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HESI 366 Pharmacology Assessment Exam Questions and Correct (answered) Answers with Ration, Exams of Nursing

King's College London (KCL)Nursing

HESI 366 Pharmacology Assessment Exam Questions and Correct (answered) Answers with Rationale Guaranteed Success. A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority for the nurse. (Rank in the priority order from highest to lowest.) 1. Airway and breathing. 2. Pain management. 3. Definitive therapy. 4. Sleep and rest. - Answers-Correct Answer: 1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy. Rationale First-level problems are immediate priorities (airway, breathing, and circulation). In this scenario, airway and breathing are the first priority, followed by pain management, Maslow's hierarchy

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HESI 366 Pharmacology Assessment Exam Questions
and Correct (answered) Answers with Rationale
Guaranteed Success.
A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has
not been sleeping well lately and is experiencing labored breathing. List the client's
problems in order of priority for the nurse. (Rank in the priority order from highest to
lowest.)
1.
Airway and breathing.
2.
Pain management.
3.
Definitive therapy.
4.
Sleep and rest. - Answers-Correct Answer:
1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy.
Rationale
First-level problems are immediate priorities (airway, breathing, and circulation). In this
scenario, airway and breathing are the first priority, followed by pain management,
Maslow's hierarchy of basic needs for rest and sleep, and then definitive drug therapies.
Which biological practices are federally regulated for healthcare workers? (Select all
that apply.)
Select all that apply
1.Standard precautions.
2. N-95 tuberculosis standard.
3. Blood-borne pathogen standard.
4. Biological product exposure limit (BPEL).
5. Resource Conservation and Recovery Act (RCRA).
6. As Low as Reasonably Allowable standard (ALARA). - Answers-3. Blood-borne
pathogen standard.
5. Resource Conservation and Recovery Act (RCRA)
Basic standards for healthcare workers, as delineated by Occupational Safety and
Health Administration (OSHA), include standard precautions, droplet precautions using
N-95 respiratory particulate masks when caring for a client who is positive for
tuberculosis, and required annual updates for healthcare workers about blood-borne
pathogen transmission, methods of minimizing exposure, and employee rights. Other
options [BPEL and ALARA ] are not federally regulated.
A client with severe depression tells the nurse, "I do not know why you bother with me
or give me pills. I am never going to get well." What is the most therapeutic response?
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Download HESI 366 Pharmacology Assessment Exam Questions and Correct (answered) Answers with Ration and more Exams Nursing in PDF only on Docsity!

HESI 366 Pharmacology Assessment Exam Questions

and Correct (answered) Answers with Rationale

Guaranteed Success.

A newly admitted client complains of pain rating a 7 on a scale of 0 to 10. The client has not been sleeping well lately and is experiencing labored breathing. List the client's problems in order of priority for the nurse. (Rank in the priority order from highest to lowest.)

Airway and breathing.

Pain management.

Definitive therapy.

Sleep and rest. - Answers-Correct Answer: 1.Airway and breathing. 2.Pain management. 3.Sleep and rest. 4.Definitive therapy. Rationale First-level problems are immediate priorities (airway, breathing, and circulation). In this scenario, airway and breathing are the first priority, followed by pain management, Maslow's hierarchy of basic needs for rest and sleep, and then definitive drug therapies. Which biological practices are federally regulated for healthcare workers? (Select all that apply.) Select all that apply 1.Standard precautions.

