HESI EXIT RN V2 EXAM (2024 / 2025) [ NEW All 160 Qs & As Included – Guaranteed Pass A+!!! (All Brand New Q&A )
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 720 mg/dL. When assessing the client, what is the priority?A. Assess for signs of fluid volume deficitB. Observe wound drainage characteristicsC. Measure the level of acute painD. Determine when the client last ate
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and dull gnawing pain that is relieved when he eats. Which is the best response by the nurse?A. Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcerB. Assure the client that his symptoms may only reflect reflux, since ulcer pain is not relieved with foodC. Instruct the client that these mild symptoms can generally be controlled with changes in his dietD. Advise the client that he needs to seek immediate medical evaluation and treatment of these symptoms
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer’s solution at 75 mL/hr IV. One hour after admission to the unit, the nurse notes 300mL of blood in the suction canister, the client’s heart rate is 155 beats/minute, and his blood pressure is 78/48 mmHg. In addition to reporting the findings to the surgeon, which action should the nurse implement first?A. Measure and document the client’s urinary outputB. Request the client’s reserved unit of packed red blood cellsC. Prepare for placement of a central venous catheterD. Increase the infusion rate of Lactated Ringer’s solution
A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution as 18 units/kg/hour. The available solution is Heparin Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should program the infusion pump to deliver how many mL/hour?
An adult male who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to the intensive care unit (ICU). The nurse notes that the suction control chamber is bubbling at the -10cm H2O mark, which fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?A. Add sterile water to the suction control chamberB. Give blood from the collection chamber as autotransfusionC. Manipulate blood in tubing to drain into chamberD. Increase wall suction to eliminate fluctuation in water seal
An adult male was diagnosed with stage IV lung cancer three weeks ago. His wife approaches the nurse and asks how she will know that her husband’s death is imminent because their two adult children want to be there when he dies. Which is the best response by the nurse? A. Gather information regarding how long it will take for the children to arriveB. Explain that the client will start to lose consciousness and the body systems will slow downC. Reassure the spouse that the healthcare provider will notify when to call the children D. Offer to discuss the client’s health status with each of the adult children
The charge nurse of a critical care unit is informed at the beginning of the shift that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a registered nurse (RN)?A. A 48-year-old marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a raceB. A 34-year-old admitted today after an emergency appendectomy who has a peripheral intravenous catheter and a Foley catheterC. A 63-year-old chain smoker admitted with chronic bronchitis who is receiving oxygen via nasal cannula and has a saline-locked peripheral intravenous catheterD. An 82-year-old client with Alzheimer’s disease and a newly-fractured femur who has a Foley catheter and soft wrist restraints applied
“The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled “”750 mcg/2.4mL””. How many mL should the nurse administer? Round to nearest tenth.”
In caring for a client with Cushing’s Syndrome, which serum laboratory value is most important for the nurse to monitor?A. CreatinineB. LactateC. GlucoseD. Hemoglobin
A client who received hemodialysis yesterday is experiencing a blood pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36 breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal edema, and an oxygen saturation on room air of 89%. Which action should the nurse take first?A. Elevate the foot of the bedB. Restrict the client’s fluidsC. Begin supplemental oxygenD. Prepare client for hemodialysis
When caring for a client with full thickness burns to both lower extremities, which assessment findings warrant immediate intervention? Select all that applyA. Sloughing tissue around wound edgesB. Complaint of increased pain and pressureC. Change in the quality of the peripheral pulsesD. Loss of sensation to the left lower extremityE. Weeping serosanguineous fluid from wounds
An older client is admitted with fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider?A. Urine specific gravity is 1.040B. Systolic blood pressure decreases 10 points when standingC. The client denies being thirstyD. Skin tenting occurs when the client’s forearm is pinched
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication?A. Difficulty locating the uterine fundusB. Excessive lochiaC. Saturation of more than one pad per hourD. Hypertension
After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with printed copies of client information in a uniform pocket. Which action should the nurse take?A. File a detailed incident report with the specific hiring facilityB. Warn the colleague that their actions are unprofessionalC. Comment anonymously about the action on a staff discussion boardD. Communicate the colleague’s actions to the unit charge nurse
The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective?A. At-risk clients received an increased number of routine health screeningsB. Clients reported having new confidence in making healthy food choicesC. Clients who incurred disease complications promptly received rehabilitation D. Client relapse of 30% in a 5-year community-wide anti-smoking campaign
While caring for a client’s postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client’s laboratory values?A. Culture for sensitive organismsB. Serum blood glucose (BG) levelC. Creatinine levelD. Serum albumin
A client is admitted with acute pancreatitis. The client admits to drinking a pint of bourbon daily. The nurse medicates the client for pain and monitors vital signs every 2 hours. Which finding should the nurse report immediately to the healthcare provider?A. Anorexia and abdominal distentionB. Abdominal pain and vomitingC. Confusion and tremorsD. Yellowing and itching of skin
A client with leukemia who is receiving a myleosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this client’s plan of care? A. Assess urine and stool for occult bloodB. Monitor for signs of activity intoleranceC. Require visitors to wear respiratory masksD. Obtain client’s temperature q4 hours
When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this findings be most significant?A. CryingB. Sitting uprightC. VomitingD. Straining on stool
A client who is admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?A. Patch one eyeB. Evaluate swallowC. Reorient oftenD. Range of motion
The nurse is caring for a client with chronic obstructive disease (COPD) who uses oxygen at 2L/minute per nasal cannula continuously. The nurse observes that the client is having increased shortness of breath with respirations at 23 breaths/minute. Which action should the nurse implement first? A. Determine if the client is experiencing any anxietyB. Auscultate the client’s bilateral lung sounds and oxygen saturationC. Notify the healthcare provider about the client’s distressD. Assess the delivery mechanism of the oxygen tank, tubing, and cannula
A client with a history of using illicit drugs intravenously is admitted with Kaposi’s sarcoma. Which intervention should the nurse include in this client’s admission plan of care? A. Assess for symptoms of AIDS dementiaB. Monitor for secondary infectionsC. Identify local HIV support groupsD. Observe for adverse drug reactions
An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client’s compliance with self care? A. Have the client vocalize the instructions providedB. Ensure that someone will stay with the client for 24 hoursC. Speak clearly and face the client for lip readingD. Provide written instructions for eye drop administration
An older woman with history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5 mg daily and has an international normalized ratio (INR) value of 5.0. Upon admission, which prescription should the nurse expect to implement?A. Administer Vitamin K injectionB. Start continuous heparin infusionC. Continue warfarin at same doseD. Transfuse unit of packed red blood cells
A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50mL/hr. The client’s urine specific gravity is 1.035. Which action should the nurse implement? A. Assess bowel sounds in all quadrantsB. Encourage popsicles and fluids of choiceC. Evaluate postural blood pressure measurementsD. Obtain a specimen for urinalysis
Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?A. Report any allergies to shellfish or iodineB. Report any painful urination, blood in urine, or feverC. Lay prone for 24 hours after the procedureD. Avoid strenuous activity and sports for at least 2 weeks
“What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?A. “”When I get out of bed quickly, I feel a little dizzy.””B. “”The dressing over my incision feels like it is too tightC. “”I’m most comfortable when the head of the bed is raised””D. “”This IV infusion makes me urinate more often than usual”””
