HESI exit 3, exit 2 on NAXLEX

The practical nurse (PN) is caring for a client who has a prescription for loratadine by mouth daily as needed. Which sign indicates to the PN that there is a need to administer the medication?

Red welts widespread over the chest. Most selected

Red welts widespread over the chest are indicative of hives (urticaria), which are often caused by allergic reactions. Loratadine can help alleviate the symptoms of hives by blocking histamine release, making it an appropriate choice for this condition.

A client has a prescription for NPH insulin 25 units before breakfast and insulin aspart before meals and hour of sleep per sliding scale. The sliding scale parameters are:. 0 units for finger stick glucose less than 170 mg/dL;. 5 units for finger stick glucose 171 to 219 mg/dL;. 10 units for finger stick glucose 220 to 269 mg/dL;. 15 units for finger stick glucose 270 to 300 mg/dL.

Call healthcare provider for finger stick glucose greater than 300 mg/dL. The client's 0730 finger stick glucose is 271 mg/dL. What is the total amount of insulin this client should receive? (Enter numeric value only.).

Correct Answer: 35

At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

Safety plan to keep in a purse at all times. Most selected

The practical nurse (PN) should provide the client with a safety plan to keep in her purse at all times. Safety planning is crucial for individuals facing domestic abuse, and having a plan readily available can be a lifesaving resource. This plan should include emergency contact numbers, information about local women's shelters, steps to take during an abusive incident, and strategies for safely leaving an abusive situation. By giving the client a safety plan, the PN empowers her with tools to protect herself and her unborn child.

The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?

Ability to swallow. Most selected

Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.

In assessing a 2-year-old boy with croup, the practical nurse (PN) finds that he has become increasingly irritable and has developed tachypnea and resting stridor. Which intervention is best for the PN to implement?

Monitor the child's oxygen saturation level via pulse oximetry. Most selected

Croup is a respiratory infection that causes inflammation and narrowing of the airway, resulting in a barking cough, hoarseness, and stridor. The PN should monitor the child's oxygen saturation level via pulse oximetry, as it can indicate the severity of the airway obstruction and the need for supplemental oxygen or other interventions.

The practical nurse (PN) determines that a client's pupils constrict as they change focus from a far object to a near object. How should the PN document this finding?

Pupils reactive to accommodation Most selected

"Pupils reactive to accommodation". accurately describes the normal physiological response of the pupils constricting as they change focus from a distant object to a nearby object. This response ensures that the appropriate amount of light enters the eyes to maintain clear vision during different distances of focus.

Prior to giving digoxin, the practical nurse (PN) assesses that a 2-month-old infant's heart rate is 120 beats/minute. Based on this finding, which action should the PN take?

Administer the medication and document the heart rate. Most selected

However, it's crucial to emphasize that the nurse should always follow the specific orders and guidelines of the healthcare provider and the facility's protocols. If there is any uncertainty or concern, the nurse should seek guidance from the charge nurse or the healthcare provider before taking any action.

The practical nurse (PN) is providing care for a client who is ordered nothing by mouth (NPO) after a small bowel resection. The client's nasogastric (NG) tube is connected to low intermitent suction. The client reports dizziness and tingling in digits.

Which assessment finding by the PN should be reported to the healthcare provider?

Heart rate of 90 beats per minute with premature ventricular contractions (PVCs) noted on telemetry. Most selected

PVCs are abnormal heartbeats that occur when a ventricle contracts earlier than expected. They can indicate electrolyte imbalance, such as hypokalemia, which can result from NG suctioning. The PN should report this finding to the healthcare provider, as it may require treatment or adjustment of the suctioning.

A 15-year-old adolescent male with a mild mental disability is hospitalized for minor surgery and tells the practical nurse (PN), "Wow! You have big breasts." Which response is best for the PN to provide?

That language is not allowed. Most selected

This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's attention to another topic or activity and document the incident.

The practical nurse (PN) is making a home visit to an older male adult who was recently diagnosed with Herpes zoster (shingles). The client reports the onset of severe burning pain along the right side of his trunk.

What action should the PN take?

Administer a prescribed PRN dose of analgesic. Most selected

This is the best action for the PN to take because it provides immediate relief for the client's pain, which can be severe and debilitating in Herpes zoster. The PN should also assess the client's pain level, location, and characteristics and document the response to the medication.

A client who had knee replacement surgery receives a prescription for enoxaparin 30 mg subcutaneously every 12 hours for 10 days. The medication is available in 30 mg per 0.3 mL prefilled syringes. How many mL should the practical nurse (PN) administer each day? (Enter numerical value only.).

Correct Answer: 0.6

Administering 30 mg of enoxaparin every 12 hours for 10 days requires calculating the total amount needed. To find the total amount, we multiply the dose (30 mg) by the frequency (2 times per day) and the duration (10 days). Thus, 30 mg x 2 x 10 = 600 mg. Since the medication is available as 30 mg per 0.3 mL prefilled syringe, we can calculate the mL required: 600 mg ÷ 30 mg/mL = 20 mL. Therefore, the practical nurse should administer 20 mL each day.

