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HESI 266 COMPREHENSIVE EXAM REVIEW QUESTIONS
AND ANSWERS WITH RATIONALE RATED 100%.
A client with acute osteomyelitis has undergone surgical debridement of the diseased bone and asks the nurse how long will antibiotics have to be administered. Which information should the nurse communicate? A. Oral antibiotics for 2 to 4 months, then for dental procedure prophylaxis. B. Parenteral antibiotics for 4 to 6 weeks, then oral antibiotics for up to 1 year. C. Parenteral antibiotics for 4 to 8 weeks, then oral antibiotics for 4 to 8 weeks. Parenteral antibiotics for 2 to 3 weeks, then oral antibiotics for 4 weeks - Answers-C Treatment of acute osteomyelitis requires the administration of high doses of parenteral antibiotics for 4 to 8 weeks, followed by oral antibiotics for another 4 to 8 weeks In planning care for a client with an acute stroke resulting in right-sided hemiplegia, which positioning should the nurse should use to maintain optimal functioning? A. Mid-Fowlers with knees supported. B. Supine with trochanter rolls to the hips. C. Sim's position alternated with right lateral position q2 hours. Left lateral, supine, brief periods on the right side, and prone - Answers-D Rationale After an acute stroke, a positioning and turning schedule that minimizes lying on the affected side, which can impair circulation and cause pain, and includes the prone position to help prevent flexion contractures of the hips, prepares the client for optimal functioning and ambulation. Which preexisting diagnosis places a client at the greatest risk of developing superior vena cava syndrome? A. Carotid stenosis. B. Steatosis hepatitis. C. Metastatic cancer. D. Clavicular fracture. - Answers-C Rationale Superior vena cava syndrome occurs when the superior vena cava (SVC) is compressed by outside structures, such as a growing tumor that impedes the return blood flow to the heart. Superior vena cava syndrome is likely to occur with metastatic cancer from a primary tumor in the upper lobe of the right lung that compresses the superior vena cava. The nurse is giving discharge instructions to a client with chronic prostatitis. What instruction should the nurse provide the client to reduce the risk of spreading the infection to other areas of the client's urinary tract? A. Wear a condom when having sexual intercourse. B. Avoid consuming alcohol and caffeinated beverages. C. Empty the bladder completely with each voiding. D. Have intercourse or masturbate at least twice a week. - Answers-D
Rationale The prostate is not easily penetrated by antibiotics and can serve as a reservoir for microorganisms, which can infect other areas of the genitourinary tract. Draining the prostate regularly through intercourse or masturbation decreases the number of microorganisms present and reduces the risk for further infection from stored contaminated seminal fluids During the initial outbreak of genital herpes simplex for a female client, what should be the nurse's primary focus in planning care? A. Promotion of comfort. B. Prevention of pregnancy. C. Instruction in condom use. Information about transmission - Answers-A Rationale The initial outbreak of genital herpes simplex in a woman causes severe discomfort. Promotion of comfort is the first priority A client who has a chronic cough with blood-tinged sputum returns to the unit after a bronchoscopy. What nursing interventions should be implemented in the immediate post-procedural period? A. Keep the client on bed rest for eight hours. B. Check vital signs every 15 minutes for two hours. C. Allow the client nothing by mouth until the gag reflex returns. D. Encourage fluid intake to promote elimination of the contrast media. - Answers-C Rationale The nasal pharynx and oral pharynx are anesthetized with local anesthetic spray prior to bronchoscopy, and the bronchoscope is coated with lidocaine (Xylocaine) gel to inhibit the gag reflex and prevent laryngeal spasm during insertion. The client should be NPO until the client's gag reflex returns to prevent aspiration from any oral intake or secretions. The nurse is assessing a client admitted from the emergency room with gastrointestinal bleeding related to peptic ulcer disease (PUD). Which physiological factors can produce ulceration? (Select all that apply.) Select all that apply A. Vagal stimulation. B. An increased level of stress. C. Decreased duodenal inhibition. D. Hypersecretion of hydrochloric acid. An increased number of parietal cells - Answers-D,E Rationale Hypersecretion of gastric juices and an increased number of parietal cells that stimulate secretion are most often the causes of ulceration. Vagal stimulation and decreased duodenal inhibition also increase the secretion of caustic fluids.
