadrant.
B. Most all permanent teeth are present.
C. Hair is within normal limits.
D. S1 murmur auscultated in supine position.
Answer: D. S1 murmur auscultated in supine position.
A female client reports to the nurse that her sleep was interrupted by "thoughts of anger toward my husband." What type of thoughts is the client having?
A. Obsessive.
B. Delusional.
C. Paranoid.
D. Phobic.
Answer: A. Obsessive.
The nurse attempts to notify the healthcare provider about a client who is exhibiting an extrapyramidal reaction to psychotropic medications. When the receptionist for the answering service offers to take a message, which nursing action is best for the nurse to take?
A. Ask when the healthcare provider plans to return to the office and the usual office hours.
B. Provide the receptionist with the client’s name. age, and type of reaction.
C, Ask the receptionist to notify the client’s family if the healthcare provider cannot be contacted.
D. Tell the receptionist to have the healthcare provider return the phone call.
Answer: D. Tell the receptionist to have the healthcare provider return the phone call.
A primipara with a breech presentation is in the transition phase of labor. The nurse visualizes the perineum and sees the umbilical cord extruding from the introitus. In which position should the nurse place the client?
A. Right lateral side with both legs flexed.
B. Left supine with thighs flexed on her abdomen.
C. Semi-Fowler's with head of bed elevated 30 degrees.
D. Supine with the foot of the bed elevated.
Answer: D. Supine with the foot of the bed elevated.
The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes?
A. Educate significant others about providing support for their partner during labor.
B. Teach and practice breathing techniques to help cope with contractions during labor.
C. Participants can identify at least three coping strategies to use during labor.
D. Introduce comfort measures that are effective techniques to use during labor and delivery.
Answer: C. Participants can identify at least three coping strategies to use during labor.
A female client makes routine visits to a neighborhood community health center. The nurse notes that this client often presents with facial bruising, particularly around the eyes. The nurse discusses prevention of domestic violence with the client even though the client does not admit to being battered. What level of prevention has the nurse applied in this situation?
A. Health promotion.
B. Primary prevention.
C. Secondary prevention.
D. Tertiary prevention.
Answer: C. Secondary prevention.
Clinical portfolios are being introduced into the performance appraisal process for staff nurses employed at a hospital. What should the nurse-manager request that each staff nurse include in the portfolio?
A. Copies of any articles the nurse has read that relate to client care on the nursing unit.
B. Evaluations by past nursing faculty and employers to document ongoing competence.
C. Letters of support from family members and friends who are healthcare professionals.
D. A self-evaluation that identifies how the nurse has met professional objectives and goals.
Answer: D. A self-evaluation that identifies how the nurse has met professional objectives and goals.
While documentation of continuing education and any certifications achieved are important to include in a clinical portfolio, (B) is not necessary. (C) is not a significant component of a clinical portfolio. When engaging in planned change on the unit, what should the nurse-manager establish first?
A. Resources needed for the change are available.
B. Staff members are aware of the need for change.
C. Goals for achieving the change are established.
D. Options for accomplishing the change are explored.
Answer: B. Staff members are aware of the need for change.
A work group is to be formed to determine a care map for a new surgical intervention that is being conducted at the hospital. Which group is likely to be most effective in developing the new care map?
A. Multidisciplinary group.
B. Single-discipline group.
C. Nurse-manager group.
D. Surgical staff group.
Answer: A. Multidisciplinary group.
The scope of professional nursing practice is determined by rules promulgated by which organization?
A. American Nurses Association (ANA).
B. State's Board of Nursing.
C. State Nursing Associations.
D. National Labor Relations Board (NLRB).
Answer: B. State's Board of Nursing.
An older client who has been bedridden for a month is admitted with a pressure ulcer on the left trochanter area. The nurse determines that the ulcer extends into the subcutaneous tissue. At which stage should the nurse document this finding?
A. Stage 3.
B. Stage 1.
C. Stage 2.
D. Stage 4
Answer: A. Stage 3.