  1. N-95 tuberculosis standard.
  2. Blood-borne pathogen standard.
  3. Biological product exposure limit (BPEL).
  4. Resource Conservation and Recovery Act (RCRA).
  5. As Low as Reasonably Allowable standard (ALARA). - Answers-3. Blood-borne pathogen standard.
  6. Resource Conservation and Recovery Act (RCRA) Basic standards for healthcare workers, as delineated by Occupational Safety and Health Administration (OSHA), include standard precautions, droplet precautions using N-95 respiratory particulate masks when caring for a client who is positive for tuberculosis, and required annual updates for healthcare workers about blood-borne pathogen transmission, methods of minimizing exposure, and employee rights. Other options [BPEL and ALARA ] are not federally regulated. A client with severe depression tells the nurse, "I do not know why you bother with me or give me pills. I am never going to get well." What is the most therapeutic response?
  1. "You need to stop thinking negative thoughts. They get in the way of your recovery."
  2. "You are no bother to me or to the staff. We want you to get well and not feel sad anymore."
  3. "I have known many clients with depression who have felt better after several weeks of treatment."
  4. "You are feeling very pessimistic, but that is part of your illness. It should go away as you recover." - Answers-3. "I have known many clients with depression who have felt better after several weeks of treatment." Stating the observation that others have recovered can give a client hope. Telling a person to stop negtive thinking is ineffective because the client must be taught cognitive strategies to stop negative thinking. Stating the person is "no bother" is arguing with the client's beliefs and attempting to tell him how to feel, both of which are not therapeutic responses. Bring up pessimistic feelings interprets the client's feelings and does not provide the same degree of hope. The nurse is caring for a client with a nursing problem of, "Infection, risk for, related to inadequate primary defenses as evidenced by surgical incision and IV access." What nursing intervention should the nurse implement?
  5. Limit visitors to immediate family to decrease exposure to infection.
  6. Maintain "clean" technique in the change of wound dressing and IV site.
  7. Assess and document skin condition around the incision and IV site at each shift.
  8. Require the use of a face mask by staff when providing care requiring close contact. - Answers-3. Assess and document skin condition around the incision and IV site at each shift. Early identification of infection leads to prompt treatment and decreased nosocomial transmission to others, so the condition of any invasive lines or breaks in the skin should be assessed and documented during each shift. A client with ulcerative colitis is scheduled for surgical creation of an ileoanal reservoir (J pouch). As part of preoperative teaching, what information should the nurse provide?
  9. The transverse loop ostomy is permanent.
  10. Easily removable appliances allow independence in self-care.
  11. Daily irrigation is started after the J pouch heals.
  12. Stool is eventually expelled through the rectum. - Answers-4. Stool is eventually expelled through the rectum. An ileal pouch-anal anastomosis (also known as the J pouch) is a surgically created ileoanal reservoir in the anal canal that preserves the rectal sphincter muscle, so that passage of stool through the rectum is the eventual result. To promote healing of the anastomosed parts of the colon, a temporary loop ostomy is created, not a permanent one. Although appliances that are easy to use are advantageous, the ostomy is reversed after healing takes place. Stool drains into the reservoir, so daily irrigation is not usually indicated.

workplace, such as the blood-borne pathogen standard, affects the workforce in terms of requirements, administration, and control strategies. Occupational safety programs are built around the workforce to strive for maximum internal productivity. Interventions are internal environmental influences of an occupational health and safety program. Socio-economic status is a demographic variable commonly used in epidemiology. The nurse is analyzing the waveforms of a client's electrocardiogram. What finding indicates a disturbance in electrical conduction in the ventricles?

  1. T wave of 0.16 second.
  2. PR interval of 0.18 second.
  3. QT interval of 0.34 second.
  4. QRS interval of 0.14 second. - Answers-4. QRS interval of 0.14 second. The normal duration of the QRS is 0.04 to 0.12 second, so a prolonged QRS indicates an electrical anomaly in the ventricles. The T wave is normally 0.16 seconds. The PR interval range is 0.12 to 0.20 second. The QT interval should be 0.31 to 0.38 second. The nurse is assigned a client with numerous treatments and decides it is not possible to complete all the needed treatments in the time scheduled for this shift. Which process should the nurse use?
  5. Delegate tasks to competent team members.
  6. Prioritize tasks with the most crucial needs first.
  7. Report the incomplete treatments to next shift nurse.
  8. Start with the easiest treatment first. - Answers-2. Prioritize tasks with the most crucial needs first. Planning care for a client with numerous treatments should be prioritized with the most crucial client needs first to the least. Delegating to others or reporting displace the nurse's responsibility to provide care. Starting with easiest is an inefficient utilization of time in meeting critical client needs. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?
  9. Use disposable plates and utensils.
  10. Stay in a room with the door closed.
  11. Dispose of soiled dressings in plastic bags that are securely closed.
  12. Others who are in the same room with the client should wear a mask. - Answers-3. Dispose of soiled dressings in plastic bags that are securely closed. Contact precautions require the use of a barrier that prevents contact with wound secretions on soiled dressings, which are best disposed of in tightly closed plastic bags. Disposable dishes is not necessary with contact precautions. Isolating themself to one room or wearing masks should be implemented for airborne, droplet precautions, or protective environments.