A client who is in active labor is admitted with her cervix dilated to 3 cm with 50% effacement and the presenting part at 0 station. An hour later, she tells the practical nurse (PN) that she wants to go to the bathroom to empty her bladder. The nurse examines the client again and determines her vaginal exam is unchanged. Which action should the PN implement?

Obtain a straight catheter kit to empty her bladder. Most selected

Obtain a straight catheter kit to empty her bladder.

The unlicensed assistive personnel (UAP) reports to the practical nurse (PN) that a male client with fluid volume overload will not allow the UAP to obtain his daily weight. Which action should the PN implement?

Consult with the client about the reasons for his refusal to be weighed Most selected

Consulting with the client about the reasons for his refusal to be weighed is the most appropriate action. Open communication with the client can help identify any concerns or fears related to the weighing process. By understanding the client's perspective, the healthcare team can work together to find a solution that ensures the client's cooperation with the weight monitoring

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most important for the practical nurse (PN) to review?

Serum creatinine. Most selected

Serum creatinine is a crucial laboratory value to assess kidney function. It is a waste product that is filtered by the kidneys, and its level in the blood is a reliable indicator of kidney function. If the serum creatinine level is elevated, it suggests impaired kidney function, which can be a warning sign of nephrotoxicity. Reviewing the serum creatinine level before administering nephrotoxic antibiotics is essential to ensure that the client's kidneys are functioning adequately and to avoid potential harm.

The healthcare provider prescribes cefazolin 500 mg IM every 6 hours. The available vial is labeled, "Cefazolin 1 gram,". and the instructions for reconstitution state, "For IM use, add 2.5 mL sterile water for injection to provide a total volume of 3.0 mL.". After reconstitution, how many mL should be administered to the client? (Enter numeric value only. If rounding is required, round to the nearest tenth.). [No changes needed].

Correct Answer: 1.6

After reconstitution, the nurse should administer 1.6 mL of the cefazolin solution to the client. The available vial is labeled "Cefazolin 1 gram,". and the instructions for reconstitution specify that 2.5 mL of sterile water for injection should be added to the vial, resulting in a total volume of 3.0 mL after reconstitution. To calculate the amount to be administered, divide the total dose (500 mg) by the total volume after reconstitution (3.0 mL): 500 mg ÷ 3.0 mL = 0.1667 mg/mL Now, multiply the concentration (0.1667 mg/mL) by the desired dose (500 mg) to find the required volume: 500 mg ÷ 0.1667 mg/mL ≈ 2999.8 mL Rounding to the nearest tenth, the nurse should administer approximately 1.6 mL of the reconstituted cefazolin solution to the client.

The practical nurse (PN) is providing instructions to the unlicensed assistive personnel (UAP) preparing to give a total bed bath to an immobile client who has continuous feeding via a gastrostomy tube (GT). Which instruction is most important for the PN to emphasize?

Keep the head of the bed raised while the tube feeding is infusing. Most selected

Keeping the head of the bed raised while the tube feeding is infusing is the most important instruction. This position helps prevent aspiration, which can lead to pneumonia, a potentially life-threatening condition. When a person is lying flat, there is a higher risk that the tube feeding formula will enter the lungs.

A client with diabetic ketoacidosis (DKA) is receiving regular insulin. Which action should the practical nurse (PN) implement to evaluate the effectiveness of the insulin dosage?

Check fingerstick blood glucose for a decrease in the level. Most selected

Regular insulin is the medication of choice for treating DKA. Its main action is to lower blood glucose levels by promoting the uptake of glucose into cells and inhibiting the production of glucose by the liver. Therefore, checking the fingerstick blood glucose level is an important indicator of the effectiveness of the insulin treatment. A decrease in the blood glucose level indicates that the insulin is working to lower the high blood sugar associated with DKA. This measurement helps the PN assess the response to treatment and adjust the insulin dosage if necessary. The other actions mentioned are also important assessments in the care of a client with DKA, but they do not specifically evaluate the effectiveness of the insulin dosage:

A new unlicensed assistive personnel (UAP) is completing an orientation assignment and is caring for an immobilized client who needs a complete bed bath. Which is the best way for the practical nurse (PN) to evaluate this UAP's performance?

Inspect the client's skin near the end of the bathing procedure. Most selected

Inspecting the client's skin near the end of the bathing procedure allows the PN to directly assess the UAP's performance and evaluate the effectiveness of the bed bath. By observing the client's skin, the PN can determine if the UAP has properly cleaned and cared for the client's skin, identified any areas that may have been missed, and ensured that proper hygiene practices have been followed.

A college student brings his roommate to the clinic because the roommate has been talking to someone who is not present. The student tells the practical nurse (PN) that his roommate is acting strange. Which question should the PN ask the client next?