After receiving report, the nurse prioritizes the client care assignment. Which client should the nurse assess first?
A. An anxious client who is 3 days post myocardial infarction.
B. A client whose blood transfusion is near completion.
C. The client with type 2 diabetes mellitus who has a call light on.
D. The client who has a new onset of difficult breathing.
Answer: D. The client who has a new onset of difficult breathing.
When meeting with the client and the family, which nursing intervention demonstrates the nurse's role as collaborator of care?
A. Referring and consulting with other healthcare specialties.
B. Informing about the finding that determine clinical diagnosis.
C. Coordinating and educating about multidisciplinary services.
D. Providing information on financial assistance programs.
Answer: C. Coordinating and educating about multidisciplinary services.
Preoperatively, a client is to receive 75 mg of meperidine (Demerol) IM. The Demerol solution contains 50 mg/mL. How much solution should the nurse administer?
A. 1.5 mL.
B. 0.5 mL.
C. 2 mL.
D. 1 mL.
Answer: A. 1.5 mL.
A low potassium diet is prescribed for a client. What foods should the nurse teach this client to avoid?
A. Mashed potatoes.
B. Dried prunes.
C. Mustard greens.
D. Cottage cheese.
Answer: B. Dried prunes.
A client is admitted with a medical diagnosis of Addisonian crisis. When completing the admission assessment, the nurse expects this client to exhibit which clinical manifestations?
A. Headache, diaphoresis, and palpitations.
B. Hypotension, rapid weak pulse, and rapid respiratory rate.
C. Thin, fragile skin, ecchymoses, and complaints of weakness.
D. Abrupt onset of hyperpyrexia, extreme tachycardia, and delirium.
Answer: B. Hypotension, rapid weak pulse, and rapid respiratory rate.
The nurse plans to suction a male client who has just undergone right pneumonectomy for cancer of the lung. Secretions can be seen around the endotracheal tube and the nurse auscultates rattling in the lungs. What safety factors should the nurse consider when suctioning this client?
A. Suction deeply and vigorously to ensure that all secretions are removed in order to prevent atelectasis.
B. Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning.
C. Suction for only 5 seconds since the client has only one lung and cannot hold his breath for very long.
D. Have another person available to hold the client's hands to prevent inadvertent removal of the suction tube.
Answer: B. Use a soft-tip rubber suction catheter and avoid deep vigorous suctioning.
A dyspneic male client refuses to wear an oxygen face mask because he states it is "smothering" him. What oxygen delivery system is best for this client?
A. Rebreather mask.
B. Venturi mask.
C. Hand-held nebulizer
D. Nasal cannula.
Answer: D. Nasal cannula.
Following major abdominal surgery, a male client's arterial blood gas analysis reveals Pa02 95mmHg and PaC02 50 mmHg. He is receiving oxygen by nasal cannula at 4 liters/minute and is reluctant to move in bed or deep breathe. Based on this information, what action should the nurse implement at this time?
A. Encourage the client to breathe slower.
B. Notify the healthcare provider of the crisis blood gas values.
C. Encourage the use of an incentive spirometer.
D. Increase the oxygen flow to 6 liters/minute.
Answer: C. Encourage the use of an incentive spirometer.
A retired office worker is admitted to the psychiatric inpatient unit with a diagnosis of major depression. The initial nursing care plan includes the goal, "Assist client to express feelings of anger." Which nursing intervention is most important to include in the client's plan of care?
A. Teach that anger will subside after two weeks on antidepressants.
B. Ask client to describe triggers of anger.
C. Gather more data about social support.
D. Collaborate with the treatment team about revising the goal.
Answer: B. Ask client to describe triggers of anger.
The nurse is conducting a drug education class for junior high school students. Which statement, provided by one of the student participants, best describes the primary characteristic of addiction?
A. Wanting the drug is all that matters to an addict.
B. Addicts who use illegal drugs are trying to escape reality.
C. Addiction causes people to steal and lie.
D. Those who are unhappy with themselves are more likely to become addicts.
Answer: A. Wanting the drug is all that matters to an addict.