When assessing a client's interior eye structures with an ophthalmoscope, which action should the nurse use?

  1. Use a red-free filter.
  2. Adjust the diopters.
  3. Direct a wide-beam light.
  4. Dilate the client's pupils. - Answers-2. Adjust the diopters. The diopter corresponds to the magnification power of the ophthalmoscope's lens, which is adjusted to bring the retina into focus when a client's error of refraction, such as myopia or hyperopia, causes a change in the eyeball shape. Using a red-free filter produces a green beam for examination of the optic disc for pallor and recognition of retinal hemorrhages. The direct wide-beam light is used to examine the anterior eye. The application of an ophthalmic mydriatic should be instilled prior to extended fundoscopic visualization. The nurse administers dopamine (Intropin) IV infusion at 3 mcg/kg/min to a critically ill, hypotensive client. What is the intended effect of this treatment? To increase
  5. blood pressure to 140/80.
  6. urine output to 55 ml/hr.
  7. pulse to 132 beats/min.
  8. respirations to 24 breaths/min. - Answers-2. urine output to 55 ml/hr. The expected outcome of this treatment is an increase in urine output due to increased renal perfusion. Dopamine, a catecholamine, provides renal and mesenteric vasodilation at a low dosage level, such as the 3 mcg/kg/minute infusion that was prescribed for this client. A higher dose of dopamine is indicated in a critically ill client who is hypotensive. During an admission assessment interview, a client states, "I do not use many drugs." How should the nurse respond?
  9. "Tell me about the drugs you use now."
  10. "Explain what you mean by many drugs."
  11. "Do you mean legal drugs or illegal ones?"
  12. "What kind of drugs are you talking about?" - Answers-1. "Tell me about the drugs you use now." Open-ended questioning allows the client provide specific information without probing. Asking the person to explain what drugs they are taking is critical of the client's descriptors and does not encourage further dialog. Asking about legal vs. illegal drugs or "kind of drugs" both are close-ended questions that require one word responses, and stop further exploration with the client. The nurse begins a physical assessment of an 8-month-old. The child is sitting contentedly on the mother's lap, chewing on a toy. Which action should the nurse implement first?
  13. Elicit reflexes.

first in the event intubation is required. Extending the clients neck is contraindicated. Although documentation is necessary, a stridor or voice change are indicators of early airway compromise. A woman visits the clinic for confirmation of pregnancy. All of her children from prior pregnancies are living. One was born at 39-weeks gestation, twins at 34-weeks gestation, and another singleton at 35-weeks gestation. How should the nurse record her gravity and parity using the GTPAL system? A. 3-0-3-0-3. B. 3-1-1-1-3. C. 4-1-2-0-4. D. 4-2-1-0-3. - Answers-C. 4-1-2-0-4. Using the GPTAL system is the correct record of gravity and parity. G reflects the total number of times the woman has been pregnant; she is pregnant for the 4th time. T indicates the number of pregnancies carried to term, not the number of deliveries at term; she has had only one pregnancy after 37-weeks gestation. P is the number of pregnancies that resulted in a preterm birth, not the number of infants born; she has had two pregnancies before 37-weeks gestation. A signifies elected abortions or miscarriages prior to the period of viability (20-weeks). L signifies the number of children born that are currently living. The registered nurse (RN) and practical nurse (PN) are working together to care for a group of clients. Which situation requires intervention by the RN?