Three weeks after discharge for an acute myocardial infarction (MI), a client returns to the cardiac center for follow-up. When the nurse asks about sleep patterns, the client tells the nurse that he sleeps fine but that his wife moved into the spare bedroom to sleep when he returned home. He states, "I guess we will never have sex again after this." Which response is best for the nurse to provide? A. Sexual intercourse can be strenuous on your heart, but closeness and intimacy, such as holding and cuddling, can be maintained with your wife. B. Sexual activity can be resumed whenever you and your wife feel like it because the sexual response is more emotional rather than physical. C. You should discuss your questions about your sexual activity with your healthcare provider because sexual activity may be limited by your heart damage. D. Sexual activity is similar in cardiac workload and energy expenditure as climbing - Answers-D Rationale Sexual intercourse after an MI, or acute coronary syndrome, has been found to require no more energy expenditure or cardiac stress than walking briskly up two flights of stairs, so if you do not experience shortness of breath or chest discomfort doing the stairs then you should be okay to resume sexual activity The nurse is caring for a client scheduled to undergo insertion of a percutaneous endoscopic gastrostomy (PEG) tube. The client asks the nurse to explain how a PEG tube differs from a gastrostomy tube (GT). Which explanation best describes how they are different? A. Method of insertion. B. Location of the tubes. C. Diameter of the tubes. D. Procedure for feedings. - Answers-A Rationale The best explanation of how a PEG tube differs from a GT is by the method of insertion. GT insertion involves making an incision in the wall of the abdomen and suturing the tube to the gastric wall. A PEG tube is more commonly used due to the fact it does not require general anesthesia and less invasive due to being inserted with endoscopic visualization through the esophagus into the stomach and then pulled through a small incision in the abdominal wall and held in place by a tiny plastic device called a "bumper" that holds the g-tube in place inside the stomach and a small water-filled balloon which keeps the stomach in place against the abdominal wall A client with a recent history of blood in his stools is scheduled for a proctosigmoidoscopy. The nurse should implement which protocols to prepare the client for this procedure? (Select all that apply.) Select all that apply A. Obtain consent for the procedure. B. Initiate preoperative sedation. C. Begin fast the morning of the procedure. D. Administer an enema before the procedure. E. Provide a clear-liquid diet 48 hours before the procedure - Answers-D,E
Rationale The usual preoperative preparation for proctosigmoidoscopy entails obtaining the client's consent to the procedure, a clear-liquid diet for 24 to 48 hours prior to the procedure, administration of an enema, and fasting on the morning of the procedure. A female client with type 2 diabetes mellitus reports dysuria. Which assessment finding is most important for the nurse to report to the healthcare provider? A. Suprapublic pain and distention. B. Bounding pulse at 100 beats/minute. C. Fingerstick glucose of 300 mg/dl. D. Small vesicular perineal lesions. - Answers-C Rationale Elevated fingerstick glucose levels need to be reported to the healthcare provider, so a plan of care can be adjusted to treat the elevated glucose level. Also, elevated glucose levels spill into the urine and provide a medium for bacterial growth When planning care for a client with right renal calculi, which nursing diagnosis has the highest priority? A. Acute pain related to movement of the stone. B. Impaired urinary elimination related to obstructed flow of urine. C. Risk for infection related to urinary stasis. D. Deficient knowledge related to need for prevention of recurrence of calculi. - Answers-A Rationale The nursing diagnosis of the highest priority is "Acute pain related the the renal calculi's movement". A client asks the nurse about the purpose of beginning chemotherapy (CT) because the tumor is still very small. Which information supports the explanation that the nurse should provide? A. Side effects are less likely if therapy is started early. B. Collateral circulation increases as the tumor grows. C. The sensitivity of cancer cells to CT is based on cell cycle rate. D. The cell count of the tumor reduces by half with each dose - Answers-D Rationale Initiating chemotherapy while the tumor is small provides a better chance of eradicating all cancer cells because 50% of cancer cells or tumor cells are killed with each dose. The nurse is caring for a client with end stage liver disease who is being assessed for the presence of asterixis. To assess the client for asterixis, what position should the nurse ask the client to demonstrate? A. Extend the left arm laterally with the left palm upward. B. Extend the arm, dorsiflex the wrist, and extend the fingers. C. Extend the arms and hold this position for 30 seconds. D. Extend arms with both legs adducted to shoulder width. - Answers-B Rationale