The nurse is caring for critically ill clients. Which client should be monitored for the development of neurogenic shock? A client with
A. congestive heart failure.
B. diabetes insipidus.
C. spinal cord injury.
D. gastrointestinal hemorrhage.
Answer: C. spinal cord injury.
Which statement by the community health nurse is most helpful to an adult who is in a crisis situation?
A. I will be your primary resource person, and will gather the information you need to get through this situation.
B. Based on past coping, I believe you will be able to deal with future problems successfully.
C. I have a plan of action that I think will help you. Would you like to see if it will work for you?
D. You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it?
Answer: D. You seem to be more tense these days. Would you like to talk about the problem and how you are dealing with it?
A child with bacterial conjunctivitis receives a prescription for erythromycin eye drops. Which information is most important for the nurse to include in the teaching plan?
A. Apply warm compresses to reduce swelling.
B. Take acetaminophen (Tylenol) for any eye discomfort.
C. Avoid sharing towels and washcloths with siblings
D. Wear sunglasses to protect eyes from sunlight.
Answer: C. Avoid sharing towels and washcloths with siblings
The school nurse is reviewing health risks associated with extracurricular activities of gradeschool children. Regular participation in which activity places the child at highest risk for developing external otitis?
A. Soccer practice at an outdoor field.
B. Roller skating at an indoor rink.
C. Batting practice at a batting cage.
D. Swimming lessons in an indoor pool.
Answer: D. Swimming lessons in an indoor pool.
The nurse is planning to conduct nutritional assessments and diet teaching to clients at a family health clinic. Which individual has the greatest nutritional and energy demands?
A. A 3-month-old infant.
B. A teenager beginning puberty.
C. A school-aged child.
D. A pregnant woman
Answer: D. A pregnant woman
The nurse is teaching staff in a long-term facility home the principles of caring for clients with essential hypertension. Which comment should the nurse include in the inservice presentation about the care of clients with hypertension?
A. Clients with an elevated blood pressure often exhibit a stiff neck and are diaphoretic.
B. Caregivers should only conduct blood pressure checks under a registered nurse's direct supervision.
C. Frequent blood pressure checks, including readings taken by automated machines, are recommended.
D. As long as clients receive daily antihypertensive medications, no further interventions -
Answer: C. Frequent blood pressure checks, including readings taken by automated machines, are recommended.
A client is admitted to the hospital for alcohol dependency. What is the priority nursing intervention during the first 48 hours following admission?
A. Monitor for increased blood pressure and pulse.
B. Administer a PRN benzodiazepine as needed for anxiety.
C. Encourage fluid intake of non-caffeinated beverages.
D. Administer thiamine (B1) to prevent Korsakoff's syndrome.
Answer: A. Monitor for increased blood pressure and pulse.
The nurse is preparing to administer a prescribed dose of acetylcysteine (Mucomyst) 600 mg PO. The 10 mL vial is labeled "Mucomyst 20% solution (20 grams/100 mL)." What volume of medication in milliliters should the nurse administer? (Enter numeric value only.)
Answer: 3
A male client diagnosed with antisocial personality disorder is morbidly obese and is placed on a low fat, low-calorie diet. At dinner the nurse notes that he is trying to get other clients on the unit to give him part of their meals. What intervention should the nurse implement?
A. Remove the client from the table and have him sit alone.
B. Report the behavior to the on-call psychologist immediately.
C. Send the client back to his room and do not allow him to eat.
D. Confront the client about the consequences of the behavior
Answer: D. Confront the client about the consequences of the behavior
In planning the care of a 3-year-old child with diabetes insipidus, it is most important for the nurse to caution the parents to be alert for which condition?
A. Increased thirst.
B. Swelling around the eyes and face.
C. Cool, diaphoretic skin.
D. Soft anterior fontanel.
Answer: A. Increased thirst.
A client assigned to a female practical nurse (PN) needs total morning care and sterile wound packing with a wet to dry dressing. The PN tells the nurse that she has never performed a wound packing. Which intervention should the charge nurse implement?