  1. A client receiving Lactated Ringer's solution requests pain medication.
  2. A client with a history of falls needs assistance to the bathroom.
  3. A client's indwelling urinary catheter requires manual irrigation.
  4. A client with an epidural infusion reports lower extremity parasthesia. - Answers-4. A client with an epidural infusion reports lower extremity parasthesia. Assessment of possible adverse effects of an epidural infusion should be performed by the RN, who has the expertise to evaluate the significance of the assessment data. The other options are skills that can be delegated to the PN. The charge nurse working on a surgical unit must discharge as many clients as possible to prepare for emergency admissions. Which client is stable enough to be discharged from the unit?
  5. An older client with end-stage cirrhosis who had a liver biopsy 4 hours ago.
  6. A client scheduled for a femoro-popliteal bypass surgery tomorrow.
  7. A middle-aged client with acute pancreatitis and lower left quadrant pain.
  8. A female client with angina and ectopy noted on the telemetry monitor. - Answers-2. A client scheduled for a femoro-popliteal bypass surgery tomorrow. The client with an elective surgical procedure can be rescheduled for a later date so is considered stable enough to be discharged. A client with a recent biopsy is not stable for discharge as the procedure can result in bleeding due to the high vascularity of the

liver. A client with acute pancreatitis is unstable, in acute pain, and at risk for rupture of diverticula. A client with rhythm irregularities has a life-threatening condition because of the risk for ventricular tachycardia. The cardiac monitor of a 50-year-old client admitted for cocaine ingestion shows ventricular tachycardia (VT) converting to ventricular fibrillation (VF). What priority action should the nurse implement?

  1. Prepare for intubation.
  2. Defibrillate at 200 joules.
  3. Insert intravenous catheter.
  4. Obtain arterial blood gases. - Answers-2. Defibrillate at 200 joules. After confirming ventricular fibrillation, rapid defibrillation is critical in re-establishing cardiac output and preserving vital organ function. After CPR is initiated and defibrillation attempted, airway intubation and intravenous access are indicated for successful resuscitation. Arterial blood gases are obtained during or after resuscitation to determine medical management for metabolic acidosis which occurs secondary to anaerobic glycolysis during VF or cardiac arrest. What is the most effective way to implement a teaching plan?
  5. Teach the information that the client wants to learn first.
  6. Streamline the teaching plan to include only essential information.
  7. Present to the client all the information necessary to meet the objectives.
  8. Provide the client with written material to review before teaching sessions. - Answers-
  9. Teach the information that the client wants to learn first. Teaching is most effective when it responds to the learner's needs, and learning begins when a person identifies a need for knowing or acquiring an ability to do something. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first?
  10. Use an electronic sphygmomanometer to take the BP every 30 minutes.
  11. Retake the blood pressure in the same arm, deflating the cuff slowly.
  12. Ask another nurse to recheck the blood pressure to compare results.
  13. Obtain another blood pressure cuff and retake the blood pressure. - Answers-2. Retake the blood pressure in the same arm, deflating the cuff slowly. The nurse should first retake the blood pressure in the right arm, deflating the cuff more slowly because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. There is no indication that the BP needs to be taken frequently. If the blood pressure remains low, further assessment is needed, which may include asking other staff to recheck the BP. If deflating the cuff slowly does not resolve the discrepancy, the nurse may then need to implement getting another BP cuff and retaking the BP.

An IV infusion stops when pressure is placed on the skin above the tip of the catheter, but will continue to flow into the subcutaneous tissue if there is infiltration, which requires removal of the IV. The other options will not resolve the infiltration. Which outcome statement or goal should the nurse include in the plan of care of an adolescent diagnosed with anorexia nervosa?