An older adult male who is in his early 70s admitted to the emergency department because of a COPD exacerbation. The client is struggling to breath and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides the nurse a copy of the client’s living will. Which action should the nurse take?A. Facilitate a family meeting with the palliative care teamB. Notify the healthcare provider of the client’s wishesC. Place a certified copy of the living will in the client’s recordD. Alert the nursing staff of the client’s do not resuscitate status
While caring for a toddler receiving oxygen via face mask, the nurse observes that the child’s lips and nares are dry and cracked. Which intervention should the nurse implement?A. Use a topical lidocaine analgesic for cracked lipsB. Use a water soluble lubricant on affected oral and nasal mucosaC. Ask the mother what she usually uses on the child’s lips and nose D. Apply a petroleum jelly to the child’s lips and nose
An unlicensed assistive personnel (UAP) is assigned to provide personal care for a client who’s prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?A. Determine the client’s level of mobility and need for assistanceB. Instruct the UAP that all clients deserve equal careC. Advise the client to maintain bedrest so that safety can be ensuredD. Assign another UAP to care for the client
Which information is most important for the nurse to obtain when determining a client’s risk for obstructive sleep apnea syndrome (OSAS)?A. Body mass indexB. Breath soundsC. Self-description of painD. Level of consciousness
The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first?A. Prepare the client for spinal anesthesiaB. Empty the client’s bladder using a straight catheterC. Convey to the client that birth is imminentD. Prepare the coach to accompany the client to delivery
A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at a parent-teacher meeting. What action is most important for the nurse to include in the meeting?A. Provide information on ways to increase activity for the familyB. Have several teachers talk about health risks associated with obesityC. Distribute a shopping list of suggested healthy snack ideasD. Determine the parents’ degree of concern
The nurse is assigning rooms for four clients, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The client with which condition should be assigned the only private room available?A. Bacterial meningitisB. Viral encephalitisC. Septic shockD. Brain abscess
A male client on the psychiatric unit is making sexual advances towards a female nurse. Which action should this nurse implement first?A. Document as specifically as possible the client’s behavior in the nurse’s notesB. Discuss with the client why he is making sexual advances toward the nurseC. Tell the client in a matter-of-fact manner to stop the sexual advancesD. Request an immediate team meeting to discuss the inappropriate behavior
After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes prednisone. Which education should the nurse provide the client with regard to taking prednisone? A. Take prednisone doses before meals on an empty stomachB. Wear sunglasses when exposed to bring sunlightC. If sequential doses are missed, notify the healthcare providerD. Schedule a monthly laboratory visit for a complete blood count
The nurse is caring for four clients. Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.2 mg/dL; Client C, newly admitted with a potassium level of 3.8 mEq/L; and Client D, scheduled for an appendectomy who has a white blood cell count of 14,000 mm3. Which intervention should the nurse implement?A. Move Client D into an isolation room 24 hours before surgeryB. Increase Client A’s oxygen to 4 liters a minute per cannulaC. Ask the dietician to add a banana to Client C’s breakfast trayD. Verify that Client B has two units of packed cells available
Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?A. Leukocytes, neutrophils, and thyroxineB. Serum potassium, calcium, and phosphorusC. Blood pressure, heart rate, and temperatueD. Erythrocytes, hemoglobin, and hematocrit
The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse’s immediate action? A. A 16-year-old client diagnosed with major depression who refuses to participate in groupB. A 14-year-old with anorexia nervosa who is refusing to eat the evening snackC. An 18-year-old client with antisocial behavior who is being yelled at by other clientsD. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby
An older male was recently admitted to the rehabilitation unit with unilateral neglect syndrome as the result of a cerebrovascular accident (CVA). Which action should the nurse include in the plan of care?A. Use hand and arm gestures to improve communication and comprehensionB. Provide additional light in the room to promote sensory stimulationC. Place a clock and calendar in the room to improve orientationD. Teach the client to turn his head from side to side for visual scanning
The nurse observes an unlicensed assistive personnel (UAP) applying an alcohol-based hand rub while leaving a client’s room after taking vital signs. What action should the nurse take?A. Instruct the UAP to return to the client’s room to perform handwashingB. Supervise the UAP in the next client’s room to evaluate hand hygiene C. Remind the UAP to continue rubbing the hands together until they are dryD. Advice the UAP to wear gloves when obtaining vital signs for all clients
To prevent medication errors by an older client who is sometimes confused, which intervention by the home health nurse is likely to be most effective? A. Have an alert family member administer medicationsB. Encourage taking medications at the same times daily C. Instruct the client to wear glasses when reading labelsD. Provide education both verbally and in written format
A male client who fell of a roof has right and left femur fractures and crushing injuries to both ankles. he is supine with bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hours. When asked to evaluate his pain on a scale of 1 to 10, he screams that it is 20. For the last 4 hours, he has received morphine 2mg IV hourly. His vial signs are heart rate 130 beats/minute, respirations 32 breaths/minute, blood pressure 180/90 mmHg. Which intervention is most important for the nurse to implement? A. Request the healthcare provider to consider a different analgesicB. Evaluate the traction for amount of tension applied to each extremityC. Determine if client is experiencing cumulative effects of the total dosageD. Assess the extremities for signs of compartment syndrome q2 hours
The nurse is assessing a client who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the healthcare provider immediately?A. Diminished breath sounds over the trocar insertion siteB. Equal bilateral chest expansionC. Scattered crackles unchanged from baselineD. Respiratory rate of 22 breaths/minute
An adult client is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement?A. Assess client’s pupils for their reaction to lightB. Request that the CT scan be done immediatelyC. Review client’s history for use of illicit drugsD. Explain the reason for using only non-narcotics
When caring for a client with a traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every 2 hours. For the past 8 hours the client’s GCS score has been 14. What does this GCS finding indicate about this client?A. Rehabilitative prognosis is an expected full recoveryB. Risk for irreversible cerebral damage related to increased ICPC. Insertion of an ICP monitoring device is necessaryD. Neurologically stable without indications of an increased ICP
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? A. Report serum albumin and globulin levelsB. Provide diet low in phosphorusC. Note signs of swelling and edemaD. Monitor abdominal girthE. Increase oral fluid intake to 1,500 mL daily
The nurse is caring for a seated client who is experiencing a tonic-clonic seizure. What actions should the nurse implement? A. Insert a bite blockB. Restrain the clientC. Loosen restrictive clothingD. Note the duration of the seizureE. Ease the client to the floor
The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?A. Positive Epstein-Barr, and malaiseB. Ear pain and feverC. Elevated WBC and sedimentation rateD. Increased BUN and serum creatinine
The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse’s proposal?A. Regional relocation center for earthquake victimsB. Vitamin supplements for high-risk pregnant womenC. Lead screening for children in low-income housingD. Case management and screening for clients with HIV
A client arrives for an annual physical exam and complains of having calf pain. The client’s health history reveals peripheral arterial disease. Which question should the nurse ask the client about expected findings related to chronic arterial symptoms?A. Were your legs ever suddenly swollen, red, warm, and painful?B. Does the calf pain occur when walking short distances?C. Did you receive treatment for weeping ulcers on lower legs?D. Have you experienced ankle edema and varicose veins?
A client is admitted with the diagnosis of Wernicke’s syndrome. Which assessment finding should the nurse use in planning the client’s care?A. DepressionB. Peripheral neuropathyC. ConfusionD. Right lower abdominal pain
A client has both a primary IV infusion and a secondary infusion of medication. An infusion pump is not available. The nurse needs to change the rate of flow of the secondary infusion. Where should the nurse regulate the rate of the secondary IV?
