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HESI Comprehensive Exam questions and answers Enalapril maleate is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication? Checking the client's blood pressure Checking the client's peripheral pulses Checking the most recent potassium level Checking the client's intake-and-output record for the last 24 hours - answers>Checking the client's blood pressure Rationale: Enalapril maleate is an angiotensin-converting enzyme (ACE) inhibitor used to treat hypertension. One common side effect is postural hypotension. Therefore the nurse would check the client's blood pressure immediately before administering each dose. Checking the client's peripheral pulses, the results of the most recent potassium level, and the intake and output for the previous 24 hours are not specifically associated with this mediation. A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction? "The test will take about 30 minutes." "I need to fast for 8 hours before the test." "I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." "I need to take a laxative after the test is completed, because the liquid that I'll have to drink for the test can be constipating." - answers>"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Rationale: No special preparation is necessary before a GI series, except that NPO (nothing by mouth) status must be maintained for 8 hours before the test. An upper GI series involves visualization of the esophagus, duodenum, and upper jejunum by means of the use of a contrast medium. It involves swallowing a contrast medium (usually barium), which is administered in a flavored milkshake. Films are taken at intervals during the test, which takes about 30 minutes. After an upper GI series, the client is prescribed a laxative to hasten elimination of the barium. Barium that remains in the colon may become hard and difficult to expel, leading to fecal impaction. A nurse on the evening shift checks a primary health care provider's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the primary health care provider's answering service and is told that the primary health care provider is off for the night and will be available in the morning. What should the nurse do next? Call the nursing supervisor Ask the answering service to contact the on-call primary health care provider Withhold the medication until the primary health care provider can be reached in the morning Administer the medication but consult the primary health care provider when he becomes available - answers>Ask the answering service to contact the on-call primary health care provider Rationale: The nurse has a duty to protect the client from harm. A nurse who believes that a primary health care provider's prescription may be in error is responsible for clarifying the prescription before carrying it out. Therefore the nurse would not administer the medication; instead, the nurse would withhold the medication until the dose can be clarified. The nurse would not wait until the next morning to obtain clarification. It is premature to call the nursing supervisor. An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the
monitor, checks the client's carotid pulse, and determines that the PVCs are not perfusing. What is the nurse's most appropriate action? Document the findings Ask the ED primary health care provider to check the client Continue to monitor the client's cardiac status Inform the client that PVCs are expected after an MI - answers>Ask the ED primary health care provider to check the client Rationale: The most appropriate action by the nurse would be to ask the ED health care provider to check the client. PVCs are a result of increased irritability of ventricular cells. Peripheral pulses may be absent or diminished with the PVCs themselves because the decreased stroke volume of the premature beats may in turn decrease peripheral perfusion. Because other rhythms also cause widened QRS complexes, it is essential that the nurse determine whether the premature beats are resulting in perfusion of the extremities. This is done by palpating the carotid, brachial, or femoral artery while observing the monitor for widened complexes or by auscultating for apical heart sounds. In the situation of acute MI, PVCs may be considered warning dysrhythmias, possibly heralding the onset of ventricular tachycardia or ventricular fibrillation. Therefore, the nurse would not tell the client that the PVCs are expected. Although the nurse will continue to monitor the client and document the findings, these are not the most appropriate actions of those provided. NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. What action should the nurse take? Administer the antihypertensive with a small sip of water Withhold the antihypertensive and administer it at bedtime Administer the medication by way of the intravenous (IV) route Hold the antihypertensive and resume its administration on the day after the ECT - answers>Administer the antihypertensive with a small sip of water Rationale: The nurse should administer the antihypertensive with a small sip of water. General anesthesia is required for ECT, so NPO status is imposed for 6 to 8 hours before treatment to help prevent aspiration. Exceptions include clients who routinely receive cardiac medications, antihypertensive agents, or histamine (H2) blockers, which should be administered several hours before treatment with a small sip of water. Withholding the antihypertensive and administering it at bedtime and withholding the antihypertensive and resuming administration on the day after the ECT are incorrect actions, because antihypertensives must be administered on time; otherwise, the risk for rebound hypertension exists. The nurse would not administer a medication by way of a route that has not been prescribed. A client who recently underwent coronary artery bypass graft surgery comes to the primary health care provider's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic? "Tell me more about what you're feeling." "That's a normal response after this type of surgery." "It will take time, but I promise you, you will get over this depression." "Every client who has this surgery feels the same way for about a month." - answers>"Tell me more about what you're feeling." Rationale: The therapeutic response by the nurse is, "Tell me more about what you're feeling." When a client expresses feelings of depression, it is extremely important for the nurse to further explore these feelings with the client. In stating, "This is a normal response after this type of surgery" the nurse provides false reassurance and avoids addressing the client's feelings. "It will take time, but I promise you, you will get over the depression" is also a false reassurance, and it does not encourage the expression of feelings. "Every client who has this surgery feels the same way for about a month" is a generalization that avoids the client's feelings.
