Hurst questions with 100% verified answers and rationales complete document 989 pages late, Exams of Health sciences

Download Hurst questions with 100% verified answers and rationales complete document 989 pages late and more Exams Health sciences in PDF only on Docsity! Hurst questions with 100% verified answers and rationales complete document 989 pages latest update A nurse has received the following arterial blood gas results on a client post bowel resection. ABGs are: pH 7.48; PCO2 30; HCO3 24. Which acid- base imbalance is the client experiencing? You answered this question Correctly Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Respiratory acidosis The nurse is developing a teaching plan covering emergency responses to smallpox. This presentation will be used with newly hired hospital employees. What information is essential for the presentation? You answered this question Incorrectly People may be exposed to smallpox but not get the disease. People may contract the disease by handling contaminated clothing or bedding. Smallpox is fatal is about 50% of cases. Smallpox victims are contagious for two weeks. Smallpox victims are isolated from others. A client with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria and hematuria. The primary healthcare provider prescribes corticosteroids. During the acute phase of the client’s illness, what is most important for the nurse to do? You answered this question Incorrectly Monitor intake and output and daily weight. Allow for frequent, uninterrupted rest periods. Institute seizure precautions. Protect client from injury that may cause bleeding. A client with chronic arterial occlusive disease has a bypass graft of the left femoral artery. Postoperatively, the client develops left leg pain and coolness in the left foot. What is the priority action by the nurse? You answered this question Incorrectly Elevate the leg. Check distal pulses. Increase the IV rate. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Notify the primary healthcare provider. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Remove necklace Elevate right arm Debride wounds The nurse is caring for a client following a transurethral resection of the prostate (TURP). The client has a 3 way irrigation catheter in place. Which observation would indicate the need to slow the irrigation? You answered this question Incorrectly Clots in urine Bladder pressure Clear urine Bladder spasms The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? You answered this question Incorrectly I'll have to take a strong laxative the night before the test. I'll have to drink contrast while x-rays are taken. I'll have a CT scan after I'm injected with a radiopaque contrast dye. I'll have an instrument passed through my mouth to my stomach. After discontinuing a peripherally inserted central line (PICC), it is most important for the nurse to record which information? You answered this question Correctly How the client tolerated the procedure. The length and intactness of the central line catheter. The amount of fluid left in the IV solution container. That a dressing was applied to the insertion site. A pregnant client has been receiving daily heparin injections for a history of deep vein thrombosis (DVTs) during pregnancy. Which laboratory test result should be immediately reported to the primary healthcare provider? You answered this question Incorrectly PT of 16 PTT of 22 INR of 2.5 Hemoglobin of 11 g/dL (6.8266 mmol/L) A nurse is caring for a client on the second day after a thoracotomy. The client reports incisional pain. The nurse assesses the client and Hurst questions with 100% verified answers and rationales complete document 989 pages latest update evaluates the vital signs. Based on the data documented in the chart, what action should the nurse Hurst questions with 100% verified answers and rationales complete document 989 pages latest update take? Exhibit You answered this question Correctly Cough and deep breathe the client. Give prescribed acetaminophen to reduce the client's fever. Medicate the client for pain. Assist the client to ambulate. A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? You answered this question Correctly Checking your vital signs frequently. Examining the dressing for bleeding. Listening to and percussing your lungs. Positioning you with your affected lung down. Palpating around the incision site for air under the skin. A nurse is teaching a client about post-procedure thoracentesis nursing care. Which statements should the nurse include? You answered this question Correctly Checking your vital signs frequently. Examining the dressing for bleeding. Listening to and percussing your lungs. Positioning you with your affected lung down. Palpating around the incision site for air under the skin. Which goal is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit? You answered this question Incorrectly Reduction of anxiety Referral to community resources Identification of lifestyle changes Verbalization of energy-conservation techniques What precautions should be taken with computer monitors that display client health information to ensure client's confidentiality? You answered this question Incorrectly Orient the screen facing the client rooms so that healthcare personnel can access the information easily. Have the screen placed facing away from any visitor or client care area where information could be viewed by unauthorized persons. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Ask the RN the reason she thinks her assignment is too heavy. Explain to the RN that all the nurses have the same number of clients. The nurse has observed that the client on the skilled nursing unit has been consuming fewer calories over the past three days. There has been no other change in the client’s condition. Which intervention is most important for the nurse to initiate? You answered this question Correctly Suggest that the family seek an appointment with the primary healthcare provider. Ask the dietician to visit the client and discuss food preferences. Note any weight loss over the next month. Continue to monitor intake over the next couple of weeks A homebound client lives alone, has a history of poorly controlled diabetes, and has an open wound on the left heel. The home health nurse is concerned about the client's condition and the possible need for a referral. Which intervention should the nurse initiate for this client? You answered this question Correctly Ask the primary healthcare provider to prescribe a diabetes educator consult. Continue to monitor the healing process of the open wound. Suggest nursing home placement to the family. Suggest that the client's church family take the client to church each week. Which assignment would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)? You answered this question Correctly Obtaining a sterile urine specimen from a foley catheter. Inserting an in-and-out catheter on a client postpartum. Taking vital signs on a client 12 hours postpartum. Removing a foley catheter on a client postpartum. The nurse delegated feeding of an elderly client to the unlicensed assistive personnel (UAP). Two hours after other trays were picked up from the rooms, the nurse notes that the client’s tray is still at the bedside. What should the nurse do first? You answered this question Incorrectly Feed the client after warming the food. Speak to the UAP to determine what happened with the feeding. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Pick up the tray and tell the UAP that she didn’t do her job. Provide a between meal supplement to the client. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update The charge nurse walks into the client's room as the nurse is preparing the client for discharge. The charge nurse overhears the nurse giving the client her phone number. The nurse says, "Call me when you get home, and maybe we can get together sometime." What should the charge nurse do? You answered this question Incorrectly Inform the nurse that you will finish getting the client ready for discharge. Tell the nurse in the client's presence that the action is inappropriate. Make no comment, and let the nurse continue to talk with the client. Stay with the client until ready to leave the unit. The RN on the unit tells the LPN/VN to perform the admission assessment on the newly admitted client. Which right of delegation did the nurse fail to consider? You answered this question Correctly The right task The right direction The right communication The right supervision A client asks to view the client’s medical records. Which response made by the nurse is most appropriate? You answered this question Correctly You will need to retain an attorney, and then have the attorney contact the medical records department in order to view your medical records. You may only view your medical records after you have been discharged from the healthcare facility. You have the right to view the medical records that pertain to your care, and to have those records explained or interpreted for you if necessary. Why do you want to view your medical records? Are you planning to file a lawsuit? A rape victim is admitted to the emergency department for care. The police and primary healthcare provider insist that the client consent to a rape kit examination, but the client refuses. What should the nurse do? You answered this question Correctly Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Instructing the UAP to stop CPR. Assisting the primary healthcare provider with the intubation process. Assisting the UAP in placing the backboard under the client to facilitate compressions. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Instructing the UAP to retrieve the crash cart. Which client should the labor nurse see first? You answered this question Incorrectly Primigravida on IV magnesium sulfate with deep tendon reflexes of 2+. Multigravida on po terbutaline with a pulse rate of 110. Primigravida on IV oxytocin with contractions every 3-4 minutes. Multigravida on po methyldopa with a blood pressure of 142/86. The nurse sees that the new medication noted in a recent medication prescription is on the client’s list of allergies. In the role of client advocate, what actions should the nurse take to ensure client safety? You answered this question Incorrectly Document the medication with times and doses to be given, then administer the medication as ordered. Notify the primary healthcare provider immediately that the medication ordered is on the client's list of medication allergies. Discontinue the medication on the client's medication administration record. Check the client's allergy band against the list of client allergies documented in the medical record. Call the pharmacy to see if the medication needs to be changed. After shift report, which client should the nurse see first? You answered this question Incorrectly Eight year old that is in skeletal traction. Six year old that had an appendectomy 6 hours ago. Unattended two year old admitted for a sleep study. Four year old cerebral palsy child with a tracheostomy admitted for UTI. Which client could the charge nurse reassign to a LPN/VN? You answered this question Correctly Eight year old in diabetic ketoacidosis Six year old in sickle cell crisis Two month old with dehydration Five year old in skeletal traction After reviewing her assignment, the LPN/VN tells the RN her Hurst questions with 100% verified answers and rationales complete document 989 pages latest update assignment is very unfair and requests that some of her clients be redistributed to the other staff. What should the RN do? You answered this question Correctly Ask the LPN/VN what her concerns are regarding her assignment. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update The nurse is preparing to make an occupied bed. Which action by the nurse is important to preserve client’s self-esteem as the task is completed? You answered this question Correctly Remove the top sheet first and replace with a clean one. Inform the client that exposure will be for a short time only Ask the client to relax as the top sheet is removed and the bottom sheet is changed. Cover the client with a bath blanket before removing any of the sheets on the bed. The nurse is providing foot care to the client who has diabetes. During foot care, the nurse teaches the client proper care of the feet. What should the nurse include in the teaching? You answered this question Correctly Inspect the feet daily for abrasions or pressure areas. Check water temperature with the hands before getting into tub. Do not use heating pads on the feet or lower legs. Thoroughly dry the feet, especially between the toes. Cut toenails rather than file them. Cut nails in a rounded fashion. The client with ulcerative colitis calls the clinic and reports increasing abdominal pain and increased frequency of loose stools. He asks the nurse to clarify the type of diet he is to follow. Which diet is best for clients with ulcerative colitis? You answered this question Correctly High vitamin High calorie Low sugar Low fiber The nurse is bathing a confused client in the acute care unit. The nurse talks quietly with the client and explains each procedure. In the middle of the bath, the client becomes very agitated, kicking and calling for help. What should the nurse do? You answered this question Correctly Complete the bath as quickly as possible. Reassure the client that everything is okay. Continue bathing with assistance from an unlicensed assistive personnel. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Stop the bath, then dress and reassure the client. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update The nurse is caring for a client admitted to the skilled nursing unit approximately 3 months ago. Since admission, the client has lost 8 pounds. There have been no documented changes in the client’s physical health. Which strategy may help to improve caloric intake for this client? You answered this question Incorrectly Encourage the client to eat meals in the room. Take the client to the dining room for all meals. Provide a high protein supplement 30 minutes before meals. Ask the unlicensed assistive personnel to feed the client at each meal. The nurse is caring for a postoperative client. The client asks the nurse the purpose of anti-embolic stockings. What is the nurse's best response? You answered this question Correctly Promotes return of venous blood to the heart and assists in preventing the blood from clotting in the legs. Since the operating room is very cold, the stockings assist in maintaining a healthy core body temperature during surgery. Promotes joint mobility and strengthens the leg muscles. Promotes the return of arterial blood to the heart and prevents blood from clotting in the legs. The nurse is assisting a new mother with breast feeding. The mother verbalizes concern that the baby is not getting adequate milk. Which observations by the nurse indicate adequate fluid intake? You answered this question Correctly Birth weight regained in 10-days Fontanels soft and depressed Pulse rate of 135/min Six to eight wet diapers every 24 hours Baby appears satisfied after feedings. Which prescriptions would the nurse recognize as