C. Wedding band. D. Left leg brace. E. Contact lenses. F. Partial dentures. - Answers-AB,E,F Rationale The removal of nail polish provides a more accurate pulse oximetry readings and evaluation of capillary refill. Hearing aids, contact lenses, and partial dentures are removed to prevent damage, loss or misplacement, or injury during surgery. Ideally, give the client's significant other the contact lenses if they are not the disposable ones, hearing aids and partial dentures once placed in an appropriate labeled container to hold for safe keeping. If no significant other is not able to hold onto the items, then secured them in an appropriate and safe place What instruction should the nurse include in the discharge teaching for a client who needs to perform self-catheterization technique at home? A. Catheterize every 3 to 4 hours. B. Maintain sterile technique. C. Use the Cred maneuver before catheterization. D. Drink 500 ml of fluid within 2 hours of catheterization. - Answers-A Rationale The average interval between catheterizations for adults is every 3 to 4 hours. Although sterile technique is indicated in healthcare facilities, clean technique is often followed by the client when performing self-catheterization at home The nurse assesses a long-term resident of a nursing home and finds the client has a fungal infection (candidiasis) beneath both breasts. To prevent nosocomial infection, which protocol should the nurse review with the rest of the staff? A. Follow contact isolation procedures. B. Wash hands after caring for the client. C. Wear gloves when providing personal care. D. Restrict pregnant staff or visitors into the room. - Answers-B Rationale The organism Candida albicans, which causes this infection, is part of the normal flora on the skin of most adults. Good handwashing is all that is needed to prevent nosocomial spread. What assessment finding should the nurse identify that indicates a client with an acute asthma exacerbation is beginning to improve after treatment? A. Wheezing becomes louder. B. Cough remains unproductive. C. Vesicular breath sounds decrease. D. Bronchodilators stimulate coughing. - Answers-A Rationale In an acute asthma attack, air flow may be so significantly restricted that breath sounds and wheezing is diminished. If the client is successfully responding to bronchodilators and respiratory treatments, wheezing should become louder as the air flow increases in
the airways. As the airways open and mucous is mobilized in response to treatment, the cough should become more productive When caring for a client with a percutaneous endoscopic gastrostomy (PEG) tube, what protocols should the nurse implement for intermittent feedings? (Select all that apply.) Select all that apply A. Assessing residual amounts once a day. B. Keeping the head of the bed elevated 30 degrees. C. Changing the enteral-feeding bag every 24 hours. D. Checking the placement of the tube by means of gastric aspiration. E. Flushing the tube with 50 ml of normal saline solution after each feeding. - Answers- B, C, D, E Rationale Keeping the head of the bed elevated 30 degrees, changing the enteral-feeding bag every 24 hours, checking the placement of the tube by means of gastric aspiration, and flushing the tube with 50 ml of normal saline solution after each feeding are interventions used to provide care of the client with a PEG tube. Residual amounts should be assessed each time, prior to each feeding The home health nurse is assessing a client with terminal lung cancer who is receiving hospice care. Which activity should be assigned to the hospice practical nurse (PN)? A. Administer medications for pain relief, shortness of breath, and nausea. B. Clarify family members' feelings about the meaning of client behaviors and symptoms. C. Develop a plan of care after assessing the needs of the client and family. Teach the family to recognize restlessness and grimacing as signs of client discomfort. - Answers-A Rationale Hospice care provides symptom management and pain control during the dying process and enhances the quality of life for a client who is terminally ill. Administering medication and monitoring for therapeutic and adverse effects is within the scope of practice for the PN. A man who smokes two packs of cigarettes a day wants to know if smoking is contributing to the difficulty that he and his wife are having getting pregnant. What information is best for the nurse to provide? (Select all that apply.) Select all that apply A. Only marijuana cigarettes affect sperm count. B. Smoking can decrease the quantity and quality of sperm. C. The first semen analysis should be repeated to confirm sperm counts. D. Cessation of smoking improves general health and fertility. E. Sperm specimens should be collected in 2 subsequent days. - Answers-B, D Rationale The use of tobacco, alcohol, and marijuana may affect a man's sperm counts.