A client is taking prescribed ibuprofen 200 mg orally four times daily, to relieve joint pain resulting from rheumatoid arthritis. The client tells the nurse that the medication is causing nausea and indigestion. What should the nurse tell the client? "I will contact your primary health care provider." "Stop taking the medication." "Take the medication with food." "Take the medication twice a day instead of four times a day." - answers>"Take the medication with food." Rationale: Ibuprofen is a nonsteroidal antiinflammatory medication. Side effects include nausea (with or without vomiting) and dyspepsia (heartburn, indigestion, or epigastric pain). If gastrointestinal distress occurs, the client should be instructed to take the medication with milk or food. The nurse would not instruct the client to stop the medication or instruct the client to adjust the dosage of a prescribed medication; these actions are not within the legal scope of the role of the nurse. Contacting the primary health care provider is premature, because the client's complaints are side effects that occasionally occur and can be relieved by taking the medication with milk or food. The night nurse is caring for a client who just had a craniotomy. The nurse is monitoring the client's Jackson-Pratt drain that is being maintained on suction. The nurse notes that a total of 200 mL of red drainage has drained from the Jackson-Pratt (J-P) tube in the last 8 hours. What action should the nurse take? Document the amount in the client's record. Discontinue the Jackson-Pratt drain from suction. Continue to monitor the amount and color of the drainage. Notify the primary health care provider immediately of the amount of drainage. - answers>Notify the primary health care provider immediately of the amount of drainage. Rationale: The nurse must immediately notify the primary health care provider of this excessive amount of drainage. The primary health care provider must also be immediately notified of any saturated head dressings. The normal amount of drainage from a Jackson-Pratt drain is 30 to 50 mL per shift. Discontinuing the suction from the J-P drain is not an option and is not done. Also, just documenting the amount in the client's record is not correct even though the nurse would document that the primary health care provider was notified of the total drain amount. Just continuing to monitor the amount of drainage is also not an option. Lorazepam 1 mg by way of intravenous (IV) injection (IV push) is prescribed for a client for the management of anxiety. The nurse prepares the medication as prescribed. Over what period of time should the nurse administer this medication? 3 minutes 10 seconds 15 seconds 30 minutes - answers>3 minutes Rationale: Lorazepam is a benzodiazepine. When administered by IV injection, each 2 mg or fraction thereof is administered over a period of 1 to 5 minutes. Ten seconds and 30 seconds are brief periods. Thirty minutes is a lengthy period. A nurse, conducting an assessment of a client being seen in the clinic for signs/symptoms of a sinus infection, asks the client about medications that he is taking. The client tells the nurse that he is taking nefazodone hydrochloride. On the basis of this information, the nurse determines that the client most likely has a history of what problem? Depression Diabetes mellitus Hyperthyroidism
Coronary artery disease - answers>Depression Rationale: The client is most likely suffering from depression. Nefazodone hydrochloride is an antidepressant used as maintenance therapy to prevent relapse of an acute depression. Diabetes mellitus, hypethyroidism, and coronary artery disease are not treated with this medication. Phenelzine sulfate is prescribed for a client with depression. The nurse provides information to the client about the adverse effects of the medication and tells the client to contact the primary health care provider immediately if he/she experiences what sign/symptom? Dry mouth Restlessness Feelings of depression Neck stiffness or soreness - answers>Neck stiffness or soreness Rationale: The client is taught to immediately contact the primary health care provider if the client experiences any occipital headache radiating frontally and neck stiffness or soreness, which could be the first sign of a hypertensive crisis. Phenelzine sulfate, a monoamine oxidase inhibitor (MAOI), is an antidepressant and is used to treat depression. Hypertensive crisis, an adverse effect of this medication, is characterized by hypertension, frontally radiating occipital headache, neck stiffness and soreness, nausea, vomiting, sweating, fever and chills, clammy skin, dilated pupils, and palpitations. Tachycardia, bradycardia, and constricting chest pain may also be