A client with Addison’s disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client’s laboratory values include: sodium 129 mEq/L, glucose 54mg, and potassium 5.3 mEq/L. When reporting the findings to the healthcare provider, the nurse anticipates a prescription for which intravenous medication? A. HydrocortisoneB. Regular insulinC. Broad spectrum antibioticD. Potassium chloride
When conducing diet teaching for a client who is on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?A. LentilsB. Potato soupC. TeaD. CheeseE. Whole grain breads
The nurse prepares an intravenous solution and tubing for a client with a saline lock, as seen in the video. What action should the nurse take next?A. Open the roller clamp on the tubing B. Label the bag of IV solutionC. Attach the tubing to the saline lockD. Flush the saline lock with saline
When entering a client’s room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?A. Tell the client to stop the inappropriate behaviorB. Complete an unusual occurrence reportC. Leave the room and close the door quietlyD. Ignore the behavior and hang the IV antibiotic
While changing a client’s postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client’s laboratory values?A. Platelet countB. Serum sodium levelC. Neutrophil countD. Hematocrit
The nurse enters a client’s room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. Which action should the nurse take first?A. Instruct the UAP to raise the bed levelB. Provide gloves for the UAP to applyC. Offer to help reposition the clientD. Place the side rails in an up position
Following a house fire, an adult male is admitted to the emergency department with partial and full thickness burns. He used a blanket to cover his head and face, but his skin is burned on the dorsal surfaces of both arms and hands, and his anterior legs. Using the Rule of Nines to assess the extent of the client’s burns, what percentage of burned body surface area should the nurse document?A. 50%B. 27%C. 9%D. 36%
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions?
An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first?A. Explore client’s readiness to discuss the situationB. Discuss treatment options for abusive partnersC. Report the finding to the police departmentD. Determine the frequency and type of client’s abuse
The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?A. Drank a glass of water in the past 2 hoursB. Verbalizes a fear of being in a confined spaceC. Experiences facial swelling after eating crabD. Reports left chest wall pain prior to admission
When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?A. Resume normal physical activityB. Give a dose of regular insulin as prescribedC. Measure urine output over the next 24 hoursD. Drink electrolyte fluid replacements
The nurse assesses a child in 90-90 skeletal traction. Where should the nurse assess for signs of compartment syndrome?
The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask and requiring staff to observe airborne, as well as standard precautions? A. A female adolescent admitted with multiple genital herpes simplex II lesionsB. An older client with scabies who is admitted from an extended care facilityC. Twin siblings admitted with scarlet fever that is complicated with pneumoniaD. A client with a positive Mantoux and sputum cultures results positive for AFB
An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?A. Bring the client to the team meeting to discuss the treatment planB. Explain the purpose of each medication the client is currently takingC. Ask the client to write feelings in a journal and then review it togetherD. Play a board game with the client and begin talking about stressors
The nurse is assessing a 4-year-old child with eczema. The child’s skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?A. Keep the nails trimmed shortB. Apply baby lotion to the skin twice daily C. Bathe the child with bath oilD. Allow the child to wear only 100% cotton clothing
A nurse working on an Endocrine Unit should see which client first?A. An older client with Addison’s disease whose current blood sugar level is 62 mg/dLB. An adult with a blood sugar of 284 mg/dL and a urine output of 350 mL in the last hourC. An adolescent male with type 1 diabetes who is arguing about his insulin doseD. A client taking corticosteroids who has become disoriented in the last two hours
The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client?A. Inspect skin for rednessB. Avoid range of motion exercisesC. Apply alcohol to the stump after bathingD. Use a residual limb shrinkerE. Wash the stump with soap and water
A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?A. Explain that counseling will be provided to give her information about her cancer riskB. Offer assurance that there are a variety of effective treatments for breast cancerC. Gather additional information about the client’s family history for all types of cancerD. Provide information about survival rates for women who have this genetic mutation
A new mother on the postpartum unit runs out of the room screaming that her newborn infant’s crib is empty and the baby is missing. What action should the nurse take first?A. Determine if the newborn is in the nurseryB. Activate the lockdown procedureC. Ask the mother if any visitors were expected to arriveD. Match ID bands of all infants and mothers on the unit
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN?A. Administer PRN oral analgesics to a client with a history of chronic painB. Transport a client who is receiving IV fluids to the radiology departmentC. Supervise a newly hired graduate nurse during an admission assessmentD. Complete ongoing focused assessments of a client with wrist restraints
The nurse is teaching a client newly diagnosed with systemic lupus erythematosus (SLE). Which information is accurate for the nurse to provide? A. The client can expect to progressively lose function in a fairly predictable sequenceB. The disease is characterized by alternating periods of flare-ups and remissionsC. Once an acute attack subsides, the client can expect to feel fine againD. Systemic lupus erythematosus (SLE) is a chronic, incurable, terminal illness
The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic hepatitis B immunizations?A. A child daycare worker who has a history of type 2 diabetes mellitusB. An office worker who requires hemodialysis for chronic kidney disease (CKD)C. A restaurant chef who was diagnosed one year ago with hepatitis AD. A sales person who travels internationally and eats food in foreign countries.
A client with metabolic syndrome plans to begin an exercise program. Which instruction is most important for the nurse to provide this client?A. Wear long sleeves and a hat when exercising outdoors in direct sunlightB. Monitor blood pressure and heart rate as exercise activity is increasedC. Weight bearing exercises are most effective in improving bone strengthD. Use hand-held weights to strengthen muscles and build muscle mass
The nurse is caring for client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD?A. Monitoring telemetry and cardiac rhythmB. Assisting client to cough and deep breathC. Increasing the client’s fluid intakeD. Administering narcotics for pain relief
“A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?A. “”Does your child seem mentally slower than his peers also?””B. “”Haven’t you been feeding him according to recommended daily allowances for children?””C. “”His smaller size is probably due to the heart disease””D. “”You should not worry about the growth tables. They are only averages for children.”””
While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask?A. Do you often have feelings of sadness?B. Are you having problems concentrating?C. Have you thought about taking your life?D. What problems are you facing right now?
A male client suffering from depression has been taking an antidepressant medication for two days. He tells the nurse that he is smiling more and feeling better. Which response is best for the nurse to provide?A. Feeling hopeful is a good sign that your depression is improving. B. Antidepressants usually begin to improve your mood after 2 to 4 weeks. C. Antidepressants can cause mild mood swings within several daysD. Antidepressants can stabilize your mood within several days.
“A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, “”Kill, kill””. What question should the nurse ask the client next? A. When did these voices begin?B. Have you taken any hallucinogens?C. Are you planning to obey the voices?D. Do you believe the voices are real?”
Which instruction should the nurse provide a pregnant client who is reporting heartburn?A. Eat small meals throughout the day to avoid a full stomach.B. Take an antacid at bedtime and whenever symptoms worsen. C. Maintain a sitting position for two hours after eating. D. Limit fluids between meals to avoid overdistension of the stomach.
“At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, “”I just know I can’t handle all the pain.”” Which is the priority nursing problem for this client?A. Pain (acute)B. Knowledge deficitC. AnxietyD. Anticipatory grieving”
“During a clinic visit, a client with a kidney transplant asks, “”What will happen if chronic rejection develops?”” Which response is best for the nurse to provide?A. A different combination of immunosuppressant medications will be implementedB. Dialysis would need to be resumed if chronic rejection becomes a realityC. Dialysis may be necessary until the chronic rejection can be reversedD. The immunosuppressant medication will be increased until the rejection subsides”
The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?A. The client will express acceptance of their newly diagnosed health status.B. The nurse will encourage the client to walk thirty minutes every dayC. The client’s blood pressure readings will be less than 160/90 mmHgD. The client’s skin on the lower legs will be intact at the next clinic visit
The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?A. Swaddle the infant in a blanket for sleepingB. Ensure that the infant’s crib mattress is firmC. Place the infant in a prone position whenever possibleD. Prop the infant with a pillow when in a side-lying position
A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client’s activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as teh control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement?A. Withhold the heparin and continue the same dose of warfarinB. Increase the warfarin doseC. Decrease the heparin doseD. Increase the heparin dose and decrease the warfarin dose
A client with a history of schizophrenia is admitted with diabetic ketoacidosis (DKA). Which nursing interventions should the nurse implement during the admission process for this client? A. Obtain psychiatric and medical admission recordsB. Hold psychotropic medications until glucose is regulated C. Interview client about reason for admission to hospitalD. Prepare the client for involuntary commitment admissionE. Review the list of home medications and dosages
The laboratory findings for a client with chronic kidney disease (CKD) include elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. Based on these findings, which action should the nurse implement?A. Provide high protein snacksB. Administer PRN oxygenC. Schedule frequent rest periods D. Monitor glucose levels q4 hours.
