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HESI EXIT COMPREHENSIVE REVIEW EXAM A& B QUESTION AND ANSWERS EXPLAINED,100% CORRECT
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HESI EXIT COMPREHENSIVE REVIEW EXAM A QUESTION AND ANSWERS EXPLAINED,100% CORRECT
HESI EXIT COMPREHENSIVE REVIEW EXAM A QUESTION AND ANSWERS EXPLAINED 1. The nurse is correct in withholding an older adult client's dose of nifedipine if ... [Show More] which assessment finding is obtained? 2. Until the census on the obstetrics (OB) unit increases, an unlicensed assistive personnel (UAP) who usually works in labor and delivery and the newborn nursery is assigned to work on the postoperative unit. Which client would be best for the charge nurse to assign to this UAP? 3. A very busy hospital unit has had several discharges and the census is unusually low. What is the best way for the charge nurse to use the time of the nursing staff? 4. When the administration at a large urban medical center decides to establish a unit to care for clients with infectious diseases, such as ebola and the avian flu, several employees express fear related to caring for these clients. When choosing staff to work on this unit, which action is best for the nurse-manager to take? 5. The nurse is planning a community teaching program regarding the use of folic acid to prevent neural tube birth defects. Which community group is likely to benefit most from this program? 6. Staff on a cardiac unit consists of an RN, two practical nurses (PNs), and one UAP. Team 1's assignment includes two clients who are both 1 day postangioplasty and two clients with unstable angina. Team 2's assignment includes all stable clients, but two clients are bedridden and incontinent. Which staffing plan represents the best use of available staff? 7. A male client with Parkinson disease is prescribed the antiparkinsonian agent amantadine HCl. Which action should the nurse take? 8. A client tells the nurse that he is suffering from insomnia. Which information is most important for the nurse to obtain? 9. A client has been on a mechanical ventilator for several days. What should the nurse use to document and record this client's respirations? 10. Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. Which intervention should the nurse implement based on these results? 11. A 77-year-old female client states that she has never been so large around the waist and that she has frequent periods of constipation. Colon disease has been ruled out with a flexible sigmoidoscopy. Which information should the nurse provide to this client? 12. A mother of a 12-year-old boy states that her son is short and she fears that he will always be shorter than his peers. She tells the nurse that her grown daughter only grew 2 inches after she was 12 years of age. To provide health teaching, which question is most important for the nurse to ask this mother? 13. Which question is most relevant to ask the parents when obtaining the history of a 2-year-old child recently diagnosed with otitis externa? 14. Prior to administering an oral suspension, which intervention is most important for the nurse to implement? 15. On conducting a routine assessment, which question should the nurse ask to determine a client's risk for open-angle glaucoma? 16. Which assessment finding for a client with peritoneal dialysis requires immediate intervention by the nurse? 17. Which client is best to assign to a graduate PN who is being oriented to a renal unit? 18. A client has been receiving levofloxacin, 500 mg IV piggyback q24h for 7 days. The UAP reports to the nurse that the client has had three loose foul-smelling stools this morning. Which intervention is most important for the nurse to implement? 19. When caring for a postpartum client, which intervention is best for the nurse to implement to promote increased peripheral vascular activity? 20. A client reports experiencing dysuria and urinary frequency. Which client teaching should the nurse provide? 21. A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states, "I can't believe this happened." Which statement by the nurse is most therapeutic? 22. The only RN on a surgical unit is performing an admission assessment on a client scheduled for surgery in 2 hours. The UAP reports to the RN that an unresponsive male client with a continuous feeding tube has just vomited. Which action should the RN delegate to the UAP? 23. The nurse is preparing to administer dalteparin subcutaneously to an immobile client who has been receiving the medication for 5 days. Which finding indicates that the nurse should hold the prescribed dose? 24. Which assessment is most important for the nurse to implement when seeing a client with multiple myeloma? 25. The charge nurse of a medical-surgical unit is alerted to an impending disaster requiring implementation of the hospital's disaster plan. Specific facts about the nature of this disaster are not yet known. Which instruction should the charge nurse give to the other staff members at this time? 26. A male client is admitted for observation after being hit on the head with a baseball bat. Six hours after admission, the client attempts to crawl out of bed and asks the nurse why there are so many bugs in his bed. His vital signs are stable, and the pulse oximeter reading is 98% on room air. Which intervention should the nurse perform first? 