being appropriate for the client with shingles? You answered this question Incorrectly Private room Negative-pressure airflow Respirator mask Face shield Positive pressure room Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Continue with the administration of antibiotic and fill out an equipment Hurst questions with 100% verified answers and rationales complete document 989 pages latest update maintenance request. Obtain a replacement pump. Tag the equipment for maintenance. A nurse is at highest risk for blood-borne exposure during which situation? You answered this question Correctly When removing a needle from the syringe. While placing a suture in the mechanical holder. Prior to inserting the intravenous (IV), the client moves causing a needle stick to the nurse. A clean needle sticks the nurse through blood-soiled gloves. A home health nurse is evaluating the home of new parents of an adoptive two year old child. Which observations should the nurse discuss with the parents as potential safety threats? You answered this question Correctly Security gates at the stairs. Cleaning supplies under sink cabinet. No blinds on windows. Use of space heaters. Water heater temperature 140°F (60°C) A nurse works in the operating room (OR) as a circulator. Which actions should the nurse perform to help prevent surgical-site infections? You answered this question Correctly Close the OR doors at all times during a surgical case. Minimize traffic in the OR. Ensure the room has negative flow. Monitor the sterile field at all times. Immediately discard any object that becomes contaminated. A nurse enters a client’s room to find the client on the floor having a seizure. Which nursing action is priority for this client? You answered this question Correctly Hold the client's arms and legs. Insert a padded tongue blade in the client's mouth. Assist the client back into the bed. Place a towel or sheet under the client's head. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update An unresponsive client brought into the emergency department (ED) begins to vomit. What intervention by the nurse would have the highest priority? You answered this question Correctly Suction the client's mouth. Turn the client onto their side. Apply oxygen per face mask. Insert an oropharyngeal airway. A nurse is preparing a lecture about suicide. Which target audience would be most appropriate? You answered this question Incorrectly A group of high school teachers A group of girl scout leaders A support group for divorced parents A group of hispanic immigrant farm workers A nurse is caring for a nonambulatory client who must be decontaminated after a chemical exposure event. What nursing action will best prevent further chemical exposure? You answered this question Correctly Don appropriate personal protective equipment (PPE). Remove only contaminated clothes. Avoid decontaminating the eyes. Use hot water during decontamination. The nurse is caring for a client while fluorouracil is being infused. The client complains of burning at the intravenous (IV) site. What should the nurse do first? You answered this question Incorrectly Apply warm compresses. Slow the infusion. Inspect the IV site. Stop the infusion. Following report, which newborn infant should the nursery nurse assess first? You answered this question Correctly Positive Babinski reflex noted. Has circumoral cyanosis. Negative Ortolani's sign noted. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update mothers who have children between the ages of 18 months to 3 years. What points about the next year should the nurse be sure to provide these mothers? Hurst questions with 100% verified answers and rationales complete document 989 pages latest update You answered this question Correctly Be strict and rigid with toilet training, rather than being accepting and letting the child lead the training. Let the parents know about the importance of letting the child do tasks alone. Provide finger foods for the child to eat. Your child will want you to provide emotional support when needed. Assist your child with all tasks to promote independence. What term should the nurse use to document that a woman is pregnant for the first time? You answered this question Correctly Primigravida Multigravida Primipara Multipara The nurse is assessing a client admitted with acute gastritis. Which client information is most significant? Exhibit You answered this question Incorrectly Takes ibuprofen for arthritis pain. Had an upper respiratory infection two weeks ago. Has a stressful job. Enjoys spicy food. A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration occurs? You answered this question Incorrectly Turn the client to the left side. Administer oxygen. Start an intravenous line. Prep the mother for cesarian section. Notify the primary healthcare provider. While discussing childhood immunizations with a parent, the parent states, "I feel that since the majority of children with whom my child will interact have been vaccinated, there is no need for my child to be immunized." What action should the nurse take? Hurst questions with 100% verified answers and rationales complete document 989 pages latest update You answered this question Correctly File a report with social services and notify the primary healthcare provider. Explain that the organism which causes the disease is still prevalent in the Hurst questions with 100% verified answers and rationales complete document 989 pages latest update "Although it hasn't been easy, I accept the loss of my soul mate." "If only we had spent more time together before the illness got so severe." A five year old is in kindergarten and goes to the nurse’s office where she reports a “stomachache”. While there, the nurse observes that the child has a large bruise on her upper arm and bruises on both ears. What should the nurse do first? You answered this question Correctly Ask the student about the bruises on her arms and ears. Do nothing as bruises are common in 5 year old children. Report the injuries immediately to the parents. Discuss the findings with the child's teacher. A nurse is caring for a client that is undergoing outpatient psychiatric treatment for somatization disorder. Which statement by the client indicates that teaching has been successful? You answered this question Correctly "I will keep a diary of times of stress and the appearance of physical symptoms." "I will simply ignore any physical complaints I get from now on." "The best way for me to stop having physical symptoms is to avoid any stress in my life." "I will take a sedative when I start having physical complaints." Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is in the acute phase of mania? You answered this question Correctly Sit with the client during meals to encourage the client to eat all foods on the tray. Assess the clients food preferences and provide only those foods for the client at meal time. Allow the client to eat in the dining room with other clients. Provide high-protein, high calorie snacks on the nursing unit between meals. The nurse is planning an activity for the client who has a diagnosis of paranoid schizophrenia. Which activity would be most appropriate for the client? You answered this question Correctly A game of scrabble with peers A group game of basketball. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update An individual art project. A card game with the nurse. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update The nurse is caring for a client admitted to the psychiatric unit with a diagnosis of major depression. What behaviors could the nurse expect upon assessment of this client? You answered this question Incorrectly Withdrawn behavior Sitting in room, lights out, drapes closed Unkempt appearance Overeating Severe Insomnia A nursing student asked the charge nurse on the psychiatric unit, "Why did you ask that client to explain the meaning of 'It’s raining cats and dogs?'” What is the charge nurse's best response? You answered this question Incorrectly "I was attempting to get the client to admit to being afraid of cats and dogs." "I am assessing the concreteness of the client's form of thought." "Phrases like this one will help the client improve his abstract thinking ability." "Concrete thinking is a higher form of thinking and means that the client's form of thought is improving." A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority? You answered this question Correctly Could you have overheard the staff talking at the desk? I will get you some medication for anxiety. What did the voice tell you? You do not have to worry about this. You are safe. A float nurse arrives on the unit to assist in the care of clients for a shift. During report, the charge nurse notes that the float nurse appears disheveled, flushed, and is trembling slightly while drinking coffee. Based on this information,what should the unit nurse do? You answered this question Correctly Ask the float nurse, "Have you been drinking?" Assign the float nurse to the least acute clients. Notify the nursing supervisor to report the observations. Notify the state board of nursing that the float nurse is an alcoholic. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update You answered this question Incorrectly The left foot is ashen in color. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Capillary refill is 6 seconds in the left extremity; 3 seconds in right extremity The skin is cooler on the left extremity Blanching disappears quicker on the left side than on the right side The client has decreased sensation on the right side A client’s last two central venous pressure (CVP) readings were 23 cm of water. The nurse would expect the client to manifest which associated signs and symptoms? You answered this question Correctly Dry oral mucus membranes Tachypnea Orthostatic hypotension Rales in the posterior chest Jugular vein distention Weight gain Blood and urine samples are sent to the laboratory for a client who has had a spinal cord injury. After reviewing these results, the nurse would expect which finding? Exhibit You answered this question Correctly Gross hematuria Septicemia Urinary tract infection Anemia Which symptoms should the nurse anticipate when caring for a client with acute cholecystitis? You answered this question Correctly Chills Fever Nausea and vomiting Increased appetite Rigidity of upper right abdomen. The nurse at the wellness clinic is teaching a client newly diagnosed with insulin- dependent diabetes mellitus. The client asks about beginning an exercise program. The nurse bases her response on the fact that exercise has what effect on the body? You answered this question Correctly Lowers the blood glucose Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Provides more energy Hurst questions with 100% verified answers and rationales complete document 989 pages latest update You answered this question Correctly Give the medication as prescribed. Hold the medication and call the primary healthcare provider. Report the behaviors to the on-coming shift. Hold the medication, check vital signs and call the primary healthcare provider. Which signs and symptoms would the nurse expect to see in a client who has taken prednisone for two months? You answered this question Incorrectly Weight loss Decreased wound healing Hypertension Decreased facial hair Moon face The nurse is preparing to administer nadolol to a hospitalized client. Which client data would indicate to the nurse that the medication should be held and the primary healthcare provider notified? You answered this question Correctly Blood pressure 102/68 Glucose 118 UOP 440 mL over previous 8 hour shift. Heart rate 56/min The nurse is caring for a client post heart transplant who is being discharged on cyclosporine and azathioprine. Which precautions would be important for the nurse to teach the client? You answered this question Incorrectly Avoid crowds. Do not obtain vaccinations. Drink at least 3 liters of fluids per day and watch the urine for sediment. Use a soft-bristled brush to clean your teeth and a safety razor to shave. Advise to use contraceptive measures during treatment. The nurse is caring for a client diagnosed with chronic kidney disease, and that has been prescribed epoetin. What should the nurse include in teaching the client the purpose for taking epoetin? You answered this question Correctly Epoetin is used for emergency treatment of anemia. Epoetin will improve quality of life, and well-being. Epoetin is used for the prevention of Pure Red Cell Aplasia (PRCA). Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Epoetin is used to treat anemia and decreases the need for transfusion. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update After the nurse administers eardrops to an adult client, it is important for the nurse to implement which action? You answered this question Correctly Leave the client lying with the unaffected ear facing up. Place a cotton ball firmly into the affected ear for 15 minutes. Pull the pinna of the ear down and back. Gently massage the tragus of the ear. The nurse is caring for a client who has hypercholesterolemia. When evaluating the effects of atorvastatin, the nurse should monitor the results of which laboratory test? You answered this question Incorrectly AST Alkaline phophatase Complete blood count Serum cholesterol levels Serum triglyceride levels The nurse is caring for a diabetic client. The client’s glucose level at 0700 is 265. What is the nurse's best action? You answered this question Correctly Hold the NPH and regular insulin Give 8 units of regular insulin and hold the NPH Give the NPH and 4 units of regular insulin Give 40 units of NPH and hold the regular insulin The nurse is caring for a client with tuberculosis receiving isoniazid therapy. Because of the possible peripheral neuropathy that can occur, which supplementary nutritional agents would the nurse expect to administer? You answered this question Incorrectly Cyanocobalamin Vitamin D Ascorbic acid Pyridoxine The nurse is caring for a client with chronic renal failure who receives dialysis treatment. Which findings would indicate to the nurse that the client's AV shunt is patent? You answered this question Incorrectly A bruit is heard with a stethoscope. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update The nurse is caring for a client admitted with heart failure. Which prescription would necessitate that the nurse seek clarification from the primary healthcare provider? You answered this question Incorrectly Furosemide 20.0 mg p.o. daily Chlordiazepoxide 50 mg p.o. q4h p.r.n. for agitation Diphenhydramine 25 mg p.o. hour of sleep for three nights Folic acid 1 mg daily Heparin 1000 IU subcutaneously daily A client is admitted to the intensive care unit after overdosing on meperidine. What is the nurse's first priority? You answered this question Correctly Maintain continuous cardiac monitoring. Administer naloxone hydrochlride 0.4 mg IV every 2-3 minutes prn. Provide alprazolam 0.25 mg PO PRN. Initiate intravenous fluid resuscitation with lactated ringers at 125 mL/hr. A home health nurse is interpreting Mantoux skin test results of clients who received the test 48 hours ago. Which clients have a positive Tuberculin Skin Test reaction? You answered this question Correctly HIV+ client with an induration of 6 millimeters. Client who immigrated from Haiti 6 months ago who has an induration of 10 millimeters. Client working at a nursing home has an induration of 8 millimeters. 