When did these voices begin?" Most selected

This is the correct answer because it is the most relevant and respectful question to ask the client next. Asking about the onset of the voices can help the practical nurse (PN) determine the possible causes and triggers of the client's hallucinations, which are sensory perceptions that occur without external stimuli. Hallucinations can be caused by various factors, such as mental disorders, substance abuse, medication side effects, physical illnesses, sleep deprivation, or stress.

The PN should ask about the frequency, duration, and content of the voices, as well as the client's response to them. The PN should also assess the client's mood, behavior, cognition, and insight. The PN should use a calm, supportive, and nonjudgmental approach when communicating with the client who is experiencing hallucinations.

Which intervention is the most important for the practical nurse (PN) to implement when applying an ice pack to a client?

Secure a protective cover over the bag. Most selected

The most important intervention for the practical nurse (PN) to implement when applying an ice pack to a client is to secure a protective cover over the bag. This is essential to protect the client's skin from direct contact with the ice pack, which can cause tissue damage, frostbite, or discomfort.Securing a protective cover, such as a thin cloth or towel, between the ice pack and the client's skin helps to create a barrier and prevent excessive cold exposure. It allows for the therapeutic benefits of the ice pack, such as reducing swelling and pain, while minimizing the risk of skin damage.

The practical nurse (PN) is caring for a client with coronary artery disease who is admitted with intermittent chest pain. The admission laboratory results indicate elevations in troponin I and creatine phosphokinase myoglobulin isoenzyme (CK-MB) levels. What should the PN consider the most significant risk for this client on the second day of admission?

The lab results indicate myocardial damage, and the client is at risk for cardiac dysrhythmias. Most selected

Elevations in troponin I and CK-MB levels indicate myocardial damage, which can result from insufficient blood supply to the heart muscle due to coronary artery disease. When the heart muscle is damaged, it can lead to abnormal electrical activity and rhythm disturbances, known as cardiac dysrhythmias. These dysrhythmias can be life-threatening and require immediate attention.

Transient ischemic attack (TIA) refers to a temporary interruption of blood flow to the brain, which is not directly related to the elevated troponin I and CK-MB levels. Therefore, monitoring neurological vital signs for TIA is not the most significant risk in this case.

Pulmonary embolism, while it is a serious condition, is not directly indicated by the elevated troponin I and CK-MB levels. Lifestyle modifications may be important for managing coronary artery disease but are not the most significant risk based on the given information.

Recurrent long-term angina pain and subsequent myocardial infarction (MI) may be a concern for the client with coronary artery disease, but the elevated troponin I and CK-MB levels suggest that myocardial damage has already occurred. The focus at this point would be on managing the acute myocardial damage and the risk of cardiac dysrhythmias.

A male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now. How should the PN respond?

Tell the client that the PN will verify that the dispensed medication is the valid prescription. Most selected

- Medication administration is a process that involves prescribing, dispensing, and giving medications to patients. It is a critical and complex task that requires accuracy, safety, and adherence to the rights of medication administration, such as the right patient, right drug, right dose, right route, right time, right documentation, and right response.- When a male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now, this may indicate a potential medication erroror discrepancy. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. A medication discrepancy is any difference between the current and previous medication regimens of a patient.- The PN should respond to the client's concern by telling him that the PN will verify that the dispensed medication is the valid prescription. This means that the PN will check the medication label, the medication order, and the medication administration record (MAR) to confirm that the medication given to the client matches the one prescribed by the healthcare provider. The PN will also compare the dispensed medication with a drug reference guide or a picture of the medication to ensure that it is the correct drug and dosage form. The PN will also report any suspected errors or discrepancies to the healthcare provider or the pharmacy for clarification or correction .- Options A, B, and D are incorrect answers, as they do not reflect the appropriate or responsible actions for the PN to take when faced with a possible medication error or discrepancy.

Which intervention is most important for the practical nurse (PN) to implement for a client who is receiving total parenteral nutrition (TPN)?

Collect fingerstick glucose levels. Most selected

Collecting fingerstick glucose levels is the most important intervention for the PN to implement for a client who is receiving TPN. TPN is a method of feeding that bypasses the gastrointestinal tract and provides all the nutritional needs of the body through a vein. TPN contains a high concentration of glucose, which can cause hyperglycemia or fluctuations in blood sugar levels. Therefore, it is essential to monitor the client's glucose levels frequently and adjust the infusion rate or insulin administration accordingly.

The practical nurse (PN) is caring for an older client who is receiving chemotherapy for lung cancer. Which finding is the highest priority for the PN to report to the charge nurse?