A client is receiving a nitroglycerin infusion at 20 mcg/min. The pharmacy dispenses an IV solution of nitroglycerin 75 mg in 250 D5W. The nurse should program the infusion pump to deliver how many mL/hr?
A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?A. Signs of addiction to opioid pain medicationB. Information about non-pharmaceutical pain relief measuresC. Referral for social services for the child and familyD. Instructions about how much fluid the child should drink
When conducting diet teaching for a client who was diagnosed with hypertension, which foods should the nurse encourage the client to eat? A. Fruits without sauceB. Canned soupC. Fresh or frozen vegetables without sauce D. Cottage cheeseE. Pickled olives
The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant’s heart rate drops to 60 beats/minute. Which action should the nurse take?A. Postpone the feeding until the infant’s vital signs are stableB. Continue the insertion since this is a typical responseC. Insert the feeding tube into the infant’s nasal passageD. Pause and monitor for a continued drop of the heart rate
A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response to the phenytoin?A. Decrease in intracranial pressure and cerebral edemaB. Increased time of ambulation between periods of rest C. Normal electroencephalogram after drug administrationD. Absence of seizure activity for the duration of treatment
The nurse is assessing a client’s breath sounds. Which medication from the client’s prescriptions will have the most positive effect on this respiratory finding?Sound: wheezingA. ChloroquineB. EnalaprilC. AlbuterolD. Losartan
The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely?A. Bring a heavy can close to body before liftingB. Locks knees while preparing food on the counterC. Widens stance while working near the sinkD. Bends from the waist to pick trash off the floorE. Leans forward to pull a pan from a high shelf
A school-aged child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/mL ampules. How many mL should the nurse administer?
In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care? A. Assess skin elasticity of the stumpB. Observe for swelling around the stumpC. Note amount and color of wound drainageD. Evaluate closest proximal pulse
During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first?A. The census report has not been completedB. A client’s wife has asked to speak with the charge nurseC. One staff member has not reported to workD. A bucket of water was spilled in the hallway
An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first?A. Document neurologic changesB. Reduce environmental stimuliC. Administer prescribed neuroleptic D. Review medications for interactions
An adult client is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes two hours or longer to complete. The client worries about staying clean and refuses to sit on any of the chairs in the day area. This client’s handwashing is an example of which clinical behavior? A. PhobiaB. AddictionC. ObsessionD. Compulsion
The nurse is preparing to send a client to the cardiac catheterization lab for elective cardioversion. Which intervention should the nurse implement before the client leaves the medical unit? A. Document that the client has remained NPOB. Confirm monitor reading in synchronous modeC. Notify the rapid response team of the transferD. Secure cardioversion pads on the client’s chest
The nurse includes assessment for fat embolism syndrome (FES) in the plan of care for a client with a fractured femur. Which findings should the nurse include that are often the earliest indication of a FES?A. Confusion, restlessnessB. Petechial rashC. Tachycardia, feverD. Pulmonary crackles
The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection?A. Blood pressure of 122/74 mmHgB. White blood count of 19,000mm3C. Moderate amount of foul-smelling lochiaD. Oral temperature of 100.2F
The nurse should be most concerned about risk for injury (falls) after administering which medication?A. PantoprazoleB. FamotidineC. ClarithromycinD. Promethazine
The charge nurse in an extended care facility in organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)?A. Measure the client’s body weight each morningB. Establish blood pressure parameters for client monitoring C. Evaluate a staff member providing wound careD. Evaluate client teaching through return demonstration
An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview?A. History of smoking over the past 6 monthsB. Sleep patterns during the previous few weeksC. Activity level prior to onset of symptomsD. Recent compliance with prescribed medications
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care the nurse finds the radiation implant in the bed. What action should the nurse take? A. Apply double gloves to retrieve the implant for disposalB. Place the implant in a lead container using long-handled forcepsC. Reinsert the implant into the vaginaD. Call the radiology department
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?A. Assess the client’s oral cavity for ulcerationsB. Monitor the client when using a straw for liquidsC. Teach coughing and deep breathing exercisesD. Request thick nectar liquids for the client
Which type of leukocyte is involved with allergic responses and the destruction of parasitic worms?A. EosinophilsB. NeutrophilsC. LymphocytesD. Monocytes
Which woman should the nurse consider at the highest risk for cervical cancer? A. History of unprotected sex with multiple partnersB. Postmenopausal for 5 years with intermittent vaginal spottingC. Taking birth control pills after 40 years of ageD. Multiparous delivery of infants more than 9 pounds
Which intervention is most important for the nurse to include in the plan of care for a client who is being mechanically ventilated and is receiving continuous enteral feedings?A. Maintain the head of the bed elevated at 45 degreesB. Check the feeding tube placement q8hours C. Assess the gastric residual volume q4hours D. Obtain a chest x-ray PRN for adventitious lung sounds
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 interventions should the nurse take to prepare the body before the family enters the room? A. Gently close the eyesB. Remove resuscitation equipment from the roomC. Take out dentures and place in a labeled cupD. Apply a body shroudE. Place a small pillow under the head
During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client’s list should the nurse encourage?A. Canned fruit in heavy syrupB. Natural whole almondsC. Plain, air-popped popcornD. Lightly salted potato chipsE. Cheddar cheese cubes
A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement?A. Bring a bedside commode to the clientB. Stand on the client’s right side as he walksC. Walk directly behind the client to prevent a fallD. Give the client a cane to hold in his right hand
The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?A. Instruct the PN that this technique promotes infection in elderly femalesB. Recommend a complete bath to cleanse the perineal area more fullyC. Evaluate the effectiveness of this measure to stimulate client voidingD. Suggest contacting the healthcare provider for a prescription for catheter insertion
An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. the nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? A. Ask family members to remain with the client in the evenings from 1700 to 2100pmB. Ensure that the client is assigned to the room close to the nurses’ stationC. Postpone administration of nighttime medications until after 2300pmD. Administer a prescribed PRN benzodiazepine at the onset of a confused state
A female child is brought to the emergency department after awakening with a bark-like cough and stridor. upon arrival to the hospital, her respirations are labored, and she is drooling. What action should the nurse implement?A. Prepare for emergency tracheotomyB. Assess the child for dehydrationC. Examine oropharyngeal area for foreign bodyD. Collect midstream urine specimen
An adolescent receives a prescription for an injection of S-matriptan succinate 4mg subcutaneously for a migraine headache. Using a vial labeled, 6mg/0.5mL, how many mL should the nurse administer?
The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order?