3 year old client with an induration of 12 millimeters. Healthy client with no known TB exposure who has an induration of 5 millimeters. The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed 1000 mL of D5 ½ NS. The IV is infusing at 25 gtts/min. (Drop factor is 60 gtts/mL). What is the infusion time in hours? Round your answer to the nearest whole number. You answered this question Correctly Enter the answer for the question below. 40 Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Rationale: Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Step 1 1000 x 60 = 25 (total fluid x drop factor = infusion time x time in minutes 60,000 = 25 x 25x = 60,000 x = 2400 min. divide by 60 = 40 hours A client diagnosed with hypothyroidism has been taking levothyroxine in increasing doses over the past week. Which findings, if present, would indicate to the nurse that the drug dosage is too high? You answered this question Correctly Angina Anorexia Palpitations Tremors Headache Hypotension Question: The charge nurse observes a staff nurse caring for a new mother with oral herpes simplex type I. Which behavior by the nurse indicates that further instruction on transmission of this disease is needed? You answered this question Incorrectly Instructs the new mother that she should not kiss the newborn. Wears gloves during the perineal and lochia assessment. Washes her hands before and after each client contact. States that the newborn may contract herpes from the birth canal. The nurse cares for a client who is scheduled for an upper GI series. The nurse teaches the client about the test. Which statement by the client indicates an understanding of the nurse's teaching? Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Only victims who enter the emergency department alone should be screened for IPV. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update he nurse is caring for a post op client who is drowsy but arousable. The client will take a few deep breaths when instructed but drifts to sleep when left alone. The O2 saturation while sleeping drops to 82% on 3 liters of nasal oxygen. The client received a dose of oxycodone/acetaminophen 2 tabs one hour ago. What is the nurse’s best action at this time? You answered this question Correctly Keep the O2 sat machine at the bedside and set the alarm to beep loudly when O2 sat drops below 93%. Give bath to arouse client and then report that oxycodone/acetaminophen 2 tabs is too much for next dose. Let the client sleep until he has rested, then discuss abuse potential of narcotics. Call the primary healthcare provider and report client assessment findings. The school nurse suspects a 5 year old has been physically abused. What would be the best way for the nurse to establish trust with this child? You answered this question Correctly Using play therapy. Asking the mother to come to the school. Hugging the child. Conducting an in-depth interview with the child. The nurse is caring for a client with a diagnosis of major depression. The client began taking a selective serotonin reuptake inhibitor (SSRI) three days ago. The client says, “I am just not feeling well. My medicine is not working.” Which reply by the nurse indicates adequate understanding of treatment? You answered this question Correctly "I agree, your medication is not working." "Your treatment may have to be changed." "Most SSRIs take about 5 days to work." "You should reach desired effect in 1-3 weeks." Hurst questions with 100% verified answers and rationales complete document 989 pages latest update A client states, "I really do not want to go through open heart surgery. I have told my children this, but they still want me to go through with the surgery. I don’t know what to do". What is the best response for the nurse as client advocate? Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Perform a rape kit in order to preserve the evidence the nurse is caring for a client with Clostridium Difficile. Which interventions should be included in the plan of care for an adult client with diarrhea? You answered this question Incorrectly Consume four glasses of water per day. Encourage client to eat bananas or clear soups. Encourage client to consume foods containing insoluble fiber. Increase soluble fiber foods in the diet such as potatoes or rice. Inform client to seek medical care if the condition persists. The nurse is caring for four clients. Which client should the nurse see first? You answered this question Incorrectly The client hospitalized with dehydration related to diarrhea. The seizure client who is currently in the postictal phase. The post-op client who received Morphine 4 mg IV 15 minutes ago. The client who is due pre-op medication now. Which ethical principle is involved when a nurse reports a medication error to the primary healthcare provider? You answered this question Correctly Nonmaleficence Beneficence Justice Fidelity A client newly diagnosed with insulin dependent diabetes mellitus is started on insulin aspart protamine suspension/insulin aspart solution mixture. The nurse would teach the client that the insulin should start to lower the blood sugar in how many minutes? Hurst questions with 100% verified answers and rationales complete document 989 pages latest update You answered this question Correctly 1. 15 2. 30 Hurst questions with 100% verified answers and rationales complete document 989 pages latest update 3. 45 4. 60 The nurse is teaching a group of clients about selective serotonin reuptake inhibitors (SSRI). Which comment by a client in the group indicates adequate understanding of the effects/side effects of the medications? You answered this question Incorrectly My weight may have decrease while taking this drug. I may expect increased sweating while taking this drug. I may actually feel more depressed while taking this medication. I should feel better within a couple of days after beginning the med. Which interventions should be included in the plan of care for an adult client with constipation? You answered this question Correctly Allow adequate time for defecation. Provide privacy for bowel elimination. Suggest increasing fluid intake (unless contraindicated). Encourage client to increase fiber in the diet. Encourage the client to delay the urge to defecate until after a meal. The primary healthcare provider prescribes an intravenous infusion of D5 W at 125 mL per hour. The tubing has a drop factor of 20 gtt/mL. How many drops per minute should the nurse administer? Round your answer to the nearest whole number. You answered this question Correctly Enter the answer for the question below. 