Reference ranges:

Blood urea nitrogen (BUN): [Adult: 10 to 20 mg/dL or 3.6 to 7.1 mmol/L]

Platelets: [150,000 to 400,000/mm3 or 150 to 400 x 109/L]

Blood urea nitrogen 75 mg/dL or 12.9 mmol/L Most selected

The finding that is the highest priority for the PN to report to the charge nurse is the blood urea nitrogen (BUN) level of 75 mg/dL or 12.9 mmol/L. This result indicates an elevated BUN level, which can be indicative of impaired kidney function. In a client receiving chemotherapy, an elevated BUN level may suggest chemotherapy-induced nephrotoxicity or other kidney-related complications. Prompt reporting is crucial to ensure appropriate intervention and management of the client's kidney function.

The practical nurse (PN) believes that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Which action should the PN take?

Call the healthcare provider and clarify the prescription. Most selected

This is the action that the PN should take if they believe that a prescription for a child is incorrect because the dosage prescribed is the usual adult dosage. Calling the healthcare provider and clarifying the prescription is the safest and most effective way to prevent medication errors and ensure the child's safety. The PN should not administer the medication until they are sure that it is correct and appropriate for the child.

Which action should the practical nurse (PNA) prioritize for postoperative patient with a PCA (Patient- Controlled Analgesia) machine?

Assessing pain management response.

This is the correct answer because it is the most important and relevant action that the PN should do for a postoperative patient with a PCA machine. A PCA machine is a computerized device that allows the patient to self-administer a preset dose of pain medication, usually an opioid, by pressing a button. The PCA machine is attached to an intravenous (IV) line that delivers the medication directly into the bloodstream. The PCA machine can provide effective and individualized pain relief for postoperative patients, as well as increase their sense of control and satisfaction¹².

The PN should assess the pain management response of the postoperative patient with a PCA machine by monitoring their pain level, vital signs, oxygen saturation, sedation level, and side effects. The PN should use a valid and reliable pain scale, such as the numeric rating scale (NRS) or the visual analog scale (VAS), to measure the patient's pain intensity and relief. The PN should also check the settings and functioning of the PCA machine, such as the dose, lockout interval, and limit. The PN should document and report the patient's pain management response and any problems or complications with the PCA machine to the health care provider.

Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)

-Time of last administration of pain medication.

- Client's pain rating on a scale of 1 to 10.

-Effectiveness of last pain medication administered.

A client reports experiencing numbness and tingling in the extremities. Which of the client's serum laboratory values should the practical nurse (PN) prioritize reporting to the healthcare provider?

Electrolytes Most selected

When a client reports experiencing numbness and tingling in the extremities, it is crucial for the practical nurse (PN) to prioritize reporting the client's electrolyte levels to the healthcare provider. Electrolytes are essential minerals that help maintain the balance of fluids in the body and enable proper nerve and muscle function. Imbalances in electrolyte levels can lead to neurological symptoms, including numbness and tingling.

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using a tympanic thermometer.Which action should the PN take first?

Observe how UAP obtains temperatures. Most selected

This is the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Observing how the UAP obtains temperatures will help the PN identify any errors or problems with the technique, equipment, or documentation. The PN can then provide feedback and guidance to the UAP to ensure accurate and reliable temperature measurements.

An older female adult who was admited to a long-term care facility yesterday is confused about what day of the week it is. Her history does not indicate that she was confused prior to admission. What action should the practical nurse (PN) take?

Remind the client what day of the week it is. Most selected

it provides reality orientation and helps the client cope with the change in environment. The client may be experiencing acute confusion or delirium due to stress, medication, infection, or other factors. The PN should remind the client of the date, time, and place frequently and use other strategies such as calendars, clocks, and familiar objects to reduce confusion.

The healthcare provider prescribed octreotide 150 mcg/day subcutaneously for a client with dumping syndrome. The medication is available in 0.2 mg/mL vials. How many mL should the practical nurse (PN) administer? (Enter numerical value only. If rounding is required, round to the nearest hundredth).

Correct Answer: 0.75

To calculate the amount of mL to administer, the PN should use the following formula:

mL = (mcg x 1 mg/1000 mcg) / (mg/mL)

Plugging in the given values, we get:

mL = (150 x 1/1000) / (0.2)

mL = 0.15 / 0.2

mL = 0.75

Therefore, the PN should administer 0.75 mL of octreotide subcutaneously.

Prior to administering pain medication to an adult postoperative client, what information should the practical nurse (PN) obtain? (Select all that apply.)

Client's pain rating on a scale of 1 to 10

The infant has hypoglycemia, which is a low blood glucose level that can cause jiteriness, lethargy, seizures, or coma. Hypoglycemia is common in infants of mothers with gestational diabetes, as they produce excess insulin in response to high maternal glucose levels. The PN should begin frequent feedings of breast milk or formula, as this can provide a source of glucose and stimulate the infant's own glucose production.

When providing client care, the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important?

Relevance to the situation. Most selected

Correct- The most important consideration when gathering evidence is its relevance to the specific situation at hand. Evidence must directly address the problem and clinical question, ensuring that the information collected is applicable, appropriate, and reliable for guiding decision-making in the current context.