OTC allergy medications may contain ephedrine, phenylephrine, or pseudoephedrine, which can cause adrenergic side effects, such as increased intraocular pressure, so a client with glaucoma should avoid using these OTC medications. A female client with hyperesthesia on the oncology unit is using a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain. Which nursing activity should the nurse implement instead of delegating to a practical nurse (PN)? A. Determine the client's level of discomfort using a pain rating scale. B. Ask the client about her past experience with chronic pain. C. Observe the client's facial expressions for pain and discomfort. D. Evaluate the client's ability to adjust the voltage to control pain. - Answers-D Rationale The oncology nurse has the knowledge and experience with the use of a transcutaneous electrical nerve stimulation (TENS) unit for chronic pain relief, so the nurse should evaluate the client's skill in effectively controlling the pain by adjusting the voltage. A client is admitted to the hospital with a traumatic brain injury after his head violently struck a brick wall during a gang fight. Which finding is most important for the nurse to assess further? A. A scalp laceration oozing blood. B. Serosanguineous nasal drainage. C. Headache rated "10" on a 0-10 scale. D. Dizziness, nausea and transient confusion - Answers-B Rationale Any nasal discharge following a head injury should be evaluated to determine the presence of cerebral spinal fluid which would indicate a tear in the dura making the client susceptible to meningitis. A young adult female reports that she is experiencing a lack of appetite, hypersomnia, stress incontinence, and heart palpitations. Which symptom is characteristic of premenstrual syndrome? A. Heart palpitations. B. Anorexia. C. Hypersomnia. D. Stress incontinence. - Answers-A Rationale Characteristic features of premenstrual syndrome include heart palpitations, sleeplessness, increased appetite and food cravings, and oliguria or enuresis. The PET (positron emission tomography) scan is commonly used with oncology clients to provide for which diagnostic information? A. A description of inflammation, infection, and tumors. B. Continuous visualization of intracranial neoplasms. C. Imaging of tumors without exposure to radiation. D. An image that describes metastatic sites of cancer - Answers-D
Rationale PET scans provide information regarding certain diseases of the heart (determination of tissue viability), brain (dementia, Parkinson's disease), and early detection of tumors and their metastasis A client is admitted to the emergency department after being lost for four days while hiking in a national forest. Upon review of the laboratory results, the nurse determines the client's serum level for thyroid-stimulating hormone (TSH) is elevated. Which additional assessment should the nurse make? A. Body mass index. B. Skin elasticity and turgor. C. Thought processes and speech. D. Exposure to cold environmental temperatures - Answers-Rationale TSH influences the amount of thyroxine secretion which increases the rate of metabolism to maintain body temperature near normal. Prolonged exposure to cold environmental temperatures stimulates the hypothalamus to secrete thyrotropin- releasing hormone, which increases anterior pituitary serum release of TSH. A nurse is preparing to insert an IV catheter after applying an eutectic mixture of lidocaine and prilocaine (EMLA), a topical anesthetic cream. What action should the nurse take to maximize its therapeutic effect? A. Rub a liberal amount of cream into the skin thoroughly. B. Cover the skin with a gauze dressing after applying the cream. C. Leave the cream on the skin for 1 to 2 hours before the procedure. D. Use the smallest amount of cream necessary to numb the skin surface - Answers-C Rationale Topical anesthetic creams, such as EMLA, should be applied to the puncture site at least 60 minutes to 2 hours before the insertion of an IV catheter. What is the priority nursing action while caring for a client on a ventilator when an electrical fire occurs in the intensive care unit? A. Tell another staff member to bring extinguishing equipment to the bedside. B. Close the doors to the client's area when attempting to extinguish the fire. C. Use a bag-valve-mask resuscitator while removing the client from the area. D. Implement an emergency protocol to remove the client from the ventilator. - Answers-C Rationale A client on a ventilator should have respirations maintained with a manual bag-valve- mask resuscitator while being moved away from the oxygen wall outlet and fire source The nurse is teaching a client about precautions for a new prescription for lovastatin (Mevacor). Which symptom should the nurse instruct the client to report to the healthcare provider immediately? A. Terrible nightmares. B. Increased nocturia. C. Severe muscle pain.