present. Dry mouth and restlessness are common side effects of the medication. Risperidone is prescribed for a client hospitalized in the mental health unit for the treatment of a psychotic disorder. Which finding in the client's medical record would prompt the nurse to contact the prescribing primary health care provider before administering the medication? The client has a history of cataracts. The client has a history of hypothyroidism. The client takes a prescribed antihypertensive. The client is allergic to acetylsalicylic acid (aspirin). - answers>The client takes a prescribed antihypertensive. Rationale: Risperidone is an antipsychotic medication. Contraindications to the use of risperidone include cardiac disorders, cerebrovascular disease, dehydration, hypovolemia, and therapy with antihypertensive agents. Risperidone is used with caution in clients with a history of seizures. History of cataracts, hypothyroidism, or allergy to aspirin does not affect the administration of this medication. A client who has been undergoing long-term therapy with an antipsychotic medication is admitted to the inpatient mental health unit. Which finding does the nurse, knowing that long-term use of an antipsychotic medication can cause tardive dyskinesia, monitor in the client? Fever Diarrhea Hypertension Tongue protrusion - answers>Tongue protrusion Rationale: The clinical manifestations include abnormal movements (dyskinesia) and involuntary movements of the mouth, tongue ("flycatcher tongue"), and face. Tardive dyskinesia is a severe reaction associated with long-term use of antipsychotic medications. In its most severe form, tardive dyskinesia involves the fingers, arms, trunk, and respiratory muscles. When this occurs, the medication is discontinued. Fever, diarrhea, and hypertension are not characteristics of tardive dyskinesia. A nurse is reviewing the record of a client scheduled for electroconvulsive therapy (ECT). Which diagnosis, if noted on the client's record, would indicate a need to contact the primary health care provider who is scheduled to perform the ECT?
To always administer less insulin on the days of soccer games That it is best not to encourage the child to participate in sports activities That the child should eat a carbohydrate snack about a half-hour before each soccer game To administer additional insulin before a soccer game if the blood glucose level is 240 mg/dL (13.3 mmol/L) or higher and ketones are present. - answers>That the child should eat a carbohydrate snack about a half-hour before each soccer game Rationale: The child with diabetes mellitus who is active in sports requires additional food intake in the form of a carbohydrate snack about a half-hour before the anticipated activity. Additional food will need to be consumed, often as frequently as every 45 minutes to 1 hour, during prolonged periods of activity. If the blood glucose level is increased (240 mg/dL [13.3 mmol/L] or more) and ketones are present before planned exercise, the activity should be postponed until the blood glucose has been controlled. Moderate to high ketone values should be reported to the primary health care provider. There is no reason for the child to avoid participating in sports. A client diagnosed with chronic kidney disease who requires dialysis three times a week for the rest of his life says to the nurse, "Why should I even bother to watch what I eat and drink? It doesn't really matter what I do if I'm never going to get better!" On the basis of the client's statement, the nurse determines that the client is experiencing which problem? Anxiety Powerlessness Ineffective coping Disturbed body image - answers>Powerlessness Rationale: Powerlessness is present when a client believes that he or she has no control over the situation or that his or her actions will not affect an outcome in any significant way. Anxiety is a vague uneasy feeling of apprehension. Some factors in anxiety include a threat or perceived threat to physical or emotional integrity or self-concept, changes in role function, and a threat to or change in socioeconomic status. Ineffective coping is present when the client exhibits impaired adaptive abilities or behaviors in meeting the demands or roles expected. Disturbed body image is diagnosed when there is an alteration in the way the client perceives his or her own body image. A nurse is providing morning care to a client in end-stage kidney disease. The client is reluctant to talk and shows little interest in participating in hygiene care. Which statement by the nurse would be therapeutic? "What are your feelings right now?" "Why don't you feel like washing up?" "You aren't talking today. Cat got your tongue?" "You need to get yourself cleaned up. You