Before leaving the room of a confused client, the nurse notes that a half-bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

Tie the knot with a double turn or square knot. Most selected

Correct - The nurse should tie the knot with a double turn or square knot. This helps ensure that the restraints remain secure and safe.

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

Administer prescribed antibiotics. Most selected

Correct- Administering prescribed antibiotics is the most important action because it can help treat the infection and prevent it from spreading to other parts of the body or to other people. MRSA is resistant to many common antibiotics, so it is essential to follow the prescription and monitor the client's response.

While receiving report for a client with carcinoma in situ of the left breast, the practical nurse (PN) reviews a pending lab report and notices increased levels of Anti-Glycan Neu5Gc Antibodies (AGNA). Which changes should the PN anticipate to be included in the client's plan of care?

Initiation of changes in infection control measures. Most selected

- Anti-Glycan Neu5Gc Antibodies (AGNA) are antibodies that recognize a carbohydrate antigen called N- glycolylneuraminic acid (Neu5Gc), which is found in animal-derived foods and tissues, but not in humans¹². Humans can incorporate Neu5Gc from their diet into their own cells, which can trigger an immune response and the production of AGNA¹².- AGNA has been associated with various inflammatory and autoimmune diseases, such as atherosclerosis, rheumatoid arthritis, Crohn's disease, and cancer¹². AGNA may also play a role in the rejection of bioprosthetic heart valves, which are made from animal tissues that contain Neu5Gc¹.- A client with carcinoma in situ of the left breast is a client with a non-invasive form of breast cancer, where the abnormal cells are confined to the ducts or lobules of the breast. This type of cancer has a high chance of cure with surgery and/or radiation therapy.- Increased levels of AGNA in a client with carcinoma in situ of the left breast may indicate that the client has an increased risk of inflammation and infection, as AGNA can activate the complement system and recruit inflammatory cells to the site of Neu5Gc expression¹². This may impair the healing process and increase the chances of complications after surgery or radiation therapy.- Therefore, the practical nurse (PN) should anticipate that the client's plan of care will include initiation of changes in infection control measures, such as prophylactic antibiotics, wound care, sterile dressing changes, and monitoring for signs and symptoms of infection (such as fever, redness, swelling, pain, or pus). These measures will help to prevent or treat any potential infection and promote wound healing.

A chronically depressed older male resident of a long-term care facility has become more reclusive and today refuses to leave his room. His family has moved away and are unable to visit as much as in the past. Which comment by the practical nurse (PN) is likely to be most helpful to this client?

May I sit with you for a while?" Most selected

This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and offers companionship, which can help reduce isolation and loneliness.

The child is a 2-year-old who fell into a pool. He was retrieved from the pool by a family member but was not breathing. The family member started CPR, and the ambulance brought him to the hospital. What factors are important in determining the level of hypoxemia that the child may have experienced during the submersion?

Select all that apply.

-Temperature of water

The **temperature of water**: Cold water can induce a diving reflex, which lowers the heart rate and oxygen consumption, and may protect the brain from hypoxic injury¹². Cold water can also cause laryngospasm, which prevents water aspiration but also impairs gas exchange.

-The amount of time the child was submerged

The **amount of time the child was submerged**: The longer the submersion, the more severe the hypoxemia and the higher the risk of brain damage and death. The survival rate decreases significantly after 5 minutes of submersion³.

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Intravenous administration of benztropine. Most selected

Correct - Acute dystonic reactions are involuntary muscle spasms caused by certain medications, including antipsychotic drugs. These reactions can sometimes affect the muscles of the face and neck, including the larynx. Benztropine is an anticholinergic medication commonly used to treat acute dystonic reactions. It works by blocking certain neurotransmitters that contribute to muscle spasms, helping to relieve the symptoms.

Before administering an antibiotic that can cause nephrotoxicity, which laboratory value is most importantfor the practical nurse (PN) to review?

erum creatinine. Most selected

Serum creatinine is the most important laboratory value to review before administering an antibiotic that can cause nephrotoxicity. Nephrotoxicity is an alteration in the function of the kidney due to exposure to certain drugs or toxins. It can be assessed by measuring the glomerular filtration rate (GFR), which is the rate of clearance of a substance from the blood by the kidneys. Serum creatinine is a waste product of muscle metabolism that is freely filtered by the glomeruli and not reabsorbed or secreted by the tubules. Therefore, it is a reliable indicator of GFR and renal function. An increase in serum creatinine indicates a decrease in GFR and renal function, which may be caused by nephrotoxic drugs.

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of fluid volume excess? (Select all that apply.)

-Palpate the rate and volume of the pulse.

The PN should palpate the rate and volume of the pulse when assessing a client for signs and symptoms of fluid volume excess.

-Measure body weight at the same time daily.

The PN should measure body weight at the same time daily when assessing a client for signs and symptoms of fluid volume excess.

-Observe the color and amount of urine.