A. Note the PN's learning need to perform a wound packing and contact nursing education to schedule a time for instruction.
B. Demonstrate the wound care procedure to the PN while the PN assists.
C. Advise the PN to review the procedure in the procedure manual and then complete the wound care.
D. Perform the wound care and have the PN provide the client's morning care.
Answer: B. Demonstrate the wound care procedure to the PN while the PN assists.
A child with Tetrology of Fallot suffers a hypercyanotic episode. Which immediate action by the nurse can lessen the symptoms of this "TET spell?"
A. Administer a dose of digoxin stat
B. Place child in knee-chest position.
C. Have child stop all current activity.
D. Remove child's constrictive clothing
Answer: B. Place child in knee-chest position.
During the assessment of a 21-year-old female client with bipolar disorder, the client tells the nurse that she has not taken her medication for three years, her mother will not let her return home, and she does not have transportation or a job. Which client goal is most important for this client?
A. Begin vocational rehabilitation.
B. Obtain housing, with possibility of returning home.
C. Become familiar with public transportation.
D. Taking medication, with community follow-up.
Answer: D. Taking medication, with community follow-up.
The nurse is preparing to administer a high volume saline enema to a client. Which information is most important for the nurse to obtain prior to administering the enema?
A. Allergies to medications.
B. Feelings about having an enema.
C. History of inflammatory bowel disorders.
D. Reason for administering the enema.
Answer: C. History of inflammatory bowel disorders.
A 63-year-old female client whose husband died one month ago is seen in the psychiatric clinic. Her daughter tells the nurse that her mother is eating poorly, sleeps very little at night, and continues to set the table for her deceased husband. What nursing problem best describes this problem?
A. Confusion related to recent death of loved one.
B. Unresolved anger related to death of husband.
C. Delayed grief reaction related to death of husband.
D. Denial related to the loss of a loved one
Answer: D. Denial related to the loss of a loved one
A nurse-manager sees a colleague taking drugs from the unit. What action should the nurse manager take?
A. Report the incident to the immediate supervisor.
B. Determine if other staff have observed similar behavior.
C. Carefully observe the nurse to verify the behavior.
D. Talk to the colleague about what was seen.
Answer: A. Report the incident to the immediate supervisor.
A client is brought into the emergency department following a sudden cardiac arrest. A full code is started. Five minutes later the family arrives with a durable power of attorney signed by the client requesting that no extraordinary measures be taken, including intubation, to save the client's life. What action should the nurse take?
A. Assess the family's support for the durable power of attorney.
B. Ask the legal department if the code should be continued.
C. Continue the code according to protocol.
D. Stop the code immediately.
Answer: D. Stop the code immediately.
A client with metastatic cancer is preparing to make decisions about end-of-life issues. When the nurse explains a durable power of attorney for health care, which description is accurate?
A. It is a form that all people must sign before admission to the hospital so that individualized treatment plans can be developed
B. It will identify someone that can make decisions for your health care if you are in a coma or vegetative state.
C. It is not legally binding, but helps the healthcare provider know exactly what medical treatments you want.
D. It allows you to document your wishes regarding life-sustaining treatment if you can't speak for yourself.
Answer: B. It will identify someone that can make decisions for your health care if you are in a coma or vegetative state.
Which documentation indicates that the nurse correctly evaluated a pain medication's effectiveness after administration? The client
A. reports decrease in pain.
B. complained of pain; PRN pain medication given.
C. smiling while visiting with family members.
D. was talking on the phone 30 minutes after pain medication was given.
Answer: A. reports decrease in pain.
After eye drops are instilled, which instruction should the nurse provide to the client?
A. Tilt your head back.
B. Look to each side.
C. Close your eyelids.
D. Blink quickly 3 times.
Answer: C. Close your eyelids.
The nurse is preparing to administer IV fluid to a client with a strict fluid restriction. IV tubing with which feature is most important for the nurse to select?