have company coming today." - answers>"What are your feelings right now?" Rationale: Asking, "What are your feelings right now?" encourages the client to identify his or her emotions or feelings, which is a therapeutic communication technique. In stating, "Why don't you feel like washing up?" the nurse is requesting an explanation of feelings and behaviors for which the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. "You aren't talking today. Cat got your tongue?" is a nontherapeutic cliché. The statement "You need to get yourself cleaned up. You have company coming today" is demanding, demeaning to the client, and nontherapeutic. Empyema develops in a client with an infected pleural effusion, and the nurse prepares the client for thoracentesis. The nurse is assisting the primary health care provider with the procedure. What characteristics of the fluid removed during thoracentesis should the nurse expect to note? Clear and yellow Thick and opaque
White and odorless Clear, with a foul odor - answers>Thick and opaque Rationale: Empyema is the accumulation of pus in the pleural space. Empyema fluid is thick, opaque, exudative, and intensely foul-smelling. Clear and yellow, white and odorless, and clear and foul-smelling are incorrect descriptions of the fluid that occurs in this disorder. An emergency department nurse is told that a client with carbon monoxide poisoning resulting from a suicide attempt is being brought to the hospital by emergency medical services. Which intervention will the nurse carry out as a priority upon arrival of the client? Administering 100% oxygen Having a crisis counselor available Instituting suicide precautions for the client Obtaining blood for determination of the client's carboxyhemoglobin level - answers>Administering 100% oxygen Rationale: With a client with carbon monoxide poisoning, the priority is to treat the client with inhalation of 100% oxygen to shorten the half-life of carbon monoxide to around an hour. Hyperbaric oxygen may be required to reduce the half-life to minutes by forcing the carbon monoxide off the hemoglobin molecule. Because the poisoning occurred as a result of a suicide attempt, a crisis counselor should be consulted, but this is not the priority. Suicide precautions should be instituted once emergency interventions have been completed and the client has been admitted to the hospital. The diagnosis is confirmed with a measurement of the carboxyhemoglobin level in the client's blood. Obtaining a blood specimen to measure the carboxyhemoglobin level is a priority; however, the nurse would immediately administer 100% oxygen to the client. A nurse is caring for a client with sarcoidosis. The client is upset because he has missed work and worried about how he will care financially for his wife and three small children. On the basis of the client's concern, which problem does the nurse identify? Anxiety Powerlessness Disruption of thought processes Inability to maintain health - answers>Anxiety Rationale: Anxiety is a vague, uneasy feeling of apprehension. Some related factors include a threat or perceived threat to physical or emotional integrity or self-concept, changes in function in one's role, and threats to or changes in socioeconomic status. The client experiencing powerlessness expresses feelings of having no control over a situation or outcome. Disruption of thought processes involves disturbance of cognitive abilities or thought. Inability to maintain health is being incapable of seeking out help needed to maintain health. A nurse, performing an assessment of a client who has been admitted to the hospital with suspected silicosis, is gathering both subjective and objective data. Which question by the nurse would elicit data specific to the cause of this disorder? "Do you chew tobacco?" "Do you smoke cigarettes?" "Have you ever worked in a mine?" "Are you frequently exposed to paint products?" - answers>"Have you ever worked in a mine?" Rationale: Silicosis is a chronic fibrotic disease of the lungs caused by the inhalation of free crystalline silica dust over a long period. Mining and quarrying are each associated with a high incidence of silicosis. Hazardous exposure to silica dust also occurs in foundry work, tunneling, sandblasting, pottery-making, stone masonry, and the manufacture of glass, tile, and bricks. The finely