The RN case manager is the best-qualified nurse to assess and provide discharge educational needs, obtain resources for the client, enhance coordination of care, and prevent fragmentation of care. A client who returns to the unit after having a percutaneous transluminal coronary angioplasty (PTCA) complains of acute chest pain. What action should the nurse implement next? A. Inform the healthcare provider. B. Obtain a 12-lead electrocardiogram. C. Give a sublingual nitroglycerin tablet. D. Administer prescribed analgesic. - Answers-C Rationale After a percutaneous transluminal coronary angioplasty (PTCA), a client who experiences acute chest pain may be experiencing cardiac ischemia related to restenosis, stent thrombosis, or acute coronary syndrome involving any coronary artery. The first action is to administer nitroglycerin to dilate the coronary arteries and increase myocardial oxygenation. A college student who is diagnosed with a vaginal infection and vulva irritation describes the vaginal discharge as having a "cottage-cheese" appearance. Which prescription should the nurse implement first? A. Cleanse perineum with warm soapy water 3 times per day. B. Instill the first dose of nystatin (Mycostatin) vaginally per applicator. C. Perform glucose measurement using a capillary blood sample. D. Obtain a blood specimen for sexually transmitted diseases (STDs). - Answers-B Rationale Candidiasis, also known as a yeast infection, is characterized by a white, vaginal discharge with a "cottage-cheese" appearance and vaginal nystatin (Mycostatin) should be implemented first to initiate treatment to provide relief of symptoms. The nurse is planning preoperative teaching for a client who will undergo a radical neck dissection and total laryngectomy. Which information has the greatest priority for this client? A. Prognosis after treatment is excellent. B. Techniques for esophageal speech are relatively easy to learn with practice. C. The stoma should never be covered after this type of surgery. D. There is a radical change in appearance as a result of this surgery. - Answers-D A client receiving the sixth unit of packed red blood cell transfusion is demonstrating signs and symptoms of a febrile, nonhemolytic reaction. What assessment finding is most important for the nurse to identify? A. Increased anxiety since the transfusion began. B. Drowsiness after receiving diphenhydramine (Benadryl). C. Complaints of feeling cold. D. Flushed skin and headache - Answers-D Rationale
The most common type of reaction is a febrile, nonhemolytic blood transfusion reaction related to leukocyte incompatibility, which causes chills, fever, headache, and flushing. Which method elicits the most accurate information during a physical assessment of an older client? A. Ask the client to recount one's health history. B. Obtain the client's information from a caregiver. C. Review the past medical record for medications. D. Use reliable assessment tools for older adults - Answers-D Rationale Specific assessment tools designed for an older adult, such as Older Adult Resource Services Center Instrument (OARS), mini-mental assessment, fall risk, depression (Geriatric Depression Scale), or skin breakdown risk (Braden Scale), consider age- related physiologic and psychosocial changes related to aging and provide the most accurate and complete information. Which sexually transmitted infection (STI) should the nurse include in a client's teaching plan about the risk for cervical cancer? A. Neisseria gonorrhoea. B. Chlamydia trachomatis. C. Herpes simplex virus. D. Human papillomavirus. - Answers-D Rationale According to the CDC (2017), it is estimated at least 80% of all women who are sexually active will contract the Human papillomavirus (HPV) in their lifetime. Certain types of HPV have been suspected to cause cervical cancer and HPV strain 16 and 18 have been identified to cause 70% of cervical cancers A client with a history of hypertension, myocardial infarction, and heart failure is admitted to the surgical intensive care unit after coronary artery bypass surgery graft (CABG). The nurse determines the client's serum potassium level is 4.5 mEq/L. What action should the nurse implement? A. Notify the healthcare provider. B. Decrease the IV solution flow rate. C. Document the finding as the only action. D. Administer potassium replacement as prescribed. - Answers-C Rationale Coronary artery bypass surgery graft (CABG) places a client at risk for hypokalemia from hemodilution, nasogastric suction, or diuretic therapy, so the serum potassium level is maintained between 4 and 5 mEq/L to avoid dysrhythmias. Documentation of the normal finding is indicated at this time. An older female client is admitted with atrophic vaginitis and perineal cutaneous candidiasis. What is the priority nursing diagnosis for this client? A. Risk for injury. B. Impaired comfort.