A. Micro drop factor.
B. Drop factor of 15 gtt/mL.
C. An intact inline filter.
D. A Buretrol attachment.
Answer: D. A Buretrol attachment.
Prior to transferring a client to a chair using a mechanical lift, what is the most important client characteristic the nurse should assess?
A. Tolerance of exertion.
B. Ability to bear weight.
C. Ability to grasp objects.
D. Upper body muscle strength.
Answer: A. Tolerance of exertion.
Lasix 20 mg PO is prescribed for a client at 0600. The medication is available in a scored tablet of 40 mg. Before breaking the tablet, what action should the nurse take?
A. Perform hand hygiene.
B. Consult with the pharmacist.
C. Chart "half tablet administered."
D. Apply non-sterile gloves.
Answer: A. Perform hand hygiene.
Which assessment finding should make the nurse suspect that a 21-year-old male client is taking anabolic steroids?
A. Describes working hard to develop muscles.
B. Acne increased on face and back.
C. Weight gain of 10 pounds in the past month.
D. Complains of increased facial hair growth.
Answer: A. Describes working hard to develop muscles.
Which instruction should the nurse include in the discharge teaching for a client who is taking an antipsychotic medication?
A. Increase daily intake of raw fruits and vegetables.
B. Follow a low carbohydrate diet.
C. Report increased urine output to the healthcare provider immediately.
D. Take a multivitamin daily.
Answer: A. Increase daily intake of raw fruits and vegetables
Prior to the discharge of a healthy 4-day-old newborn, the nurse is collecting the blood specimens to screen for phenylketonuria (PKU), the Guthrie inhibition assay blood test. What action should the nurse implement to ensure the validity of the test?
A. Instruct the mother to bring the newborn back in one week to have this test completed.
B. Collect the blood prior to the next 4-hour feeding to obtain a fasting specimen.
C. Obtain venipuncture specimens to prevent hemolysis when expressed from capillaries.
D. Assess the newborn’s feeding patterns of formula or breast milk which has “come in.”
Answer: D. Assess the newborn’s feeding patterns of formula or breast milk which has “come in.”
Which nursing intervention is an example of a competent performance criterion for an occupational and environmental health nurse?
A. Implements health programs for construction workers.
B. Designs quality improvement methods that measure health outcomes.
C. Serves as a consultant to businesses and management.
D. Conducts research studies that enhance health safety.
Answer: A. Implements health programs for construction workers.
The nurse is caring for a client who is the daughter of a local politician. When the nurse approaches a man who is reading the names on the hall doors, he identifies himself as a reporter for the local newspaper and requests information about the client's status. Which standard of nursing practice should the nurse use to respond?
A. Advocacy.
B. Caring.
C. Veracity.
D. Confidentiality.
Answer: D. Confidentiality.
A client is being admitted to the medical unit from the emergency department after having a chest tube inserted. What equipment should be brought to this client's room?
A. Endotracheal tube.
B. Crash cart.
C. Partial rebreather oxygen mask.
D. Rubber-tipped clamps.
Answer: D. Rubber-tipped clamps.
A male client, who has been smoking 1 pack of cigarettes every day for the last 20 years, is scheduled for surgery and will be unable to smoke after surgery. During preoperative teaching, the client asks the nurse what symptoms he may expect after surgery from nicotine withdrawal. Which response is best for the nurse to provide?
A. You should have minimal withdrawal symptoms.
B. Headache and hyperirritability are common.
C. A common withdrawal response is hypertension
D. Expect to have a loss of appetite and tachycardia.
Answer: B. Headache and hyperirritability are common.
The nurse identifies bright-red drainage, about 6 cm in diameter, on the dressing of a client who is one day post abdominal surgery. Which action should the nurse take next?
A. Notify the healthcare provider of a potential for hemorrhage.
B. Reassess dressing in one hour for increased drainage.
C. Mark the drainage on the dressing and take vital signs.
D. Remove the dressing and assess the surgical incision site.
Answer: C. Mark the drainage on the dressing and take vital signs.