A nurse who will be staffing a booth at a health fair is preparing pamphlets containing information regarding the risk factors for osteoporosis. Which risk factors does the nurse include in the pamphlet? Select all that apply. Smoking A high-calcium diet High alcohol intake White or Asian ethnicity Participation in physical activities that promote flexibility and muscle strength - answers>Smoking High alcohol intake White or Asian ethnicity Rationale: Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Risk factors include being 65 years or older in women, 75 years or older in men, family history of the disorder, history of fracture after age 50, white or Asian ethnicity, low body weight and slender build, chronically low calcium intake, a history of smoking, high alcohol intake, and lack of physical exercise or prolonged immobility. A nurse is providing instruction to a client with osteoporosis regarding appropriate foods to include in the diet. What one food item high in calcium does the nurse tell the client to eat? Corn Cocoa Peaches Sardines - answers>Sardines Rationale: Foods high in calcium include milk and milk products, dark-green leafy vegetables, tofu and other soy products, sardines, and hard water. Osteoporosis is a chronic metabolic disease in which bone loss results in decreased density and sometimes fractures. Corn, cocoa, and peaches do not contain appreciable amounts of calcium. A nurse is providing information about home care to a client with acute gout. Which measures does the nurse tell the client to take? Select all that apply. Drinking 2 to 3 L of fluid each day Applying heat packs to the affected joint Resting and immobilizing the affected area Consuming foods high in purines Performing range-of-motion exercise to the affected joint three times a day - answers>Drinking 2 to 3 L of fluid each day Resting and immobilizing the affected area Rationale: Gout is a systemic disease in which urate crystals are deposited in the joints and other tissues, resulting in inflammation. In acute gout, rest and immobilization are recommended until the acute attack and inflammation have subsided. Local application of cold may help relieve the pain. The application of heat is avoided because it may worsen the inflammatory process. Dietary instructions include reducing or eliminating alcohol intake and avoiding excessive intake of foods containing purines (e.g., sweetbreads, yeast, heart, herring, herring roe, sardines). The client is encouraged to drink 2 to 3 L of fluid per day to help eliminate uric acid and to prevent the formation of renal calculi. A nurse is gathering subjective and objective data from a client with suspected rheumatoid arthritis (RA). Which early manifestations of RA would the nurse expect to note? Select all that apply. Fatigue
Anemia Weight loss Low-grade fever Joint deformities - answers>Fatigue Low-grade fever Rationale: Early manifestations of RA include fatigue, low-grade fever, weakness, anorexia, and paresthesias. Rheumatoid arthritis is a chronic, progressive, systemic and inflammatory autoimmune disease process that affects the synovial joints, resulting in their destruction. Anemia, weight loss, and joint deformities are some of the late manifestations. A nurse is reviewing the medical record of a client with a suspected systemic lupus erythematosus (SLE). Which manifestations of SLE would the nurse expect to find noted in the client's medical record? Select all that apply. Fever Vasculitis Weight gain Increased energy Abdominal pain - answers>Fever Vasculitis Abdominal pain Rationale: Systemic lupus erythematosus is a chronic, progressive, inflammatory disorder of the connective tissue that can cause the failure of major organs and body systems. Manifestations include fever, fatigue, anorexia, weight loss, vasculitis, discoid lesions, and abdominal pain. Erythema, usually in a butterfly pattern (hence the nickname "butterfly rash"), appears over the cheeks and bridge of the nose. Other manifestations include nephritis, pericarditis, the Raynaud phenomenon (discoloration of fingers and/or toes after exposure to changes in temperature), pleural effusions, joint inflammation, and myositis. A nurse is providing dietary instructions to a client who is taking tranylcypromine sulfate. Which foods does the nurse tell the client to avoid while she is taking this medication? Select all that apply. Beer Apples Yogurt Baked haddock Pickled herring Roasted fresh potatoes - answers>Beer Yogurt Pickled herring Rationale: Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) used to treat depression. The client must follow a tyramine-restricted diet while taking the medication to help prevent hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided include meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausages (e.g., salami, pepperoni, bologna). In addition, figs, bananas, aged cheeses, yogurt and sour cream, beer, red wine, alcoholic beverages, soy sauce, yeast extract, chocolate, caffeine, and aged, pickled, fermented, or smoked foods must be avoided. Many over-the-counter medications contain tyramine and must be avoided as well.