27. A five year old is in Bryant's traction for intervention for a fractured femur. Which finding by the nurse would require intervention? 28. The nurse is preparing assignments for the day shift. Which client should be assigned to the staff RN rather than a PN? . 29. Because of census overload, the charge nurse of an acute care medical unit must select a client who can be transferred back to a residential facility. The client with which symptomology is the most stable? 30. The health care provider prescribes 1000 mL of Ringer's lactate solution with 30 units of oxytocin (Pitocin) to infuse over 4 hours for a client who has just delivered a 10-lb infant by cesarean section. The tubing has been changed to a 20 gtt/mL administration set. The nurse should set the flow rate at how many gtt/min? 31. A comatose client is admitted to the critical care unit, and a central venous catheter is inserted by the health care provider. What is the priority nursing assessment before initiating IV fluids? . 32. When assisting a client who has undergone a right above-knee amputation with positioning in bed, which action should the nurse include? . 33. The nurse would be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the health care provider if which finding was documented? 34. Which intervention(s) is(are) most helpful in evaluating the effectiveness of nursing and medical treat-ments for dehydration in a 36-month-old child? (Select all that apply.) 35. The nurse should encourage a laboring client to begin pushing at which point? 36. The nurse is developing a health risk assessment protocol for use in a well-baby clinic in a low-income neighborhood. Which information is most important for the nurse to include in the assessment? 37. A 40-year-old office worker who is at 36 weeks' gestation presents to the occupational health clinic complaining of a pounding headache, blurry vision, and swollen ankles. Which intervention should the nurse implement first? 38. Which situation demonstrates proper application of client confidentiality requirements for the Health Insurance Portability and Accountability Act (HIPAA)? 39. The nurse plans to evaluate the effectiveness of a bronchodilator. Which assessment datum indicates that the desired effect of a bronchodilator has been achieved? 40. A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide PO and 40 mg of furosemide PO daily. Today, at a routine clinic visit, the client's serum potassium level is 4 mEq/L. What is the most likely cause of this client's potassium level? 41. The nurse is teaching the parents of a 10-year-old child with rheumatoid arthritis measures to help reduce the pain associated with the disease. Which instruction should the nurse provide to these parents? 42. A registered nurse (RN) delivers telehealth services to clients via electronic communication. Which nursing action creates the greatest risk for professional liability and has the potential for a malpractice lawsuit? 43. Transcutaneous electrical nerve stimulation (TENS) is prescribed for a client with chronic back pain. Which action(s) should the nurse take when preparing the client for this type of pain relief? (Select all that apply.) 44. The health care provider prescribes 1000 mL of a D5W solution to infuse over 8 hours for a client who has had an appendectomy. The IV tubing being used delivers 15 gtt/mL. The nurse should set the flow rate at how many gtt/min? (If rounding is necessary, round to the nearest whole drop.) . 45. The charge nurse of a 16-bed medical unit is making 0700 to 1900 shift assignments. The team consists of two RNs, two PNs, and two UAP. Which assignment is the most effective use of the available team members? 46.The antigout medication allopurinol is prescribed for a client newly diagnosed with gout. Which comment by the client warrants intervention by the nurse? 47.The charge nurse working in the surgical department is making shift assignments. The shift personnel include an RN with 12 years of nursing experience, an RN with 2 years of nursing experience, and an RN with 3 months of nursing experience. Which client should the charge nurse assign to the RN with 3 months of experience? 48.After administration of a 0730 dose of Humalog 50/50 insulin to a client with diabetes mellitus, which nursing action has the highest priority? 49.Which assessment finding indicates that nystatin swish and swallow, prescribed for a client with oral candidiasis, has been effective? 50Two days after swallowing 30 tablets of alprazolam, a client with a history of depression is hemodynamically stable but wants to leave the hospital against medical advice. Which nursing action(s) is(are) most likely to maintain client safety? (Select all that apply.) 