  1. Improve the client's body perception.
  2. Consume at least 50% of all meals.
  3. Exercise no more than one hour daily.
  4. 5% decrease in serum potassium levels. - Answers-2. Consume at least 50% of all meals. An outcome statement should be measurable and provide observable behaviors that indicate the client's problem is resolving. Self-starvation is the major problem associated with anorexia nervosa, so stating the person should consuming 50% of diet should be included in this client's plan of care. "Improve body perception" is vague and not measurable. Adolescents with anorexia nervosa often obsessively exercise to lose additional weight, so defining exercise time limits may be excessive. Clients with anorexia have an increased risk for hypokalemia, so decreasing serum potassium levels is an inappropriate goal for this client. The nurse working in the oncology clinic at a cancer center is involved in supporting clients and families who must cope with the diagnosis of cancer. Which client is likely to cope best with the diagnosis of cancer?
  5. An older man who is always happy and chooses to view only the good in every situation.
  6. A single mother who seeks the support of her two teenage daughters during difficult times.
  7. A successful businessman who is accustomed to handling highly-stressful situations.
  8. A teacher who seeks information about her disease and wants to continue teaching. - Answers-4. A teacher who seeks information about her disease and wants to continue teaching. Those who seek information about their disease while attempting to carry on with their lives as best they can are likely to handle the diagnosis of cancer best. Those who use repression to deal with traumatic events often have difficulty expressing their feelings. Depending on children for support, especially when the children are teenagers, may be disappointing. Someone who is used to handling high-stress situations is used to being in control, and control over a life-threatening diagnosis is not always possible. A client with severe preeclampsia is receiving magnesium sulfate 2 grams IV hourly. The nurse assesses the client and finds: blood pressure 140/90, pulse 100, respirations 10, deep tendon reflexes 1+, and urinary output 130 ml in 4 hours. The nurse will discontinue the magnesium infusion based on which assessment finding?
  9. Deep tendon reflexes 1+.
  1. Blood pressure of 140/90.
  2. Respirations of 10.
  3. Urinary output of 130 ml in 4 hours. - Answers-3. Respirations of 10. With respirations less than 12, the client is at risk for developing respiratory arrest and the magnesium sulfate should be discontinued. Other cardinal signs of magnesium toxicity include urinary output <100 ml/4 hours (or 25 ml/hour) (D) and absent reflexes. Reflexes of 1+ are hypoactive but present. A client with preeclampsia can seize with blood pressures lower than 140/90. Magnesium sulfate is not an antihypertensive. A male client is receiving total parenteral nutrition (TPN) through a central venous catheter (CVC) in the right subclavian vein and is reluctant to move his right arm or turn his head toward the CVC site. What nursing action should the nurse implement first?
  4. Flush the catheter to maintain patency of the CVC access.
  5. Describe the placement and rationale for care of the catheter.
  6. Reassure the client that the TPN administration is temporary.
  7. Provide passive range of motion to the right arm and neck. - Answers-2. Describe the placement and rationale for care of the catheter. A client's anxiety or fear about a treatment or procedure is commonly the result of a lack of knowledge, so providing information, such as drawings or pictures, and explanations about the catheter, may help the client understand the catheter's function and decrease his anxiety regarding its presence. Following the administration of morphine sulfate 10 mg IV, the nurse determines that the client's respirations are six breaths per minute. What action should the nurse take first?
  8. Assess the client's current oxygen saturation level.
  9. Auscultate the client's breath sounds bilaterally.
  10. Prepare to administer a dose of naloxone (Narcan) IV.
  11. Attempt to arouse the client to stimulate respirations. - Answers-4. Attempt to arouse the client to stimulate respirations. The nurse should first attempt to stimulate respirations by arousing the client. This measure is noninvasive and may produce an immediate increase in respiratory rate. If this action is unsuccessful, the nurse should then implement the other options listed. A client with aortic valve stenosis develops heart failure (HF). Which pathophysiological finding occurs in the myocardial cells as a result of the increased cardiac workload?
  12. Increase in size.
  13. Decrease in length.
  14. Increase in number.
  15. Decrease in excitability. - Answers-1. Increase in size.
  1. "An antibiotic ointment is placed in each newborn's eyes to prevent infection."
  2. "Conjunctivitis neonatorum is common in newborns."
  3. "This type of question should be discussed with your pediatrician."
  4. "Most infants have drainage from their eyes which usually resolves within 2 to 3 days of life." - Answers-1. "An antibiotic ointment is placed in each newborn's eyes to prevent infection." Antibiotic ointments, such as erythromycin ointment, are placed in the lower conjunctiva of each eye to prevent chlamydia and gonorrhea. The nurse is teaching a client how to self-administer a subcutaneous injection. To help ensure sterility of the procedure, which subject is most important for the nurse to include in the teaching plan?
  5. Hand washing prior to preparation of the injection.
  6. Method used to aspirate medication from a vial.
  7. Selection and rotation of injection sites.
  8. Proper disposal of injection equipment. - Answers-2. Method used to aspirate medication from a vial. To maintain sterility of the procedure, the most important factor to include in the teaching plan is how to manipulate the syringe parts so that the medication maintains sterility during the preparation and administration. The other options are teaching topics, but are not components of maintaining sterile technique while administering an injection. What is the underlying pathophysiologic process between free radicals and destruction of a cell membrane?