The PN should observe the color and amount of urine when assessing a client for signs and symptoms of fluid volume excess.

The patient is being assisted to the bathroom for the first time. The recent experience caused a sudden guard and ended up at the hospital. The options for the practical course (PN) are:

Return the patient to bed and maintain bed rest until the local flow stabilizes Most selected

The patient experienced a sudden guard while being assisted to the bathroom, which led to their hospitalization. The most appropriate action for the practical nurse (PN) in this situation is to prioritize the patient's safety and well-being. Returning the patient to bed and maintaining bed rest allows for stability and minimizes the risk of further complications or injury.

By providing a safe and controlled environment, the PN can monitor the patient's condition and collaborate with the healthcare team to determine the appropriate course of action moving forward. Options a), c), and d) are not relevant or appropriate in this context.

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.).

-Fresh or frozen vegetables without sauce.

Fresh or frozen vegetables without sauce. Rationale: Fresh or frozen vegetables without sauce are excellent choices for a client with hypertension. These foods are low in sodium and can help manage blood pressure effectively. The absence of added sauces ensures that there is no hidden sodium content.

- Fruits without sauce.

Fruits without sauce. Rationale: Fruits without sauce are also suitable for clients with hypertension. They are naturally low in sodium and provide essential nutrients that can support blood pressure control. The absence of sauce ensures that no additional sodium is added.

A client who weighs 176 pounds receives a prescription for norepinephrine 2 mcg/min intravenously (IV). The IV bag is labeled, "Norepinephrine 4 mg in dextrose 5% in water (D; W) 1,000 mL." How many mL/hour should the nurse program the infusion pump? (Enter numerical value only.).

3.5 mL/hour

The correct answer is 3.5 mL/hour. To calculate the infusion rate, you can use the following formula: Infusion rate (mL/hour) = (Desired dose in mcg/min × Volume in mL) / Concentration in mcg/mL In this case: Desired dose = 2 mcg/min Volume = 1000 mL (the IV bag) Concentration = 4 mg in 1000 mL (or 4,000 mcg in 1000 mL) Now, plug these values into the formula: Infusion rate (mL/hour) = (2 mcg/min × 1000 mL) / 4000 mcg/mL Infusion rate (mL/hour) = (2000 mcg/min) / 4000 mcg/mL Infusion rate (mL/hour) = 0.5 mL/min To find the hourly rate, you need to convert minutes to hours by dividing by 60: 0.5 mL/min ÷ 60 min/hour ≈ 0.0083 mL/hour Rounded to the nearest whole number, the nurse should program the infusion pump at approximately 3.5 mL/hour.

After an increase in the number of suicides in a community, the nurse is developing a class for adolescents about mental health.Which type of activity should the nurse include in the teaching?

Exploration of stress self-management techniques.

The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery.Which menu item(s) should the nurse request for this client? (Select all that apply).

-Orange juice.

Orange juice is acceptable for a client on a clear liquid diet because it is a clear liquid and provides essential nutrients like vitamin C.

-Chicken broth.

Chicken broth is an appropriate choice for a clear liquid diet as it is clear, provides some protein, and is easy to digest.

-Black coffee.

Black coffee is also considered a clear liquid and can be included in a clear liquid diet for this client.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Note the presence of an auscultatory gap. Most selected

Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows.Which response provides the best explanation?

Brain damage with CP is not progressive but does have a variable course.

The practical nurse (PN) notices that one of the unlicensed assistive personnel (UAP) working in the long- term care facility consistently records subnormal temperatures when using a tympanic thermometer.

Which action should the PN take first?

Observe how UAP obtains temperatures Most selected

This is the first action the PN should take when noticing that the UAP consistently records subnormal temperatures when using a tympanic thermometer. Observing how the UAP obtains temperatures will help the PN identify any errors or problems with the technique, equipment, or documentation.

The PN can then provide feedback and guidance to the UAP to ensure accurate and reliable temperature measurements.

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wish to see the body before it is taken to the funeral home.Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.).

-Take out dentures and place in a labeled cup.

is a necessary step to ensure the comfort and dignity of the deceased. It helps maintain the appearance and respect for the deceased person.

-Gently close the eyes.

is a common practice to provide a more peaceful and natural appearance to the deceased. It also prevents the eyes from remaining partially open, which can be distressing for family members.

-Place a small pillow under the head.

is done to maintain the natural alignment of the head and neck. This helps create a more lifelike appearance and enhances the comfort of the deceased.

-Remove resuscitation equipment from the room.

is essential for maintaining the dignity of the deceased and creating a more peaceful environment for the family. It also helps prevent any distressing reminders of the resuscitation attempt.

A nurse is documenting the data collected from an ongoing assessment of a client who has diabetes mellitus. The nurse writes, "The client reports feeling thirsty and hungry all the time." How should the nurse label this type of data?