51.The nurse is preparing a client for surgery scheduled in 2 hours. A UAP is helping the nurse. Which task is important for the nurse to perform, rather than the UAP? 52. The nurse is assisting a father to change the diaper of his 2-day-old infant. The father notices several bluish-black pigmented areas on the infant's buttocks and asks the nurse, "What did you do to my baby?" Which response is best for the nurse to provide? 53. When the nurse-manager posts a schedule for volunteers to be on call, one staff member immediately signs up for all available 7-to-3 day shifts. Other staff members complain to the charge nurse that they were not permitted the opportunity to be on call for the day shift. What action should the nurse-manager implement? 54. A 2-day postpartum mother who is breastfeeding asks, "Why do I feel this tingling in my breasts after the baby sucks for a few minutes?" Which information should the nurse provide? . 55. The nurse is teaching a client newly diagnosed with diabetes mellitus about the subcutaneous administration of regular and NPH insulin. Which statement indicates that the client needs further instruction? 56. The charge nurse overhears a staff member asking for a doughnut from a client's meal tray. Which action should the charge nurse implement? 57. A nurse-manager of a long-term care facility learns that the nursing administrator plans to remove the television from the residents' day room because night shift staff members are sitting around watching television. How should the nurse-manager respond to this situation? 58. The nurse assesses a client while the UAP measures the client's vital signs. The client's vital signs change suddenly, and the nurse determines that the client's condition is worsening. The nurse is unsure of the client's resuscitative status and needs to check the client's medical record for any advanced directives. Which action should the nurse implement? 59. The client with which fasting plasma glucose level needs the most immediate intervention by the nurse? 60. A client with acquired immunodeficiency syndrome (AIDS) is hospitalized after a recent discharge. Which nursing intervention is most important in reducing the client's stress associated with repeated hospitalization? 61. A client with small cell carcinoma of the lung has also developed syndrome of inappropriate antidiuretic hormone (SIADH). Which outcome finding is the priority for this client? 62. A client who is on the outpatient surgical unit is preparing for discharge after a myringotomy with placement of ventilating tubes. Which response by the client indicates that further teaching is necessary? 63. A client with human immunodeficiency virus (HIV) infection has white lesions in the oral cavity that resemble milk curds. Nystatin preparation is prescribed as a swish and swallow. Which information is most important for the nurse to provide the client? 64.The health care provider performs a bone marrow aspiration from the posterior iliac crest for a client with pancytopenia. Which action should the nurse implement first? 65. An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy for pneumonia. Stool cultures reveal the presence of C. difficile. While planning care, which nursing goal should the nurse establish as the priority? 66.A client with glomerulonephritis is scheduled for a creatinine clearance test to determine the need for dialysis. Which information should the nurse provide the client prior to the test? 67. A client with hemiparesis needs assistance transferring from the bed to the wheelchair. The nurse assists the client to a sitting position on the side of the bed. Which action should the nurse implement next? 68. The nurse formulates a nursing diagnosis of pain related to muscle spasms for a client with extreme lower back pain associated with acute lumbosacral strain. Which is the best intervention for the nurse to implement? 69. A nurse is planning client care and wants to verify the steps for a specific client procedure. Which action should the nurse take? 70. A female client arrives for an annual well-woman checkup and cervical Pap test and tells the nurse that she has been using an over-the-counter (OTC) vaginal cream for the past 2 days to treat an infection. Which initial response should the nurse make? 71. A client with hepatic failure tells the nurse about recent use of acetaminophen. How should the nurse respond to this client's statement? . 72. Which physiologic finding in an older adult contributes to an adverse drug reaction? 73. Which pathophysiologic response supports the contraindication for opioids, such as morphine, in clients with increased intracranial pressure (ICP)? 74. A client who is admitted with emphysema is having difficulty breathing. In which position should the nurse place the client? 75. An older client who resides in a long-term care facility is hearing-impaired. How should the nurse modify interventions for this client? 76. A client with hemiplegia who is on bed rest is turned to the supine position, and the nurse determines that the client's hips are externally rotated. Which intervention is most important for the nurse to implement? 