  9. Inadequate mitochondrial ATP.
  10. Enzyme release from lysosomes.
  11. Defective chromosomes for protein.
  12. Defective integral membrane proteins. - Answers-2. Enzyme release from lysosomes. Oxidative damage to cells is thought to be a causative factor in disease and aging. If free radicals bind to polyunsaturated fatty acids found in the lysosome membrane, the lysosome, nicknamed "suicide bags", leaks its protein catalytic enzymes intracellularly and the cell is destroyed.Inadequate ATP production and defective protein synthesis lead to cell death either as the result of defective chromosomes or production of defective integral proteins. The nurse is preparing to perform oral care for an unconscious client.In what order should the nurse implement the nursing actions? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.)
  13. Raise bed to a comfortable working height.
  14. Position the client in a flat side-lying position.
  15. Place an emesis basin under the client's chin.
  1. Lower the side rail between the nurse and the client. - Answers-1. Raise bed to a comfortable working height.
  2. Lower the side rail between the nurse and the client.
  3. Position the client in a flat side-lying position.
  4. Place an emesis basin under the client's chin. To ensure client and nurse safety when performing oral care for an unconscious client, first raise the bed to a comfortable working level, then lower the side rail between the nurse and the client, position the client in a flat side-lying position, and place a towel and an emesis basin under the client's chin. An overweight adolescent girl has been to the school nurse three times in the last two months complaining of vaginal and urinary tract infections. What action should the nurse take first?
  5. Counsel the girl regarding hygiene.
  6. Ask if she is going to the bathroom frequently.
  7. Teach the girl the importance of practicing safe sex.
  8. Encourage the girl to see the school counselor. - Answers-2. Ask if she is going to the bathroom frequently. The nurse should ask questions directed toward symptoms of diabetes. Recurrent vaginal and urinary tract infections are often an early sign of diabetes. A client who had a cesarean section two weeks ago is admitted to the hospital for an infected surgical abdominal wound. Which room is best for the nurse to assign this client?
  9. A negative pressure room.
  10. A semi-private room on a surgical unit.
  11. A postpartum room in the birthing center.
  12. A private room on a medical unit. - Answers-4. A private room on a medical unit. To protect others from contamination, the nurse should assign this client to a private room. Isolation room is not indicated(A) is an isolation room used for clients with TB. (B) should not be assigned because of the possibility of cross-contamination by the infected client. (C) should not be assigned because the OB unit is considered "clean." A client with glaucoma is scheduled for surgery. Which pre-operative prescription should the nurse question?
  13. Morphine sulfate 5 mg IV on call to operating room.
  14. Atropine sulfate 0.4 mg IM on call to operating room.
  15. Betaxolol (Betoptic) one drop in each eye the morning of surgery.
  16. Benzodiazepine (Valium) 5 mg by mouth the morning of surgery. - Answers-2. Atropine sulfate 0.4 mg IM on call to operating room. Many ophthalmic agents used to reduce intraocular pressure (IOP) in glaucoma cause miosis, which increases the outflow of aqueous humor. Atropine is an anticholinergic
  1. Collect blood for hemoglobin and hematocrit.
  2. Start the first transfusion of blood.
  3. Insert an indwelling urinary catheter.
  4. Encourage alternate rest periods with activity. - Answers-2. Start the first transfusion of blood. The hemoglobin of 6 gm/dl (normal is 14 to 18 gm/dl in males) and the 82% O saturation (normal is 96 to 100%) indicates the client is hypoxic, so the first transfusion of blood should be started. Rechecking labs should be obtained after the client is transfused to evaluate its effectiveness. Placing a catheter is not indicated at this time. Rest periods should be included in the plan of care, but is not as essential as giving the transfusion at this time. The nurse observes an empty secondary infusion of diltiazem (Cardizem) is attached to the client's IV pump, but realizes that this client has no prescription for Cardizem. In what sequence, from first to last, should the following interventions be implemented? (Place the first action on top and last action on the bottom.)
  5. Measure the client's vital signs.
  6. Review medications client is taking.
  7. Complete an incident report.
  8. Notify the healthcare provider. - Answers-1. Measure the client's vital signs.
  9. Review medications client is taking.
  10. Notify the healthcare provider.
  11. Complete an incident report. Cardizem is a calcium channel blocker that decreases blood pressure, and slows SA or AV node conduction, which can cause bradycardia or cardiac arrhythmias, so the client's vital signs should be measured first to determine the client's reaction to the medication error. The client's current medications should be reviewed before notifying the healthcare provider, and then the incident report completed. About mid-morning, a 10-year-old child reports to the school nurse complaining of nausea, dizziness, and chills. Further assessment reveals that this child is sweating profusely and has a blood glucose level of 57 mg/dl. Based on these assessment findings, which food is best for the nurse to encourage the child to eat?
  12. A chocolate bar.
  13. A soft drink.
  14. Peanut butter crackers.
  15. A piece of buble gum. - Answers-3. Peanut butter crackers. Peanut butter crackers provide a complex carbohydrate, plus protein and fat. This child is exhibiting signs and symptoms of mild to moderate hypoglycemia and needs to eat about 15 grams of carbohydrates to increase the blood sugar level. Complex carbohydrates are broken down more slowly and are slower acting than simple sugars, so they prevent the blood glucose level from peaking and then dropping precipitously.