42 The nurse is caring for a client who receives hemodialysis Hurst questions with 100% verified answers and rationales complete document 989 pages latest update You answered this question Correctly Teaching the client perineal care. Changing a colostomy bag on a client. The nurse is planning health promotion strategies for an older client on a limited, Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Serving the diet tray for a diabetic client. Taking the initial vital signs on a client who is to receive blood. The emergency department called the LDR to give report on a 24 year old primigravida at term, having contractions every 5-8 minutes. The unit is very busy, and all the RNs are with other clients. What action by the charge nurse would be most appropriate? You answered this question Incorrectly Request that the emergency department hold the client until one of the RNs is available to do the initial assessment. Instruct the LPN/VN to obtain initial vital signs and connect the client to a fetal monitor, then report this data to the charge nurse. Assign an LPN/VN to complete the nursing history and an initial obstetric assessment on this client. Inform one of the RNs that a client is coming from the ED and that a nursing history should be completed as soon as possible. A client has been admitted to the psychiatric unit with a diagnosis of schizophrenia. Which client behaviors does the nurse anticipate? You answered this question Incorrectly Slumped posture Waxy flexibility Grandiosity Anxiety Agitated behavior A client diagnosed with bipolar mania was prescribed lithium carbonate 2000 mg daily two months ago. What is the nurse's best action? Exhibi t You answered this question Correctly Record the lab results in the chart and recheck in one month. Inform the primary healthcare provider that the lithium level is too high. Notify the primary healthcare provider because the sodium level is too high. The nurse is planning health promotion strategies for an older client on a limited, Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Let the primary healthcare provider know that the magnesium level is too low. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Where should the nurse dispose of the medication vials? You answered this question Correctly In a puncture-resistant biohazard container In a chemotherapy sharps container In a biohazard waste container In a chemical container Which goal is the most important for the nurse to address for a client admitted to the cardiac rehabilitation unit? You answered this question Correctly Reduction of anxiety Referral to community resources Identification of lifestyle changes Verbalization of energy-conservation techniques The nurse is evaluating care provided by an unlicensed assistive personnel (UAP). Which action should the nurse stop the UAP from performing? You answered this question Correctly Emptying the Jackson-Pratt (JP) drainage of the client post cholecystectomy. Performing passive range of motion (ROM) on the client with right sided paralysis. Placing the traction weights on the bed to transfer the client to x-ray. Discarding the first urine voided by the client starting a 24 hour urine test. A nurse has received the following arterial blood gas results on a client post bowel resection. ABGs are: pH 7.48; PCO2 30; HCO3 24. Which acid- base imbalance is the client experiencing? You answered this question Correctly Metabolic alkalosis Metabolic acidosis Respiratory alkalosis Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Respiratory acidosis What is the most important action for the nurse to take in order to prevent adverse drug reactions/interactions in an elderly client who takes multiple medications? You answered this question Incorrectly Implementing a thorough client assessment. Instructing the client about adverse drugs reactions. Explaining to the client that approximately 12% of hospital admissions of older adults are due to a drug reaction. Teaching the client that the chances of adverse reactions are directly proportional to the number of medications taken. A schizophrenic client tells the nurse, “The President of the United States just told me to leave the hospital immediately because a spy is on the way to tap into the secret information in my brain.” What is the nurse's best response? You answered this question Incorrectly The voice you heard is because of your illness and will go away in time. I know you think the President of the United States is talking to you, but I do not see the President. We are the only ones here. I find it hard to believe that you have talked to the President of the United States. This is not the White House! I think the primary healthcare provider needs to increase your medication dose, since you are still hearing voices. he nurse is caring for an HIV positive client in an outpatient clinic. The nurse teaches the client about their medication therapy and assesses that the client understood the teaching when the client makes which response? You answered this question Correctly "I will only need to take one type of HIV medication at a time." "This medication will cure my HIV." "When my CD-4 count returns to normal, I can resume having unprotected sex." "If I develop signs of an infection, I should call my primary healthcare provider." Hurst questions with 100% verified answers and rationales complete document 989 pages latest update The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the primary healthcare provider? You answered this question Correctly "When I was 8 years old I had chickenpox." "I had rheumatic fever when I was 10 years old." "There is a strong history of gastric cancer in my family." "I have pain in my hip with any movement." The nurse is planning care for a pediatric client reporting acute pain with sickle cell crisis? What should the nurse identify as an appropriate goal for this client? You answered this question Correctly Client will report a pain level of less than 2 on a Faces scale. The nurse will administer prescribed pain meds around the clock. Client will only take breakthrough pain medication. Client will use distraction instead of pain medication. A nurse is teaching a renal transplant client about self care after discharge. As part of the information about transplant rejection, the nurse cautions the client to notify the primary healthcare provider of which occurrence? You answered this question Incorrectly Ecchymosis of incision Tenderness over the kidney Frequent polyuria Subnormal temperature The client has been prepared for surgery. As the nurse is discussing the post-op expectations, the client says to the nurse, "I am not sure what other options are available to me". What should the nurse do? You answered this question Correctly Call the primary healthcare provider and ask that they visit the client Hurst questions with 100% verified answers and rationales complete document 989 pages latest update client is in need of emergent care? You answered this question Correctly A 52 year old who has a partially amputated finger. A 9 month old with temperature of 103°F (39.4°C). A two year old with excessive drooling and a weak cough. A 28 year old experiencing a migraine headache for three days. An elderly client is admitted to the floor with vomiting and diarrhea for three days. She is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action? You answered this question Correctly Intake and output every shift Lung assessments every 2-4 hours Vital signs every shift IV site assessment every 2-4 hours Which assignment would be most appropriate for the charge nurse to assign to the LPN/VN in the Labor, Delivery, Recovery, Postpartum Unit (LDRP)? You answered this question Correctly Primipara needing assistance with breastfeeding. Multipara complaining of a headache and epigastric discomfort. Primipara who is two days post op cesarean section. Primipara who is preeclamptic in active labor. Multipara post op cesarean section with a PCA pump. A client who has been on a psychiatric unit because of several attempted suicides states, “I am happy to be going home today.” What is the nurse's best analysis of this statement? You answered this question Correctly No longer has depression. Has developed appropriate coping mechanisms. May have decided on another suicide plan. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Is happy to go home and see family. The nurse is caring for a client with a perineal burn. The skin is not intact. What signs are suggestive of infection? You answered this question Incorrectly Color Changes Drainage Odor Fever Bleeding Increased Pain The nurse is caring for a client with hypothyroidism. Which dietary consideration is most important for the nurse to teach this client? You answered this question Incorrectly Increase carbohydrate intake. Increase fluid intake. Avoid shellfish. Increase fiber. A nursing student observes a psychiatric client sitting alone. The client is talking, but occasionally stops and leans to the side as if listening to someone. The client then laughs. What is this client most likely experiencing? You answered this question Correctly Auditory hallucinations Delusions Catatonic excitement Anergia Which client must the nurse assign to a private room? You answered this question Incorrectly Primiparous client who delivered twins at 28 weeks gestation two days ago Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Postpartum client on IV Ampicillin and Gentamicin for chorioamnionitis Postpartum client whose 2 hour old infant is being worked up for sepsis Postpartum client 32 hours after delivery with a temperature of 101º F (3 Labetalol has been prescribed for a client in the emergency room. Prior to administering this medication, what assessment should the nurse perform? You answered this question Correctly Listen to the client's breath sounds. Check the client's temperature. Monitor for peripheral edema. Auscultate the apical pulse rate. Post thyroidectomy, the nurse assesses for complications by performing which assessment? You answered this question Correctly Perform accucheck every 6 hours Check for a positive Chvostek's Assess swallowing reflex Monitor neck dressings for change in fit and comfort Administer DDAVP per nasal spray for UOP greater than 200 mL/hour A client is returned to the surgical unit following gastric/esophageal repair of a hiatal hernia, with an IV, NG tube to suction, and an abdominal incision. To prevent disruption of the esophageal suture line, what is most important for the nurse to do? You answered this question Correctly Assess the wounds for drainage. Give ice chips sparingly. Maintain the patency of the NG tube. Monitor for the return of peristalsis. What information would be included when a disaster relief nurse counsels parents of young clients who have experienced a disaster? Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Treat a mild episode with 10-15 grams of carbohydrate. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update The client should consume 12 ounces of regular cola. The client should consume 2 cups of orange juice without added sugar. The nurse is teaching a client regarding herbal therapy. What is the main goal of herbal therapy? You answered this question Incorrectly To treat a specific disease or symptom by taking prescription medications. To restore balance within the body by supporting the client's self-healing ability. To avoid the use of toxic chemicals within the body. To incorporate Eastern healing practices into Western medicine. The nurse working in a pediatrician's office is teaching an adult couple with small children about proper medication administration for children. What statement by the couple would indicate that further teaching is needed? You answered this question Correctly We should carefully measure elixir medication with the provided dropper. Our children should not watch us take medicine. We tell our children the medicine is candy so they will take it without a fuss. Even though medicine comes in a childproof container, we will put medication out of reach. A client is admitted to the pediatric unit with a diagnosis to rule out tuberculosis (TB). What room assignment by the charge nurse would be best? You answered this question Correctly Private room only. Private room and place on protective isolation. Room with a client with a respiratory infection. Room with a client who is 24 hours post operative. The primary healthcare provider prescribes a combination of pyrazinamide and isoniazid to treat a client with tuberculosis. The Hurst questions with 100% verified answers and rationales complete document 989 pages latest update client asks the nurse, "Why am I taking two drugs?" Which explanation should the nurse give the client? Hurst questions with 100% verified answers and rationales complete document 989 pages latest update The client at the mental health center has voiced suicidal thoughts and has access to firearms at home. Which action by the nurse is priority? You answered this question Correctly Empathize with the client and listen to feelings. Inform the family and ask them to remove the guns. Chart the thinking pattern and make a follow up appointment. Ask the client to return to the clinic tomorrow for further evaluation. While preparing a fact sheet for a client diagnosed with a vancomycin-resistant enterococcus (VRE) urinary tract infection (UTI), the home health nurse should include which instructions? You answered this question Incorrectly Wash hands with hot water and soap when hands are soiled. Clean the bathroom and kitchen with soap and water. Gloves are not needed in the home since contamination with VRE has already occurred. Wash hands after using the bathroom and before preparing food. Clean the bathroom and kitchen with warm water and bleach. The nurse is administering medication to an elderly client who has no visitors. The client takes the pills and as the client hands the medication cup back to the nurse, grabs onto the nurse's hand tightly. What is the most logical rationale for the client's action? You answered this question Correctly Confusion and disorientation. Scared and lonely and grabs the nurse’s hand for comfort. Would like to talk with the nurse. Would like to reminisce with the nurse. A client is transported via ambulance to the Emergency Department with severe, crushing chest pain radiating up the left jaw. The client is diaphoretic with a blood pressure of 136/88, HR 102, R 24, T98.6ºF (37.0ºC). The primary healthcare provider prescribes Oxygen at 2 liters/nasal cannula, morphine 2 mg IVP, acetylsalicylic acid 81 mg, and nitroglycerin 0.4 mg SL. What instruction should the nurse give the client when administering the aspirin? Hurst questions with 100% verified answers and rationales complete document 989 pages latest update You answered this question Correctly Chew the aspirin prior to swallowing. Place the aspirin under the tongue so that it can dissolve. Swallow the aspirin tablet. Insert the aspirin between the cheek and gum for greater absorption. The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment goals have not been met? You answered this question Correctly Diuresis Dyspnea on exertion Persistent cough Warm, dry skin Heart rate irregular at 118/min Alert and oriented Which findings would indicate to the nurse that a client with Addison's disease has received too much glucocorticoid replacement? You answered this question Incorrectly Dry skin and hair Hypotension Rapid weight gain Decreased blood glucose level Increased cholesterol The nurse has been caring for a client in the home who is experiencing new onset of constipation. Which goal is most appropriate for a client reporting constipation? You answered this question Correctly Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Client will have one bowel movement each day. Client will no longer experience constipation. Client will return to his normal bowel elimination habits. Client will have more frequent bowel movements. The staff nurse is caring for a 