Subjective data

Subjective data. Rationale: Subjective data are information provided by the client, including their feelings, perceptions, and experiences. The statement correctly labels the data as subjective, as it reflects the client's report of thirst and hunger.

After a client receives a dose of albuterol, the nurse evaluates the medication's effects by auscultating the client's lung fields.Which action should the nurse take next based on the assessment? (Please listen to the audio clip to select the option that applies.To repeat, click the play button again.).

Use a peak flow meter to assess the respiratory status.

Use a peak flow meter to assess the respiratory status. Assessing the client's respiratory status using a peak flow meter is the most appropriate next action after administering albuterol, a bronchodilator. It helps determine the client's lung function and response to the medication. This information guides further interventions and treatment decisions.

A client at 42-weeks gestation arrives at the labor and delivery unit for a scheduled induction but refuses the prescribed oxytocin infusion because she wants to have a "natural" delivery.Which action is most important for the nurse to implement?

Discuss alternative ways to support the client's birth plan.

Discuss alternative ways to support the client's birth plan. This is the correct choice because it directly addresses the client's refusal of the oxytocin infusion and desire for a "natural" delivery. Exploring alternative methods for inducing or facilitating labor in a way that aligns with the client's birth plan is essential.

A nurse is caring for a client who has Alzheimer's disease.Which of the following findings should the nurse expect?

Failure to recognize familiar objects.

Failure to recognize familiar objects is a common symptom of Alzheimer's disease. This is referred to as agnosia, where individuals may struggle to recognize familiar people, objects, or places. It results from the progressive damage to brain regions responsible for memory and sensory processing.

A client is admitted following a motor vehicle collision.When assessing the client's level of consciousness, the nurse notes that the client no longer responds to commands.The nurse initiates a painful stimulus and the client responds by pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward.Which action should the nurse implement?

Document the purposeful response to pain.

Documenting the purposeful response to pain is the correct initial action in this scenario. The client's response, which involves pulling the arms inward with elbows and wrists flexed and extending the legs with the toes pointed downward, is known as decerebrate posturing. It is a specific neurological response to painful stimuli and may indicate a brain injury. Documenting this response is crucial for the client's medical record and helps the healthcare provider assess the severity of the neurological injury.

A client is recovering in the critical care unit following a cardiac catheterization.Intravenous (IV) nitroglycerin and heparin are infusing.The client is sedated but responds to verbal instructions.After changing positions, the client complains of pain at the right groin insertion site.Which action should the nurse implement?

Check femoral site for hematoma formation.

Checking the femoral site for hematoma formation is the most appropriate action in response to the client's complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Checking for hematoma allows the nurse to assess for bleeding and take appropriate measures to manage it.

A client is admitted to the intensive care unit (ICU) with a spinal cord injury (SCI) following a motor vehicle collision .Which nurse should be contacted to coordinate the progression of the client's care?

Nurse case manager.

A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg by mouth (PO) for withdrawal symptoms.The client begins to complain of feeling nervous and tells the nurse that her bones are itching.Which finding should the nurse identify as a contraindication for administering the medication?

Hypertension.

The contraindication for administering clonidine in this scenario is hypertension. Clonidine is an antihypertensive medication and can lower blood pressure. If the client has hypertension, giving clonidine could exacerbate the problem and cause further reduction in blood pressure, potentially leading to complications.

A 70-year-old female presents to the emergency department triage with a noticeable facial droop and garbled speech.

After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand.

The triage nurse does a rapid assessment of the client.

1915: Client arrives via personal car to the emergency department with facial drooping and garbled speech.

1920: Vital Signs:. Temperature: 98.2°F (36.8° C). Heart rate: 92 beats/minute.

Respirations: 24 breaths/minute.

Blood pressure: 210/98 mm Hg. Oxygen saturation: 95% on room air.

The nurse performs an initial rapid assessment of the client and observes facial drooping and garbled speech.

Drag one condition and one client finding to complete the sentence(s). Based on the collected data, the nurse recognizes that the client is most likely exhibiting signs of ______ as evidenced by ______.

Stroke, Neurological defects and Garbled speech

rationale: Stroke is a medical emergency that often presents with facial drooping and garbled speech, both of which are observed in this client. A stroke occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients. This can lead to brain cells dying in minutes. The client's high blood pressure (210/98 mm Hg) is a significant risk factor for stroke. Normal blood pressure ranges from 90/60 mm Hg to 120/80 mm Hg.

A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss.The client's medical history includes hypertension, gouty arthritis, and cholecystitis.Which instruction should the nurse include in the discharge teaching?

Encourage active range of motion to limit stiffness.

Encouraging active range of motion to limit stiffness is the most appropriate instruction in this situation. The client's inability to bear weight on the right ankle after making dietary changes may be related to musculoskeletal issues or gouty arthritis. Active range of motion exercises can help prevent stiffness and improve joint function.

An older male client is admitted with the medical diagnosis of a possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side.