The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client’s plan of care? A. Ensure adequate IV and oral fluid intakeB. Provide ice packs to major joint areasC. Space analgesics to prevent addiction to narcoticsD. Re-enforce the importance of nutritional balance
The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSAB. Serum creatinine of 4.5 mg/dLC. Serum sodium of 145 mEq/LD. White blood cell count of 12,000mm3
A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication?A. Monitor your blood pressure regularlyB. Report unusual bruising or bleedingC. Elevate your feet if swelling occursD. Check your pulse rate every day
Which snack selection indicates to the nurse that a school-age boy with gastroesophageal reflux understands his dietary restrictions?A. Sugar cookiesB. PizzaC. Chocolate milkshakeD. Tacos
After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X-ray findings that indicate the CVC tip is in the client’s superior vena cava. Which action should the nurse implement? A. Notify the healthcare provider of the need to reposition the catheterB. Remove the catheter and apply direct pressure for 5 minutesC. Secure the catheter using aseptic techniquesD. Initiate intravenous fluids as prescribed
“The nurse is caring for a client admitted for evaluation of a descending aortic aneurysm. While outside the room documenting, the nurse hears the client screaming. The client tells the nurse that the pain is “”sharp, like something inside is ripping and tearing.”” The client also reports dizziness. Which of the following is the likely cause? A. Impending rupture of the aneurysmB. The client is having a panic attackC. Clotting of the aneurysmD. The client is hallucinating from the opioids”
The nurse is teaching a primigravida about preeclampsia. Which findings are indicators of preeclampsia and should be reported to the healthcare provider? A. Blurred visionB. HeadacheC. Lack of appetiteD. Urinary frequencyE. Chills and feverF. Swollen hands
After removing a client’s dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?
An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He found wandering into another client’s room and is returned to his room by the unlicensed assistive personnel (UAP). Which actions should the nurse take? A. Review the client’s most recent serum electrolyte valuesB. Assign the UAP to re-assess the client’s risk for fallsC. Report mental status changes to the healthcare providerD. Apply soft upper limb restraints and raise all four bed rails E. Assess the client’s breath sounds and oxygen saturation
A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client?A. A bedside commode is positioned near the bedB. A saline lock is present in the right forearmC. A full pitcher of water is on the bedside tableD. A low sodium diet tray was brought to the roomE. The client is lying in a supine position in bed
What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump?A. Initiate the dosage lockout mechanism on the PCA pumpB. Assess the client’s ability to use a numeric pain scaleC. Assess the abdomen for bowel soundsD. Instruct the client to use the medication before the pain becomes severe
An older client comes to the clinic with a family member. When the nurse attempts to take the client’s health history, the client does not respond to questions in a clear manner. What action should the nurse implement first?A. Provide a printed health care assessment formB. Ask the family member to answer the questionsC. Defer the health history until the client is less anxiousD. Assess the surroundings for noise and distractions
Which conditions are most likely to respond to treatment with antihistamines? A. BronchitisB. MyocarditisC. Otitis mediaD. Contact dermatitisE. Allergic rhinitis
The nurse is providing care for a child who is brought to the emergency department a few days after a laceration to the leg from a barbed wire fence. The child has not received any tetanus immunizations and is manifesting early signs of muscular rigidity with spasms and jaw clenching or trismus. Which intervention should be the nurse’s highest priority for this child? A. Suction oropharyngeal secretionsB. Prepare for intubation with mechanical ventilationC. Minimize stimulation from sound, light, and touchD. Monitor IV infusions
The nurse identifies an electrolyte imbalance, crackles on auscultation and an elevated blood pressure in a client with progressive heart disease. Which intervention should the nurse include in the plan of care?A. Measure ankle circumferenceB. Record usual eating patternsC. Evaluate for muscle crampingD. Document abdominal girth
The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client’s psychosocial need for acceptance?A. Encouraging the client to join a support group B. Wearing gloves when interviewing the clientC. Allowing the client to ventilate feelingsD. Shaking the client’s hand during an introduction
An adult woman who was recently diagnosed with type 2 DM is seen in the clinic for laboratory tests. The client’s height is 5 feet 2 inches and weight is 165 pounds. Her recent laboratory findings are described above. In planning nutrition teaching for this client, what diet modifications should the nurse recommend? Labs: Creatinine 1.0 mg/dLBUN 16 mg/dlDiagnostics: Total cholesterol 250 mg/dlLDL 175 mg/dlHDL 35 mg/dlTriglyceride 250 mg/dlFlowsheets: Glucose 150 mg/dlA1c 9%A. Decrease processed carbohydrate in dietB. Eliminate alcohol intake except for special occasionsC. Restrict protein to 10% of total calories in dietD. Increase dietary fiber such as whole grainsE. Reduce daily fat intake to 10% of total calories
The nurse is caring for a client who is admitted to the emergency center after a motor vehicle collision. The client begins to experience a decreased level of consciousness and the pupils do not respond equally to light. Which vital signs changes indicate the client is manifesting Cushing’s triad?A. Blood pressure of 80/40 mmHg, weak heart rate of 40 beats/minute, Cheyne-Stokes respirations of 10 breaths/minuteB. Blood pressure 180/120 mmHg, weak heart rate of 92 beats/minute, Kussmaul respirations of 18 breaths/minuteC. Blood pressure of 180/80 mmHg, bounding heart rate of 50 beats/minute, respirations of 30 breaths/minute with apneic episodesD. Blood pressure of 90/60 mmHg, strong heart rate of 60 beats/minute, eupneic respirations of 16 breaths/minute
A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide? A. Immunizations can trigger a relapse of the disease, so get plenty of extra rest. B. These early signs of an infection may require medical treatment with antibioticsC. These are common side effects of the vaccines and will resolve in a few daysD. Plans to move into the dormitory need to be postponed for at least a semester
The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement? A. Move the client to a quiet place on the untiB. Encourage the client to use the punching bagC. Use firmness and direct the client to sit for awhile D. Suggest to the client that he take a walk
The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL is alert and diaphoretic. What action should the charge nurse take? A. Assess client for polyuria and polyphagiaB. Give the client a glass of orange juice C. Notify the healthcare providerD. Collect a blood sample for hemoglobin A1c
While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?A. Assist the client to lie back in bedB. Administer a nebulizer treatmentC. Call for an Ambu resuscitation bagD. Increase oxygen to 6 liters/minute
The parents of a 6 year old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?A. Provide a list of alternative activities that are less likely to cause the child to experience fatigueB. Explain that their child is too young to understand the risks associated with swimmingC. Encourage the parents to allow the child to continue attending swimming lessons with supervisionD. Suggest that the child be encouraged to participate in a team sport to encourage socialization
“A client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or “”goose bumps””. The nurse should assess for which trigger? A. Loud hallway noiseB. Frequent coughC. FeverD. Full bladder”
A new nurse is preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? A. Suggest the nurse use a 20-gauge needle B. Direct the nurse to change the IV tubing C. Instruct the nurse to remove the needleD. Prompt the nurse to apply povidone to the site
The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety?A. Assess for discomfort when procedure is completedB. Verify that the client has given informed consentC. Instruct the client to keep hands under the sterile fieldD. Pour cleansing solution onto the sterile cloth field
While changing a client’s postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take? A. Start progressive mobilizationB. Request a nutrition consultC. Request a wound culture and sensitivityD. Force oral fluids
A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin?A. Regular contractions occurring every 10 minutesB. Sterile vaginal exam revealing 3cm dilationC. Biophysical profile results showing oligohydramniosD. Fetal heart tones located in upper right quadrants
An older male client was successfully treated for Herpes zoster (shingles) with an antiviral medication reports that he is now experiencing pain on his trunk where the lesions were located. Which action should the nurse take? A. Review the medication record to determine when the last analgesic was administeredB. Reassure the client that the infection is resolved and the pain should soon disappearC. Teach the client about the importance of completing the full course of antiviral medicationD. Contact the healthcare provider about the need to resume the client’s antiviral medication