77. A client hospitalized for meningitis is demonstrating nuchal rigidity. Which symptom is this client likely to be exhibiting? 78. A child is having a generalized tonic-clonic seizure. Which action should the nurse take? 79. A client with rhabdomyolysis tells the nurse about falling while going to the bathroom and lying on the floor for 24 hours before being found. Which current client finding is indicative of renal complications? 80. A client with acute renal failure (ARF) starts to void 4 L/day 2 weeks after treatment is initiated. Which complication is important for the nurse to monitor the client for at this time? 81. The nurse is obtaining a client's sexual history. Which finding requires additional follow-up regarding the client's self-image? 82. A 50-year-old man arrives at the clinic with complaints of pain on ejaculation. Which action should the nurse implement? 83. The nurse meets resistance while flushing a central venous catheter (CVC) at the subclavian site. Which action should the nurse perform? 84. According to Erikson, which client should the nurse identify as having difficulty completing the developmental stage of older adults? 85. Upon assessing a newborn male, the nurse finds the urethral meatus opens on ventral side of penis behind the glans. The nurse would recognize this finding is consistent with which finding? 86. A nurse who has recently completed orientation is beginning work in the labor and delivery unit for the first time. When making assignments, which client should the charge nurse assign to this new nurse? 87. The RN is caring for a client who is in skeletal traction. Which activity should the RN assign to the PN? 88. A client with schizophrenia tells the nurse, "The world is coming to an end. All the violence in the Middle East is soon going to destroy the entire world!" How should the nurse respond? 89. The nurse is preparing a client for surgical stabilization of a fractured lumbar vertebrae. Which indica-tion(s) best supports the client’s need for insertion of an indwelling urinary catheter? (Select all that apply.) 90. A male client with arterial peripheral vascular disease (PVD) complains of pain in his feet. Which instruction should the nurse give to the UAP to relieve the client's pain quickly? . 91. What instruction(s) related to foot care is(are) appropriate for the client with type 1 diabetes mellitus? (Select all that apply.) 92. The nurse performs an assessment on a client with heart failure. Which finding(s) is(are) consistent with the diagnosis of left-sided heart failure? (Select all that apply.) 93. The nurse calls the primary health care provider to report the status of a postsurgical client. Place the statements in the correct SBAR communication format. 94. The nurse administers levothyroxine to a client with hypothyroidism. Which data indicate(s) that the drug is effective? (Select all that apply.) 95. The nurse performs tracheostomy suctioning on a comatose client. Place the interventions in order from first to last. 96. The nurse recognizes which behaviors in a client as warning signs of an impending suicide attempt? (Select all that apply.) 97. Which nursing intervention(s) should be implemented when caring for a client with bipolar disorder in the manic phase? (Select all that apply.) 98. The nurse assists the health care provider with an amniocentesis during the third trimester of pregnancy. Which intervention(s) would the nurse expect to implement after the procedure? (Select all that apply.) 99. A child with nephrotic syndrome is receiving prednisone. Which choice of breakfast foods at a fast food restaurant indicates that the mother understands the dietary guidelines necessary for her child? 100. Which findings would suggest to the nurse that diagnosis of glomerulonephritis is correct? [Show Less]
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HESI EXIT COMPREHENSIVE REVIEW EXAM B QUESTION AND ANSWERS EXPLAINED,100% CORRECT
HESI EXIT COMPREHENSIVE REVIEW EXAM B QUESTION AND ANSWERS EXPLAINED 1.Which information is most concerning to the nurse when caring for an older client w... [Show More] ith bilateral cataracts? 2.When caring for a client hospitalized with Guillain-Barré syndrome, which information is most important for the nurse to report to the primary health care provider? 3. A client is admitted with a diagnosis of leukemia. This condition is manifested by which of the following? 4. The nurse enters the examination room of a client who has been told by her health care provider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client? 5. A nurse working in the emergency department admits a client with full-thickness burns to 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first? 6. The nurse walks into the room and observes the client experiencing a tonic-clonic seizure. Which intervention should the nurse implement first? 7. Which intervention should be included in the plan of care for a client admitted to the hospital with ulcerative colitis? 8. A nurse implements an education program to reduce hospital readmissions for clients with heart failure. Which statement by the client indicates that teaching has been effective? 