A client with a markedly distended bladder is diagnosed with hydronephrosis and left hydroureter after an IV pyelogram. The nurse catheterizes the client and obtains a residual urine volume of 1650 ml. This finding supports which pathophysiological cause of the client's urinary tract obstruction?

  1. Obstruction at the urinary bladder neck.
  2. Ureteral calculi obstruction.
  3. Ureteropelvic junction stricture.
  4. Partial post-renal obstruction due to ureteral stricture. - Answers-1. Obstruction at the urinary bladder neck. Hydroureter (dilation of the renal pelvis), vesicoureteral reflux (backward movement of urine from the lower to upper urinary tracts), and hydronephrosis (dilation or enlargement of the renal pelvis and calyces) result from post-renal obstruction which can consequently result in chronic pyelonephritis and renal atrophy. Ascending urinary reflux occurs when normal ureteral peristaltic pressure is met with an increase in urinary pressure occurring during bladder filling if the urinary bladder neck is obstructed. When making a home visit to a family with a teething 4-month-old, what information is most important for the nurse to provide the parents?
  5. Though child development is characterized by individual differences, first teeth usually erupt during the seventh month.
  6. Providing cooled teething toys can help decrease the discomfort associated with tooth eruption.
  7. No action is required for the common symptoms associated with teething, which include drooling, irritability, and poor sleeping.
  8. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. - Answers-4. A slight fever is often associated with teething, but a fever lasting more than three days requires medical attention. A slight fever that persists longer than three days is likely to be associated with a pathological process, not teething, and the parents should seek the attention of their healthcare provider if it occurs. A client who had a normal vaginal delivery 10 days ago is re-hospitalized for lethargy and increased lochia flow with a foul odor. Initial assessment reveals a pulse rate of 94 beats/minute, a temperature of 102.2 F, chills, pelvic pain, and uterine tenderness. What action should the nurse take?
  9. Review the complete blood count.
  10. Tell client to discard pumped milk.
  11. Initiate a 24-hour urine collection.
  12. Arrange for the baby to room-in. - Answers-1. Review the complete blood count.