One day after abdominal surgery, a client with obesity reports pain and heaviness in the right calf. Which action should the nurse implement? A. Encourage ambulation in the roomB. Palpate the femoral pulseC. Observe for unilateral swellingD. Apply a warm compress to the area
A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? A. Initiate seizure precautionsB. Assess neurological status every 8 hoursC. Limit oral water intakeD. Administer a hypertonic IV fluids as prescribed
The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? A. Peripheral pallor of the skinB. Increased pulse rateC. Clenched fistsD. RestlessnessE. Increased temperatureF. Increased respiratory rate
After the risks and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart beating during the procedure. What action should the nurse take?A. Postpone the procedure until the client understands the risks and benefitsB. Notify the healthcare provider of the client’s lack of understandingC. Explain the procedure again in detail and clarify any misconceptionsD. Call the client’s next of kin and have them provide verbal consent
Following a total knee replacement, a client is discharged from the hospital with a prescription for warfarin. In reviewing discharge teaching, the client tells the nurse that he will avoid eating foods high in potassium, such as bananas and melon. How should the nurse respond?A. Discuss necessary fluid restrictions as well as food restrictionsB. Explain that no dietary restrictions are needed with warfarinC. Review teaching about the effects of foods rich in Vitamin KD. Provide a written list of additional foods high in potassium K
A 62-year-old male client tells the nurse that he has a high-density lipoprotein (HDL) level of 85 mg/dl. Which action should the nurse take?A. Encourage the client to reduce consumption of fatty foodsB. Ask the client about hereditary cardiac risk factorsC. Confirm that this value is helpful in reducing cardiac riskD. Explain that the client may need medication therapy
A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client’s plan of care?A. Determine if the client is over-hydrating to feel satiatedB. Maintain the client on an NPO statusC. Encourage positive self accolades for dietary adherenceD. Administer daily vitamin supplements
A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?A. Diapering will be provided since hospitalization is stressful to preschoolersB. Children usually resume their toileting behaviors when they leave the hospitalC. A potty chair should be brought from home so he can maintain his toileting skillsD. A retraining program will need to be initiated when the child returns home
A clinical trial is recommended for a female client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. the client’s son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond?A. Explain to the family that they must accept their mother’s decisionB. Discuss success of clinical trials and ask the client to consider participating for one monthC. Ask the client with her children present if she fully understands the decision she has madeD. Explore the client’s decision to refuse treatment and offer support.
TermText
The LPN/LVN is preparing to ambulate a postoperative client after cardiac surgery. The nurse plans to do which to enable the client to best tolerate the ambulation?
A client is wearing a continuous cardiac monitor, which begins to alarm at the nurse’s station. The nurse sees no electrocardiographic complexes on the screen. The nurse should do which first?
The LPN/LVN in a medical unit is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles, and the nurse suspects pulmonary edema. The nurse immediately notifies the registered nurse and expects which interventions to be prescribed? Select all that apply.
The nurse is monitoring a client following cardioversion. Which observations should be of highest priority to the nurse?
The nurse is assisting in caring for the client immediately after insertion of a permanent demand pacemaker via the right subclavian vein. The nurse prevents dislodgement of the pacing catheter by implementing which intervention?
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, and the client is visibly anxious. The LPN/LVN understands that a life-threatening complication of this condition is which?
A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. The nurse should check the client for which next?
The nurse has reinforced instructions to the client with Raynaud’s disease about self-management of the disease process. The nurse determines that the client needs further teaching if the client states which?
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to breath sounds, expecting to hear which breath sounds bilaterally?
The LPN/LVN is collecting data on a client with a diagnosis of right-sided heart failure. The nurse should expect to note which specific characteristic of this condition?
The LPN/LVN is checking the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. The nurse interprets that the neurovascular status is which?
A client with a diagnosis of rapid rate atrial fibrillation asks the nurse why the health care provider is going to perform carotid massage. The LPN/LVN responds that this procedure may stimulate which?
A client is admitted to the hospital with possible rheumatic endocarditis. The LPN/LVN should check for a history of which type of infection?
client has an Unna boot applied for treatment of a venous stasis leg ulcer. The LPN/LVN notes that the client’s toes are mottled, and cool and the client verbalizes some numbness and tingling of the foot. Which interpretation should the nurse make of these findings?
A client with angina complains that the anginal pain is prolonged and severe and occurs at the same time each day, most often in the morning. On further data collection, the nurse notes that the pain occurs in the absence of precipitating factors. How should the LPN/LVN best describe this type of anginal pain?
The LPN/LVN is monitoring a client with an abdominal aortic aneurysm (AAA). Which finding is probably unrelated to the AAA?
“An emergency department client who complains of slightly improved but unrelieved chest pain for 2 days is reluctant to take a nitroglycerin sublingual tablet offered by the nurse. The client states, “”I don’t need that—my dad takes that for his heart. There’s nothing wrong with my heart.”” Which description best describes the client’s response?”
A client is scheduled for a cardiac catheterization using a radiopaque dye. The LPN/LVN checks which most critical item before the procedure?
A client is scheduled for a dipyridamole thallium scan. The LPN/ LVN should check to make sure that the client has not consumed which substance before the procedure?
An ambulatory clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a non cardiac problem?
A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit with cardiac monitoring via telemetry. The nurse assisting in caring for the client expects to note which type of activity prescribed?
The LPN/LVN is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use?
A client is diagnosed with thrombophlebitis. The nurse should tell the client that which prescription is indicated?
A client returns to the nursing unit after an above knee amputation of the right leg. In which position should the nurse place the client?
The LPN/LVN is collecting data from a client about medications being taken, and the client tells the nurse that he is taking herbal supplements for the treatment of varicose veins. The nurse understands that the client is most likely taking which?
The LPN/LVN is planning to reinforce instructions to a client with peripheral arterial disease about measures to limit disease progression. The nurse should include which items on a list of suggestions to be given to the client? Select all that apply.
A client is at risk for developing disseminated intravascular coagulopathy (DIC). The LPN/LVN should become concerned with which fibrinogen level?
A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. The LPN/LVN should take which action first?
The LPN/LVN notes bilateral 2+ edema in the lower extremities of a client with known coronary artery disease who was admitted to the hospital 2 days ago. Based on this finding, the nurse should implement which action?
A client brings the following medications to the clinic for a yearly physical. The LPN/LVN realizes which medication has been prescribed to treat heart failure?
- A student nurse is assigned to assist in caring for a client with acute pulmonary edema who is receiving digoxin (Lanoxin) and heparin therapy. The nursing instructor reviews the plan of care formulated by the student and tells the student that which intervention is unsafe?
A client has an inoperable abdominal aortic aneurysm (AAA). Which measure should the nurse anticipate reinforcing when teaching the client?
“The LPN/LVN finds a client tensing while lying in bed staring at the cardiac monitor. Which is the nurse’s best response when the client states, “”There sure are a lot of wires around there. I sure hope we don’t get hit by lightning!””?”
The LPN/LVN is asked to assist another health care member in providing care to a client who is placed in a modified Trendelenburg’s position. The nurse interprets that the client is likely being treated for which condition?
A client is seen in the health care provider’s office for a physical examination after experiencing unusual fatigue over the last several weeks. Height is 5 feet, 8 inches, with a weight of 220 pounds. Vital signs are temperature 98.6° F oral, pulse 86 beats per minute, respirations 18 breaths per minute, and blood pressure 184/96 mm Hg. Random blood glucose is 110 mg/dL. In order to best collect relevant data, which question should the LPN/LVN ask the client first?
The client scheduled for a right femoropopliteal bypass graft is at risk for compromised tissue perfusion to the extremity. The LPN/LVN takes which action before surgery to address this risk?