9. After assessing a 26-year-old client with type 1 diabetes mellitus, which data may indicate that the client is experiencing chronic complications of diabetes? 10. When caring for a client with a tracheostomy, which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? 11. The charge nurse is making assignments for the upcoming shift. Which client is most appropriate to assign to the practical nurse (PN)? 12. A nurse performs an initial admission assessment of a 56-year-old client. Which factor(s) would indicate that the client is at risk for metabolic syndrome? (Select all that apply.) 13. Which clinical manifestation in the client with hyperthyroidism is most important to report to the health care provider? 14. The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for cataract surgery. Which response by the client indicates that the drug was effective? 15. A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash on the right lateral abdominal area. Which drug should the nurse expect to administer to treat this condition? 16. When assessing a 38-year-old client with tuberculosis who is taking rifampin, which finding would be most important to report to the primary health care provider immediately? 17. A client with non-Hodgkin lymphoma has been prescribed cyclophosphamide IV for therapy. Which assessment finding would need to be reported immediately to the oncologist? 18. A nurse is assessing a client with heart failure who has been prescribed digoxin for therapy. Which finding indicates an issue with the medication management? 19. Which statement by the U.S. Food and Drug Administration (FDA) is an example of a black box or black label warning for the drug clopidogrel? 20. The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which actions should the nurse expect to implement? (Select all that apply.) 21. Which action by the nurse is consistent with culturally competent care? 22. The charge nurse reviews the charting of a graduate nurse. Which indicates a need for further education on documentation? 23. Which data obtained during a respiratory assessment for a 78-year-old client is most important to report to the primary health care provider? 24. The nurse hears a series of long-duration, discontinuous, low-pitched sounds on auscultation of a client's lower lung fields. Which documentation of this finding is correct? 25. The nurse empties a client's urinary drainage from an indwelling Foley catheter. Which finding should be reported to the primary health care provider? 26. When blood or blood products are administered, which task can be assigned to the licensed practical nurse (PN)? 27.The charge nurse observes a student nurse enter the room of a client who is prescribed airborne precautions. The application of which personal protective equipment by the student indicates a correct understanding of this precaution? 28. The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? 29. A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is most significant? 30. The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure is correct? 31. The nurse is caring for a client on the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? 32. Which disaster management intervention by the nurse is an example of primary prevention? 33. The nurse teaches a class on bioterrorism. Which methods of transmission are possible with the biologic agent Bacillus anthracis(Anthrax)? (Select all that apply.) 34. The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, with some visible subcutaneous fat. How should the nurse stage this pressure ulcer? 35. The nurse prepares to administer ophthalmic drops to a client prior to cataract surgery. List the steps in the order that they should be implemented from first step to final step. 36. The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is <2 within 45 minutes after pain medication has been administered." Formulating the expected outcome is an example of which step in the nursing process? 37. When assessing safety for the older adult, which of the following is of highest priority to the nurse? 38. While assessing a client with recurring chest pain, the unit secretary notifies the nurse that the client's health care provider is on the telephone. What action should the nurse instruct the unit secretary to implement? 39. The family of a male adult with schizophrenia does not want the client to be involved in decisions regarding his treatment. The nurse should inform the family that the client has a right to be involved in his treatment planning based on which law? 40. An adult female who presents at the mental clinic trembling and crying becomes distressed when the nurse attempts to conduct an assessment. She complains about the number of questions that are being asked, which she is convinced are going to cause her to have a heart attack. What action should the nurse take? 41. A client in an acute psychiatric setting asks the nurse if their conversations will remain confidential. How should the nurse respond? 