When entering the room, the nurse finds the client's wife tearful and tries unsuccessfully to give him a drink of water.

Which action should the nurse take?

Ask the wife to stop and assess the client's swallowing reflex

A nurse is planning care for a client with a phobia. Which nursing intervention is appropriate for this client?

Encouraging the client to face their fear gradually.

Encouraging the client to face their fear gradually is an appropriate nursing intervention for a client with a phobia. This approach is consistent with exposure therapy, which is a widely recognized and effective treatment for phobias. Exposure therapy involves gradually exposing the client to the feared object or situation in a controlled and supportive environment. By doing so, the client can learn to confront and manage their fear over time. This approach is evidence-based and helps the client build resilience and reduce anxiety.

A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit.

After completing a health history, the nurse should discuss which topic of pregnancy at this initial visit

Knowledge about labor and delivery.

rationale: Knowledge about labor and delivery. This is the correct choice because the initial prenatal visit should include education about pregnancy, labor, and delivery. Providing the client with essential knowledge about what to expect during labor and delivery empowers her to make informed decisions and plan for her childbirth experience.

What are the signs and symptoms of DKA? Select all that apply.

-Hyperglycemia.

Choice A rationale: Hyperglycemia is a key symptom of DKA. It occurs when there is an insufficient amount of insulin in the body to allow glucose to enter cells for use as energy. As a result, the body begins to break down fat for fuel, leading to the production of ketones and causing blood glucose levels to rise. Normal blood glucose levels are between 4.0 to 6.0 mmol/L when fasting and up to 7.8 mmol/L two hours after eating2.

-Ketonuria.

Choice B rationale: Ketonuria, or the presence of ketones in the urine, is another symptom of DKA. When the body breaks down fat for energy, ketones are produced. If too many ketones build up in the blood, they can spill over into the urine1.

-Metabolic acidosis.

Choice C rationale: Metabolic acidosis occurs in DKA due to the accumulation of ketones in the blood. Ketones are acidic, and when they build up in the blood, they cause the blood to become more acidic, leading to metabolic acidosis

-Dehydration.

Choice E rationale: Dehydration is a common symptom of DKA. High blood glucose levels lead to increased urination as the body tries to get rid of the excess glucose. This can result in dehydration1.

-Kussmaul respirations.

Choice F rationale: Kussmaul respirations are a type of hyperventilation that occurs in DKA as the body tries to get rid of excess acids (ketones) through the lungs by breathing rapidly and deeply1.

A nurse is administering tetracycline to a client who has acne vulgaris.The client tells the nurse that he usually takes calcium supplements with his meals.How should the nurse respond?

"You should take calcium supplements at least 2 hours before or after tetracycline."

The nurse should recommend that the client take calcium supplements at least 2 hours before or after tetracycline. This approach ensures that the client receives the full therapeutic benefit of the antibiotic while still meeting their calcium needs separately.

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis.The client reports having unprotected sex.Which response should the nurse provide?

Explain that reinfections occur from sex with untreated partners.

Explain that reinfections occur from sex with untreated partners. Rationale: This is the correct response. Syphilis is a sexually transmitted infection that can be treated with antibiotics, but reinfections can occur if sexual partners are not treated. This response provides essential information about the potential consequences of unprotected sex with untreated partners.

The nurse is preparing a community outreach program on primary disease prevention.Which topic should the nurse plan to include in this event?

Immunizations that are available

An older male client is admitted with the medical diagnosis of a possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side.

When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water.

Which action should the nurse take?

Ask the wife to stop and assess the client's swallowing reflex

A client arrives at the emergency department with chest pain after taking sildenafil.Based on the client's history, which medication should the nurse withhold?

Nitroglycerin.

Nitroglycerin should be withheld in this scenario. Sildenafil is a medication used to treat erectile dysfunction and pulmonary arterial hypertension. It can potentiate the vasodilatory effects of nitroglycerin, leading to a severe drop in blood pressure. Concomitant use of nitroglycerin and sildenafil is contraindicated due to the risk of significant hypotension, which can be life-threatening.

A woman at 12 weeks' gestation comes to the clinic for her first prenatal visit.

After completing a health history, the nurse should discuss which topic about pregnancy at this initial visit?

Knowledge about labor and delivery.

Knowledge about labor and delivery. This is the correct choice because the initial prenatal visit should include education about pregnancy, labor, and delivery. Providing the client with essential knowledge about what to expect during labor and delivery empowers her to make informed decisions and plan for her childbirth experience.

A client has been diagnosed with depression and has a history of suicide attempts.What intervention is essential for the nurse to implement?

Removing any potential means of self-harm from the client's environment.

Removing any potential means of self-harm from the client's environment is the most essential intervention in this scenario. It is crucial to ensure the client's safety by eliminating access to items or substances that could be used for self-harm, such as medications, sharp objects, or other dangerous items. This intervention helps reduce the immediate risk of harm.