3-month old client receiving potassium IV therapy. Which actions indicate to the charge nurse that the staff nurse understands IV management? You answered this question Incorrectly Uses a 15 gtt factor drip chamber when changing the IV tubing. Applies elbow restraints to prevent dislodgement of the IV catheter. Checks the IV site for blood return hourly. Instructs unlicensed assistive personnel (UAP) to count drip rate hourly. Attaches a volume-controlled IV administration set to IV bag prior to beginning IV therapy. A client received a severe burn to the right hand. When dressing the wound, it is important for the nurse to do what? You answered this question Correctly Apply a wet to dry dressing for debridement. Wrap each digit individually to prevent webbing. Open blisters to allow drainage prior to dressing. Allow the client to do as much of the dressing change as possible. A nurse notes that a client with end-stage chronic renal failure has dry, itchy skin, white crystals on the skin and uremic halitosis. Which nursing intervention would be appropriate for this client? You answered this question Incorrectly Encourage use of cotton gloves during sleep Apply emollients to the skin Bathe in tepid water Cut fingernails short Provide mouth care prior to meals Hurst questions with 100% verified answers and rationales complete document 989 pages latest update Administer the ibuprofen at 45 mg by mouth every 6 hours. Contact the nursing supervisor regarding the prescription. Ask the pharmacist to calculate the appropriate dose. Notify the primary healthcare provider. An intubated client admitted to the intensive care unit appears anxious and fearful of the equipment in the room. The nurse observes this and takes the time to explain each piece of equipment and its role in providing care to the client. How does this action demonstrate client advocacy? You answered this question Correctly Providing information to the client and fostering a sense of security. Promoting client compliance. Assuring client safety. Ensuring the client's wishes for treatment are followed. A client will be undergoing a thoracentesis for a large right pleural effusion. The nurse knows that further teaching is necessary when the client makes which statement? You answered this question Correctly "It is important that I do not cough during the procedure." "This procedure will require me to be placed on a ventilator." "I will be in a sitting position leaning forward." "The primary healthcare provider knows from the x-ray where the fluid is" The lactation consultant is preparing to make rounds on the breastfeeding clients on the LDRP. Which client should the consultant see first? You answered this question Incorrectly The mother who is nursing her newborn every 2-3 hours for 15-20 minutes at a time. The mother who stated that her newborn sucks in short bursts and has audible swallowing. The mother who reported blisters on her nipples and pain whenever the newborn latches on. The mother who stated that her baby was so good that she has to wake him for each feeding. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update A client has a prescription for digoxin 0.125 mg IV push every morning. Prior to administering digoxin, the nurse notes that the digoxin level drawn this morning was 0.9 ng/mL. Which action would it be most important for the nurse to take? You answered this question Incorrectly Administer the digoxin. Hold the digoxin. Notify the primary healthcare provider. Repeat the digoxin level. Which risk factor is it most important for the nurse to instruct the about breast cancer? You answered this question Correctly Menopause before the age of 50 Drinking one glass of wine daily Multiparity Early menarche The nurse is caring for a client in the emergency department. The primary healthcare provider prescribed penicillin 100,000 units IM. The drug label reads penicillin 300,000 units/mL. The nurse would administer how many mL of this medication? Round your answer using two decimal points. You answered this question Correctly Enter the answer for the question below. 0.33 As a treatment for impotency, a client is being taught to self- administer papaverine injections into the penis. Which statement indicates to the nurse that the client understands a serious adverse reaction associated with this injection? You answered this question Correctly "I should have a full erection within 15 minutes after I inject the medication." "I can expect the injection site to be tender after the medication is Hurst questions with 100% verified answers and rationales complete document 989 pages latest update injected." "After injecting the medication into the penis several times, a plaque area may Hurst questions with 100% verified answers and rationales complete document 989 pages latest update You answered this question Incorrectly Apneustic Ataxic Cheyne-Stokes Cluster The nurse is caring for a client that was admitted to the hospital 48 hours ago for complications resulting from an automobile accident. The nurse observes an increase in vital signs, increased sweating, and tremors of the extremities. The client further reports feeling extremely anxious. The client’s physical condition does not seem to be consistent with the symptoms noted. Which item in the admission assessment may be crucial, given the symptoms noted? You answered this question Correctly Routinely takes vitamin supplements at home. Drinks several alcohol beverages daily. Has a history of myocardial infarction. Has been diagnosed with renal failure. The nurse is having an education class for pregnant women. A question is raised about exercise. What is the nurse’s best response? You answered this question Correctly Discuss with healthcare provider your current exercise regimen and history. You can continue any exercise that you have been doing before pregnancy. If you haven't already started an exercise program, you should wait until after delivery. Exercise is required during pregnancy for a minimum of 30 minutes each day. The nurse is assigned a group of clients. For which client would the use of acetaminophen pose a higher risk? You answered this question Incorrectly 42 year old female who abuses cocaine. 54 year old male who abuses alcohol. 23 year old female who has asthma. 34 year old male with sickle cell anemia. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update What is the nurse's priority when preparing a client for a paracentesis? 2. Provide distraction by asking the client to sing with the nurse. Chills Fever Nausea and vomiting 5. Rigidity of upper right abdomen. Hurst questions with 100% verified answers and rationales complete document 989 pages latest update You answered this question Correctly Place client in the prone position. Position the client flat with right arm behind the head. Ask the client to empty bladder. Obtain client's vital signs immediately prior to the procedure. In the event of a medication incident, which situations should the nurse notify the primary healthcare provider? You answered this question Incorrectly All of the time. Client is harmed or dies. Medication incident is a near miss. Nurse administers an incorrect dosage. Client questions the medication color. The nurse is providing care to a 5 year-old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? You answered this question Correctly 1. Encourage the client to talk about the pain. 3. Suggest that the client try to relax. 4. Encourage the client to control the pain. Which symptoms should the nurse anticipate when caring for a client with acute cholecystitis? You answered this question Correctly 4. Increased appetite