At approximately 18 months of age, most toddlers manifest lower nutritional need and decreased appetite, a phenomenon known as "physiologic anorexia" which is often manifested as a picky, fussy eater with strong taste preferences, and erratic eating patterns. Toddlers are learning to differentiate self and social boundaries and may be disruptive while sitting at the table, so offering nutritious finger foods is a good way to ensure proper nutrition during this stage. Which intervention should the school nurse implement to decrease the incidence of hepatitis A in a preschool setting?

  1. Promote hygiene by ensuring that children's faces and hair are kept clean.
  2. Ensure that all enrolled children have been immunized for Hepatitis A.
  3. Put a strip bandage on bleeding injuries to prevent contamination of others.
  4. Teach children the correct handwashing technique to use after toileting. - Answers-2. Ensure that all enrolled children have been immunized for Hepatitis A. The CDC recommended immunization schedule for children includes the hepatitis A vaccine (HAV), so follow-up of enrolled children's immunization status with HAV or human-immune gamma globulin should be implemented. Preschoolers should be taught the importance of hygiene practices, such as keeping themselves clean or correct handwashing technique, but hepatitis A is transmitted via the fecal-oral route and immunization provides the best universal protection. Hepatitis A is not transmitted through blood contact. The unlicensed assistive personnel (UAP) informs the nurse that a client whose heart rhythm has been stable is now exhibiting a rapid, irregular pulse. What action should the nurse implement first?
  5. Document the change in pulse rate on the graphics sheet.
  6. Review the client's medical history for cardiac problems.
  7. Reassess the rate and characteristics of the client's pulse.
  8. Ask the UAP to recheck the client's pulse in thirty minutes. - Answers-3. Reassess the rate and characteristics of the client's pulse. A change in heart rate or rhythm reflects a change in physiologic homeostasis that may be potentially life threatening, so it is most important to immediately reassess the client's pulse rate and characteristics. After reassessing the client, the nurse should document the findings, review the client's medical record for related history, and determine further needed intervention, such as rechecking the client's vital signs. The blood pressure readings obtained by a unlicensed assistive personnel (UAP) are consistently different from those obtained by other staff members. What action should the charge nurse take first?
  9. Counsel the UAP about the inaccurate blood pressure readings.
  10. Observe the UAP performing blood pressure measurements.
  11. Make staff members aware of the possible errors in blood pressure readings.
  1. Ask the education department to provide additional training for the UAP. - Answers-2. Observe the UAP performing blood pressure measurements. The charge nurse should first observe the UAP's performance to determine if the UAP is performing the task appropriately. If the UAP needs education, the charge nurse can provide instruction real time. Which assessment is most important for the nurse to implement when performing a comprehensive assessment for an older adult?
  2. Chronic illnesses.
  3. Functional abilities.
  4. Immunologic function.
  5. Physical signs of aging. - Answers-2. Functional abilities. The focus of a geriatric assessment is to determine the older client's functional abilities, so appropriate interventions can be planned and implemented to maintain and enhance independence. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?
  6. Place a sterile drape under the client's buttocks.
  7. Instruct the client to inhale and then exhale slowly.
  8. Discard the gloves and apply new sterile gloves.
  9. Apply a sterile lubricant to the end of the catheter. - Answers-4. Apply a sterile lubricant to the end of the catheter. After testing the balloon for patency, the nurse should next lubricate the end of the catheter. The sterile drape should already be positioned under the client's buttocks. The client is instructed in breathing just prior to insertion. A client is receiving an intramuscular injection at the ventrogluteal site. At what angle should the nurse insert the needle? (Enter numeric value only.) - Answers- The angle for needle insertion when performing intramuscular injections is 90 degrees. The nurse asks an older female client with cognitive impairment who has been hospitalized for three days how her previous evening was. The client replies, "I had the best time. My husband took me out to dinner and then to a concert. The music was wonderful." Which term should the nurse document to best describe the client's response?
  10. Delusions.
  11. Confabulation.
  12. Concretization.
  13. Circumstantiality. - Answers-2. Confabulation.