B. Ectopic stimulus in the atria is suppressed by the device usurping depolarization. C. An impulse is fired every second to maintain a heart rate of 60 beats per minute. D. An electrical stimulus is discharged when no ventricular response is sensed - Answers-D Rationale The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased, such as a symptomatic dysrhythmias like atrial fibrillation with a slow ventricular response. Pacing modes that are synchronous (impulse generated on demand or as needed according to the patient's intrinsic rhythm) send an electrical signal from the pacemaker to the wall of the myocardium stimulating it to contract when no ventricular depolarization is sensed Which client is at highest risk for compromised psychological adjustment after a hysterectomy? A. A 46-year-old woman with three children and a recent promotion at work. B. A 55-year-old woman with abnormal bleeding and pain for 3 years. C. A 62-year-old widow who has three friends who had uncomplicated hysterectomies. D. A 29-year-old woman whose uterus ruptured after giving birth to her first child. - Answers-D Rationale The client who is a primipara and is still in her childbearing years and is at highest risk for unresolved conflicts about the end of her childbearing opportunities. A client in the preoperative holding area receives a prescription for midazolam (Versed) IV. The nurse determines that the surgical consent form needs to be signed by the client. Which action should the nurse implement? A. Give the drug and allow the client to read and sign the consent form. B. Counter-sign the client's initials on the consent form after giving the drug. C. Withhold the drug until the client validates understanding of the surgical procedure and signs the consent form. D. Call the healthcare provider to explain the surgical procedure before the client signs the consent. - Answers-C Rationale Midazolam, a benzodiazepine sedative, is commonly used for conscious-sedation intraoperatively and interferes with the client's cognition and level of consciousness, so the consent form should be signed before the drug is administered. A client who is admitted to the coronary care unit with a myocardial infarction (MI) begins to develop increased pulmonary congestion, an increase in heart rate from 80 to 102 beats per minute, and cold, clammy skin. What action should the nurse implement? A. Notify the healthcare provider. B. Increase the IV flow rate. C. Place the client in the supine position. D. Prepare the client for an emergency echocardiography - Answers-A Rationale
Increased pulmonary congestion, increased heart rate, and cold, clammy skin in a client with a myocardial infarction indicate impending cardiogenic shock related to heart failure, a common complication of MI. The healthcare provider should be notified immediately for emergency interventions of this life-threatening complication The nurse is caring for a client who returns to the unit following a colonoscopy. Which finding should the nurse report to the healthcare provider immediately? A. Large amounts of expelled flatus with mucus. B. Tympanic abdomen and hyperactive bowel sounds. C. Increased abdominal pain with rebound tenderness. D. Complaint of feeling weak with watery diarrheal stools - Answers-C Rationale Positive rebound tenderness following a colonoscopy may be an indication of a perforation and the development of peritonitis and requires follow-up immediately. Which finding should the nurse identify as an indication of carbon monoxide poisoning in a client who experienced a burn injury during a house fire? A. Pulse oximetry reading of 80%. B. Expiratory stridor and nasal flaring. C. Cherry red color to the mucous membranes. D. Presence of carbonaceous particles in sputum. - Answers-C Rationale The saturation of hemoglobin molecules with carbon monoxide molecules, instead of oxygen molecules and the subsequent vasodilation induced cherry red color of the mucous membranes is an indication of carbon monoxide poisoning. The nurse is caring for a male client who had an inguinal herniorrhaphy 3 hours ago. The nurse determines the client's lower abdomen is distended and assesses dullness to percussion. What is the priority nursing action? A. Assessment of the client's vital signs. B. Document the finding as the only action. C. Determine the time the client last voided. D. Insert a rectal tube for the passage of flatus. - Answers-C Rationale Swelling at the surgical site in the immediate postoperative period can impact the bladder and prostate area causing the client to experience difficulty voiding due to pressure on the urethra. To provide additional data supporting bladder distention, the last time the client voided should be determined next A male client with sickle cell anemia, who has been hospitalized for another health problem, tells the nurse he has had an erection for over 4 hours. What action should the nurse implement first? A. Notify the client's healthcare provider. B. Document the finding in the client record. C. Prepare a warm enema solution for rectal instillation.