When preparing a client for a pericardiocentesis, which position does the LPN/LVN place the client in?
For a client diagnosed with pulmonary edema, the LPN/LVN establishes a goal to have the client participate in activities that reduce cardiac workload. Which client activities will contribute to achieving this goal?
The LPN/LVN is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client’s baseline. As an immediate action before help arrives, the nurse should perform which action?
The LPN/LVN has reinforced home care instructions to a client who had a permanent pacemaker inserted. Which educational outcome has the greatest impact on the client’s long-term cardiac health?
The clinic nurse is obtaining cardiovascular data on a client. The LPN/LVN prepares to check the client’s apical pulse and places the stethoscope in which position?
The LPN/LVN is caring for a client who has been admitted to the hospital with a diagnosis of angina pectoris. The client is receiving oxygen via nasal cannula at 2 L. The client asks the nurse why the oxygen is necessary. The LPN/LVN bases the response on which information?
The licensed practical nurse (LPN) is assisting in caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The registered nurse administers morphine sulfate to the client as prescribed by the health care provider. Following administration of the morphine sulfate, the LPN plans to monitor which indicator(s)?
A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions?
The LPN/LVN is caring for a client with a diagnosis of myocardial infarction (MI) and is assisting the client in completing the diet menu. Which beverage does the nurse instruct the client to select from the menu?
The LPN/LVN is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question?
The LPN/LVN has reinforced dietary instructions to a client with coronary artery disease. Which statement by the client indicates an understanding of the dietary instructions?
The LPN/LVN is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?
The LPN/LVN is assisting in caring for a client in the telemetry unit and is monitoring the client for cardiac changes indicative of hypokalemia. Which occurrence noted on the cardiac monitor indicates the presence of hypokalemia?
“While the nurse is involved in preparing a client for a cardiac catheterization, the client says, “”I don’t want to talk with you. You’re only the nurse. I want my doctor.”” Which response by the nurse should be therapeutic?”
The LPN/LVN reinforces instructions to a client at risk for thrombophlebitis regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?
A client with a history of angina pectoris tells the nurse that chest pain usually occurs after going up two flights of stairs or after walking four blocks. The LPN/LVN interprets that the client is experiencing which type of angina?
The LPN/LVN is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary in order to control disease progression. Which statement by the client indicates a need for further teaching?
The LPN/LVN is working with a client who has been diagnosed withPrinzmetal’s (variant) angina. The nurse plans to reinforce which information about this type of angina when teaching the client?
The LPN/LVN working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse?
The LPN/LVN is discussing smoking cessation with a client diagnosed with coronary artery disease (CAD). Which statement should the nurse make to the client to try to motivate the client to quit smoking?
A client with heart failure is scheduled to be discharged to home with digoxin (Lanoxin) and furosemide (Lasix) as ongoing prescribed medications. The nurse teaches the client to report which sign/symptom that indicates the medications are not producing the intended effect?
A client has experienced an episode of pulmonary edema. The LPN/ LVN determines that the client’s respiratory status is improving if which breath sounds are noted?
A client in pulmonary edema has a prescription to receive morphine sulfate intravenously. The licensed practical nurse assisting in caring for the client determines that the client experienced an intended effect of the medication if which is noted?
The LPN/LVN is providing discharge teaching for a post-myocardial infarction (MI) client who will be taking 1 baby aspirin a day. The nurse determines that the client understands the use of this medication if the client makes which statement?
The LPN/LVN determines that a client with coronary artery disease (CAD) needs further teaching about disease management if the client makes which statement?
An older client with ischemic heart disease has experienced an episode of dizziness and shortness of breath. The nurse reviews the plan of care and notices documentation of decreased cardiac output, dyspnea, and syncopal episodes. The nurse plans to take which important action?
The LPN/LVN is planning adaptations needed for activities of daily living for a client with cardiac disease. The nurse should incorporate which instruction in discussion with the client?
An adult client just admitted to the hospital with heart failure also has a history of diabetes mellitus. The nurse calls the health care provider to verify a prescription for which medication that the client was taking before admission?
Acetylsalicylic acid (aspirin) is prescribed for a client before a percutaneous transluminal coronary angioplasty (PTCA). When the nurse takes the aspirin to the client, the client asks the nurse about its purpose. What is the purpose of the aspirin?
The nurse is caring for a client with coronary artery disease, and a topical nitrate is prescribed for the client. Why is acetaminophen (Tylenol) usually prescribed to be taken before the administration of the topical nitrate?
The nurse is assisting in developing a plan of care for a client who will be returning to the nursing unit following a cardiac catheterization via the femoral approach. Which nursing intervention should be included in the postprocedure plan of care?
The nurse is reinforcing dietary instructions to a client with heart failure (HF). The nurse determines that the client understands the instructions if the client states that which food item will be avoided?
A client seeks medical attention for intermittent episodes in which the fingers of both hands become cold, pale, and numb. The client states that they then become reddened and swollen with a throbbing, achy pain and Raynaud’s disease is diagnosed. Which factor would precipitate these episodes?
A client is admitted to the hospital with a diagnosis of pericarditis. The nurse reviews the client’s record for which sign or symptom that differentiates pericarditis from other cardiopulmonary problems?
The nurse is beginning to ambulate a client with activity intolerance caused by bacterial endocarditis. The nurse determines that the client is best tolerating ambulation if which parameter is noted?
The nurse is assisting a hospitalized client who is newly diagnosed with coronary artery disease (CAD) to make appropriate selections from the dietary menu. The nurse encourages the client to select which meal?
A client with known coronary artery disease (CAD) begins to experience chest pain while getting out of bed. The nurse should take which action?
The nurse is setting up the bedside unit for a client being admitted to the nursing unit from the emergency department with a diagnosis of coronary artery disease (CAD). The nurse should place highest priority on making sure that which is available at the bedside?
The nurse determines that a client with coronary artery disease (CAD) understands disease management if the client makes which statement?
A client has just completed an information session about measures to minimize the progression of coronary artery disease (CAD). Which statement indicates an initial understanding of lifestyle alterations?
The nurse is collecting data on a client who was just admitted to the hospital with a diagnosis of coronary artery disease (CAD). The client reveals having been under a great deal of stress recently. Which should the nurse do next?
A client with a diagnosis of myocardial infarction has a new activity prescription allowing the client to have bathroom privileges. As the client stands and begins to walk, the client begins to complain of chest pain. The nurse should take which action?
A client being seen in the emergency department for complaints of chest pain confides in the nurse about regular use of cocaine as a recreational drug. The nurse takes which important action in delivering holistic nursing care to this client?
The nurse is planning measures to decrease the incidence of chest pain for a client with angina pectoris. The nurse should do which intervention to effectively accomplish this goal?
A client in a long-term care facility who has a history of angina pectoris wants to go for a short walk outside with a family member. It is a sunny but chilly December day. The nurse should perform which intervention to care for this client in a holistic manner?
The LPN/LVN carries out a standard prescription for a stat electrocardiogram (ECG) on a client who has an episode of chest pain. The nurse should take which action next?
A client admitted to the hospital with a diagnosis of myocardial infarction (MI) tells the nurse that the pain likely resulted from the fried chicken sandwich that the client had for lunch. The nurse’s response is based on which fact?
The nurse is preparing to provide a therapeutic environment for a client who recently had a myocardial infarction (MI). Which are characteristics of a therapeutic environment?
A client who experienced a myocardial infarction (MI) tells the nurse that he is fearful about not being able to return to a normal life. Which action by the nurse is therapeutic at this time?