42. Which intervention is most important when caring for a client immediately after electroconvulsive therapy (ECT)? 43. A client in the psychiatric setting with an anxiety disorder reports chest pain. Which action should the nurse take first? 44. The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor? 45. A client who is prescribed chlorpromazine HCl for schizophrenia develops rigidity, a shuffling gait, and tremors. Which action by the nurse is most important? 46. A nurse is interviewing a mother during a well-child visit. Which finding would alert the nurse to continue further assessment of the infant? 47. Which vaccination should the nurse administer to a newborn? 48. Which vital sign in a pediatric client is most important to report to the primary health care provider? 49. The nurse prepares to administer amoxicillin clavulanate potassium (Augmentin) to a child weighing 15 kg. The prescription is for 15 mg/kg every 12 hours by mouth. How many milliliters should the nurse administer when supplied as below? 50. The nurse prepares to administer acetaminophen oral suspension to a child who weighs 66 lb. The prescription reads: Administer 15 mg/kg every 6 hours by mouth. The Tylenol is available 150 mg/5 mL. What is the correct dosage as indicated on the figure. Click Image to Enlarge (From Kee JL, Hayes ER, McCuistion LE. Pharmacology: A nursing process approach, ed 7, St. Louis, 2011, Elsevier.) 51. The nurse expects a clinical finding of cyanosis in an infant with which conditions? (Select all that apply.) 52. Which nursing intervention should be implemented postoperatively in an infant with spina bifida after repair of a meningocele? 53. When caring for a hospitalized child with type 1 diabetes mellitus, which intervention can the nurse delegate to the unlicensed assistive personnel (UAP)? 54. The outpatient clinic nurse is reviewing phone messages from last night. Which client should the nurse call back first? 55. Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider? 56. When caring for a client in labor, which finding is most important to report to the primary health care provider? 57. Which interventions should be performed by the nurse when caring for a woman in the fourth stage of labor? (Select all that apply.) 58.In caring for a pregnant woman with gestational diabetes, the nurse should be alert to which finding? 59. The nurse anticipates administering Rho(D) immune globulin (RhoGAM) to which individuals? (Select all that apply.) 60. When assessing a normal newborn, which findings should the nurse expect? (Select all that apply.) 61. The nurse is caring for a client with heart failure who develops respiratory distress and coughs up pink frothy sputum. Which action should the nurse take first? 62. When caring for a postsurgical client who has undergone multiple blood transfusions, which serum laboratory finding is of most concern to the nurse? 63. The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; PCO2, 50 mm Hg; PO2, 70 mm Hg; HCO3, 26 mEq/L. How should the nurse interpret these results? 64. The nurse is caring for a client who develops ventricular fibrillation. Which action should the nurse take first? 65. When caring for an 80-year-old client with pneumonia, which finding is of most concern to the nurse? 66. The nurse is caring for a client with a cerebrovascular accident (CVA) who is receiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? 67. The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing intervention has the greatest priority when planning this client's care? 68. Which finding should be reported to the primary health care provider when caring for a client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)? 69. Which instructions should the nurse include in the discharge teaching plan of a male client who has had a myocardial infarction and who has a new prescription for nitroglycerin (NTG)? (Select all that apply.) 70. Which of the following cardiac rhythms is represented in the image? (From Lewis SL, Dirksen SR, Heitkemper MM, et al. Medical-surgical nursing, ed 8, St. Louis, 2011, Mosby.) 71. The nurse prepares to administer digoxin, 0.125 mg PO, to an adult client with heart failure and notes that the digoxin serum level in the laboratory report is 1 ng/mL. Which action should the nurse take? 72. The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication? 73. The nurse in the emergency department is caring for a client with type 1 diabetes mellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? 74. The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 am, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemic reaction? 75. The nurse assesses a client who is taking indomethacin (Indocin) for arthritic pain. Which of the following is most important to report to the primary health care provider? 76. The nurse is caring for a client with deep vein thrombosis who is on a continuous IV heparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse take? 77. The nurse is caring for a hospitalized client with myasthenia gravis. Which finding requires the most immediate action by the nurse? 