A. Ongoing antibiotic therapy is needed for one year. B. The client should not undergo magnetic resonance imaging. C. Increased frequency of assessment for prostatic cancer is needed. D. The client should not be catheterized through the stent for at least three months - Answers-D Rationale A prostatic stent is a cylinder shape tube that is placed in the urethra to relieve prostatic pressure from an enlarged prostate and improve urine flow. To prevent complications, the client should be cautioned against catheterization through the prostatic stent for three months after stent placement A 48-year-old client with endometrial cancer is being discharged after a total hysterectomy and bilateral salpingo-oophorectomy. Which client statement indicates that further teaching is needed? A. "Well, I don't have to worry about getting pregnant anymore." B. "I can't wait to go on the cruise that I have planned for this summer." C. "I know I will miss having sexual intercourse with my husband." D. "I have asked my daughter to stay with me next week after I am discharged - Answers-C Rationale Further teaching is needed in response to the client's misunderstanding of not being able to have sexual intercourse after a hysterectomy, needs to be addressed. Which intervention should the nurse implement that best confirms placement of an endotracheal tube (ETT)? A. Use an end-tital CO2 detector. B. Ascultate for bilateral breath sounds. C. Obtain pulse oximeter reading. D. Check symmetrical chest movement - Answers-A Rationale The end-tidal carbon dioxide detector indicates the presence of CO2tidalby a color change or number indicated on the detector, which is supporting evidence that the ETT is in the trachea, not the esophagus A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement? A. Encourage fluids to 3000 ml per day. B. Change the client's position every two hours. C. Keep the head of the bed elevated 30 degrees. D. Turn off the television and darken the room - Answers-D Rationale To decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or rotational movement, such as sudden head movements or position changes, should be minimized. To effectively manage the client's symptoms, turn off the
television, darken the room by minimizing fluorescent lights, flickering television lights, and distracting sounds What is the primary nursing problem for a client with asymptomatic primary syphilis? A. Acute pain. B. Risk for injury. C. Sexual dysfunction. D. Deficient knowledge. - Answers-D Rationale An asymptomatic client with primary syphilis is most likely unaware of this disease, so to prevent transmission to others and recurrence in the client, the priority nursing diagnosis is deficient knowledge of the disease pathophysiology Which finding should the nurse report to the healthcare provider for a client with a circumferential extremity burn? A. Full thickness burns rather than partial thickness. B. Supinates extremity but unable to fully pronate the extremity. C. Slow capillary refill in the digits with absent distal pulse points. D. Inability to distinguish sharp versus dull sensations in the extremity - Answers-C Rationale A circumferential burn can form an eschar that results from burn exudate fluid that dries and acts as a tourniquet as fluid shifts occur in the interstitial tissue. As edema increases tissue pressure, blood flow to the distal extremity is compromised, which is manifested by slow capillary refill and absent distal pulses, so the healthcare provider should be notified about any compromised circulation that requires escharotomy. The nurse directs an unlicensed assistive personnel (UAP) to obtain the vital signs for a client who returns to the unit after having a mastectomy for cancer. What information should the nurse provide the UAP? A. Elevate the arm with an IV infusing on the operative side with a pillow. B. Apply the blood pressure cuff to the arm on the non-operative side. C. Position the arm on the operative side close to the body. D Collect a fingerstick blood specimen from the arm on the operative side - Answers-B Rationale The nurse give the UAP the following instructions when providing care to a post-op mastectomy client. Blood pressure readings should be obtained from the arm on the nonoperative side to reduce the risk of injury of the extremity that may have compromised lymphatic drainage postoperatively. The arm on the operative side of the mastectomy should be elevated on a pillow above the level of the right atrium to facilitate lymphatic drainage. A client who is admitted to the emergency department with a possible tension pneumothorax after a motor vehicle collision is having multiple diagnostic tests. Which finding requires immediate action by the nurse? A. Serum amylase of 132 units/L. B. Serum sodium of 134 mEq/L.