A client complaining of chest pain has an as-needed (PRN) prescription for sublingual nitroglycerin (Nitrostat). Before administering the medication to the client, the nurse should first check which?
“A client who has undergone femoropopliteal bypass grafting says to the nurse, “”I hope I don’t have any more problems that could make me lose my leg. I’m so afraid that I’ll have gone through this for nothing.”” Which is an appropriate nursing response?”
The nurse is teaching a hospitalized client who has had aortoiliac bypass grafting about measures to improve circulation. The nurse should tell the client to do which?
A client is admitted to the hospital with possible rheumatic heart disease. The LPN/LVN collects data from the client and checks the client for which signs/symptoms?
A client with infective endocarditis is at risk for heart failure. The nurse monitors the client for which signs and symptoms of heart failure?
A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the health care provider to write a prescription for the client to remain on bed rest. In which position should the bed be positioned?
The nurse is collecting data from a client with varicose veins. Which finding would the nurse identify as an indication of a potential complication associated with this disorder?
A client with coronary artery disease has selected guided imagery to help cope with psychological stress. Which statement by the client indicates understanding of this stress reduction measure?
A client, who is 36 hours post-myocardial infarction, has ambulated for the first time. The nurse determines that the client best tolerated the activity if which observation is made?
The nurse is planning a dietary menu for a client with heart failure being treated with digoxin (Lanoxin) and furosemide (Lasix). Which would be the best dinner choice from the daily menu?
A client has received instructions about an upcoming cardiac catheterization. The nurse determines that the client has the best understanding of the procedure if the client knows to report which symptoms?
The nurse is caring for a client diagnosed with Buerger’s disease. Which finding should the nurse determine is a potential complication associated with this disease?
The nurse has completed nutritional counseling with an overweight client about weight reduction to modify the risk for coronary artery disease (CAD). The nurse should determine the teaching is successful if the client states that which weight loss goal is safe?
The nurse has reinforced instructions to the family of an older client who seems anxious about being discharged after cardiac surgery. The nurse understands further teaching is needed if a family member makes which statement?
The nurse monitors the laboratory data on a client at risk for coronary artery disease. A fasting blood glucose reading of 200 mg/dL is recorded on the chart. The nurse analyzes this result as indicative of which finding?
The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement?
The nurse has given simple instructions on preventing some of the complications of bed rest to a client who experienced a myocardial infarction. The nurse should intervene if the client was performing which of these contraindicated activities?
A client with a diagnosis of heart failure (HF) is preparing for discharge to home from the hospital. Which condition indicates the client is ready for discharge to home?
A client admitted to the hospital with coronary artery (CAD) disease complains of dyspnea at rest. The nurse determines that which would be of most help to the client?
The nurse is evaluating the effects of care for the client with deep vein thrombosis. Which limb observations should the nurse note as indicating the least success in meeting the outcome criteria for this problem?
A client is at risk for complications of heart failure. Which is the nurse’s priority for early detection of the most likely cause of complications with this client?
“A female client complains of an “”odd, left-sided, twinge-like pain”” along the anterior axillary line and states she has had this feeling for the past 3 days. Which is the initial action?”
A client’s blood pressure is 100/78 mm Hg; the client has tachycardia and is cool and pale. The nurse assists the client to which position to promote tissue oxygenation and alleviate hypoxia?
The nurse notes this rhythm on the client’s cardiac monitor. The nurse next reports that the client is experiencing which heart rhythm? Refer to figure.
The client’s B-type natriuretic peptide (BNP) level is 691 pg/mL. Which intervention should the nurse institute when providing care for the client?
A hypertensive client who has been taking metoprolol (Lopressor) has been prescribed to decrease the dose of the medication. The client asks the nurse why this must be done over a period of 1 to 2 weeks. In formulating a response, the nurse incorporates the understanding that abrupt withdrawal could affect the client in which way?
A client is admitted to the hospital with a venous stasis leg ulcer. The nurse inspects the ulcer expecting to note which observation?
A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed, the nurse places a sign above the bed stating that the client should remain on bed rest and in which position?
A client’s serum calcium level is 7.9 mg/dL. The nurse is immediately concerned, knowing that this level could lead to which complication?
A client has a history of left-sided heart failure. The nurse should look for the presence of which finding to determine whether the problem is currently active?
The nurse is told during shift report that a client is having occasional ventricular dysrhythmias. The nurse reviews the client’s laboratory results, recalling that which electrolyte imbalance could be responsible for this development?
A licensed practical nurse (LPN) is assisting in the care of a client who is having central venous pressure (CVP) measurements taken by the registered nurse (RN). The LPN should assist the RN by placing the bed in which position for the reading?
The nurse is assisting a client who will wear a Holter monitor for continuous cardiac monitoring over the next 24 hours. The nurse takes which action to assist the client?
A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic?
The nurse is assisting in the care of a client with myocardial infarction who should reduce intake of saturated fat and cholesterol. The nurse should help the client comply with diet therapy by selecting which food items from the dietary menu?
The nurse is assisting a client admitted to the hospital with pulmonary edema to prepare for discharge. The nurse should reinforce with the client the importance of complying with which measure to prevent a recurrence?
The nurse is assisting in the care of a client diagnosed with rheumatic heart disease. The nurse should reinforce instructions to the client to notify the dentist before dental procedures for which reason?
A client with a history of angina pectoris complains of substernal chest pain. The nurse checks the client’s blood pressure and administers nitroglycerin 0.4 mg sublingually. Five minutes later, the client is still experiencing chest pain. If the blood pressure is still stable, the nurse should take which action next?
The health care provider is discharging a client with a diagnosis of chronic heart failure. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply.
The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include? Select all that apply.
The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect? Select all that apply.
A client with hyperlipidemia is seen in the clinic for a follow-up visit. Which dietary modifications should the nurse include to lower the risk of coronary heart disease? Select all that apply.
The LPN/LVN is caring for a client with left-sided heart failure. Which clinical signs are most important for the nurse to communicate to the health care provider? Select all that apply.
The nurse is admitting a client with acute pericarditis who reports chest pain. When planning the client’s care, which position should the nurse encourage the client to assume to alleviate the chest pain? Select all that apply.
The health care provider is discharging a client with a diagnosis of primary hypertension. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply.
The nurse is planning care for a client with diabetes mellitus who has gangrene of the toes to the midfoot. Which goal should be included in this client’s plan of care?
The LPN/LVN is conducting an osteoporosis screening clinic at a health fair. What information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.)
An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that this client’s tongue is somewhat cracked and his eyeballs appear sunken into his head. Which nursing intervention is indicated?
The nurse is assessing a client who presents with jaundice. Which assessment finding is most important for the nurse to follow up?
Which content about self-care should the LPN/LVN include in the teaching plan of a female client who has genital herpes? (Select all that apply.)
The LPN/LVN is interviewing a client who is taking interferonalfa-2a (Roferon-A) and ribavirin (Virazole) combination therapy for hepatitis C. The client reports experiencing overwhelming feelings of depression. Which action should the nurse implement first?
A client in the emergency department is bleeding profusely from a gunshot wound to the abdomen. In what position should the nurse immediately place the client to promote maintenance of the client’s blood pressure above a systolic pressure of 90 mm Hg?
The nurse assesses a client who has been prescribed furosemide (Lasix) for cardiac disease. Which electrocardiographic change would be a concern for a client taking a diuretic?
When a nurse assesses a client receiving total parenteral nutrition (TPN), which laboratory value is most important for the nurse to monitor regularly?
A 62-year-old woman who lives alone tripped on a rug in her home and fractured her hip. Which predisposing factor most likely contributed to the fracture in the proximal end of her femur?