78.The nurse is planning the care for a client who is admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventions should the nurse include in this client's plan of care? (Select all that apply.) 79. A client with type 2 diabetes has a plantar foot ulcer. When developing a teaching plan regarding foot care, what information should the nurse obtain first from the client? 80. A nurse working in a community health setting is performing primary health screenings. Which individual is at highest risk for contracting an HIV infection? 81. A client at 32 weeks of gestation is hospitalized with preeclampsia, and magnesium sulfate is prescribed to control the symptoms. Before the next dose of MgSO4 is given, which assessment finding indicates that the client is at risk for toxicity? 82. A client comes to the obstetric clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the nurse, "I'm having second thoughts about wanting to have this baby." Which response is best for the nurse to make? 83. A primipara presents to the perinatal unit describing rupture of the membranes (ROM), which occurred 12 hours prior to coming to the hospital. An oxytocin infusion is begun, and 8 hours later the client's contractions are irregular and mild. What vital sign should the nurse monitor with greater frequency than the typical unit protocol? 84. An adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazineHCl to IM fluphenazinedecanoate because of medication noncompliance. What should the nurse teach the client and family about this change in medication regimen? 85. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last 6 months. The client has not gone to work for a month, has been terminated from her job, and has not left the house since that time. This client is displaying symptoms of which disorder? 86. A 12-year-old boy complains to the nurse that he is "short" (4′5″ [53 inches]). His twin sister is 5 inches taller than he is (4′10″ [58 inches]). Based on these findings, what conclusion should the nurse reach? 87. When administering an intramuscular injection, which factor is most important to ensure the best medication absorption? 88. An older client calls the clinic and complains of feeling very weak and dizzy. Further assessment by the nurse indicates that the client self-administered an enema of 3 L of tap water because of constipation. What is the most likely cause of the client's symptoms? 89. The nurse plans to teach blood glucose self-monitoring to a client who is newly diagnosed with diabetes mellitus type 1, and the health care provider has given the client a schedule for testing. In addition to the prescribed schedule, the nurse should also instruct the client to check the blood glucose level in which circumstance? 90. An 8-year-old child is receiving digoxin for congestive heart failure (CHF). In assessing the child, the nurse finds that her apical heart rate is 80 beats/min, she complains of being slightly nauseated, and her serum digoxin level is 1.2 ng/mL. What action should the nurse take? 91. A client who is first day postoperative after a mastectomy becomes increasingly restless and agitated. Vital signs are temperature, 100° F; pulse, 98 beats/min; respirations, 24 breaths/min; and blood pressure, 120/80 mm Hg. Which intervention should the nurse implement first? 92. A client is receiving propylthiouracil (PTU) prior to thyroid surgery. Which diagnostic test results indicate that the medication is producing the desired effect? 93. A client exhibits symptoms of alcohol intoxication. The blood alcohol level is 200 mg (0.2%). Which measurement tool is best for the nurse to use during the initial assessment of this client? 94. A client with bipolar disorder is seen in the mental health clinic for evaluation of a new medication regimen that includes risperidone. The nurse notes that the client has gained 30 lb in the past 3 months. Which assessment is most important for the nurse to obtain? 95. A client is admitted to a mental health unit because of mild depression. When asked, he denies suicidal ideation, but the nurse reads in the psychosocial assessment that there were attempts to overdose on aspirin 5 years earlier. Which intervention is most important for the nurse to implement? 96. A couple expresses concern and fear prior to having an amniocentesis to determine fetal lung maturity. To assist them in coping with this situation, which intervention is best for the nurse to implement? 97. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care? 98. The nurse is assessing a client at 20 weeks' gestation. Which measurement should be compared with the client's current weight to obtain the most accurate data about her weight gain during pregnancy? 99. Which intervention(s) should the nurse implement when administering a new prescription of amitriptyline HCl to a client with a depressive disorder? (Select all that apply.) 100. The nurse assesses a woman in the emergency room who is in her third trimester of pregnancy. Which finding(s) is(are) indicative of abruptio placentae? (Select all that apply.) [Show Less]
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