A client with agoraphobia will undergo systematic desensitization through graduated exposure. In explaining the treatment to the client, what does the nurse tell the client this technique involves? Having the client perform a healthy coping behavior Having the client perform a ritualistic or compulsive behavior Providing a high degree of exposure of the client to the stimulus that the client finds undesirable Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening - answers>Gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening Rationale: The technique of systematic desensitization involves gradually introducing the client to a phobic object or situation in a predetermined sequence of least to most frightening with the goal of defusing the phobia. Having the client perform a healthy coping behavior is the description of modeling. Performing ritualistic or compulsive behaviors is a behavior characteristic of clients with obsessive-compulsive disorder. Having the client perform a ritualistic or compulsive behavior may not be therapeutic; additionally, it is not associated with systematic desensitization. Providing a high degree of exposure to a stimulus that the client finds undesirable is the technique known as flooding. The nurse is caring for a client who has just undergone esophagogastroduodenoscopy (EGD). The client says to the nurse, "I'm really thirsty — may I have something to drink?" Before giving the client a drink, what would the nurse do? Check the client's vital signs Check for the presence of a gag reflex Assess the client for the presence of bowel sounds Ask the client to gargle with a warm saline solution - answers>Check for the presence of a gag reflex Rationale: After an EGD, the nurse places the highest priority on assessing the client for the return of the gag reflex. In preparation for EGD, the client's throat is usually sprayed with an anesthetic to dampen the gag reflex and permit the introduction of the endoscope used to visualize the gastrointestinal structures. No food or oral fluids are given to the client until the gag reflex is fully intact.Vital signs are checked frequently, but this action is not associated with giving the client oral fluids. The client may be asked to use throat lozenges or a saline gargle to relieve a sore throat after the test, but neither action is related to giving the client oral fluids; additionally, neither action would be taken until the gag reflex had been detected again. Bowel sounds are not affected by this test. A nurse is developing a plan of care for a pregnant client with sickle-cell disease. Which concern does the nurse recognize as the priority? Inability to cope Decreased nutrition Decreased fluid volume Inability to tolerate activity - answers>Decreased fluid volume Rationale: Decreased fluid volume is the priority concern in this situation, followed by decreased nutrition. Inability to tolerate activity and inability to cope compete for third priority, depending on the client's specific signs/symptoms at the time. Sickle cell disease is a genetic disorder that is manifested as chronic anemia, pain, disability, organ damage, increased risk for infection, and early death. In this disorder the red blood cells assume a sickle shape, become rigid, and clump together. Dehydration can precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and the fetus, including interruption of blood flow to the respiratory system and placenta. A nurse is preparing a pregnant client in the third trimester for an amniocentesis. What does the nurse tell the client is the reason amniocentesis is often performed during the third trimester?
To know the sex of the fetus To discover genetic characteristics To establish an accurate age for the fetus To assess the degree of fetal lung maturity - answers>To assess the degree of fetal lung maturity Rationale: Amniocentesis is the aspiration of fluid from the amniotic sac for examination. Common indications for amniocentesis during the third trimester include assessment of fetal lung maturity and evaluation of fetal condition when the woman has Rh isoimmunization. A common purpose of amniocentesis in the second trimester is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Other methods of genetic analysis, such as those for metabolic defects in the fetus, may be performed on the cells as well. The sex and age of the fetus are not determined with the use of amniocentesis. A nurse provides instruction to a pregnant woman about foods containing folic acid. Which of these foods does the nurse tell the client to consume as sources of folic acid? Select all that apply. Bananas Potatoes Spinach Legumes Whole grains Milk products - answers>Spinach Legumes Whole grains Rationale: Some foods high in folic acid are glandular meats, yeast, dark-green leafy vegetables, legumes, and whole grains. Folic acid is needed during pregnancy for healthy cell growth and repair. A pregnant woman should have at least four servings of folic acid-rich foods per day. Bananas provide potassium. Potatoes provide vitamin B6, and milk products are a source of calcium. A nurse caring for a client with preeclampsia prepares for the administration of an intravenous infusion of magnesium sulfate. Which substance does the nurse ensure is readily available? Vitamin K Protamine sulfate Potassium chloride Calcium gluconate - answers>Calcium gluconate Rationale: Calcium gluconate should be available at the bedside of a client receiving an intravenous infusion of magnesium sulfate to reverse magnesium toxicity and prevent respiratory arrest if the serum magnesium level becomes too high. Magnesium sulfate, which has anticonvulsant properties, is used for a client with preeclampsia to help prevent seizures (eclampsia). It also causes central nervous system depression, however, so toxicity is a concern. Vitamin K is the antidote for warfarin sodium (Coumadin). Protamine sulfate is the antidote for heparin. Potassium chloride is used to treat potassium deficiency. A nurse is monitoring a client receiving terbutaline by intravenous infusion to stop preterm labor. The nurse notes that the client's heart rate is 120 beats/min and that the fetal heart rate is 170 beats/min. What is the most appropriate action the nurse should take? Contact the primary health care provider Document the findings Continue to monitor the client
Rationale: A major complication of a missed abortion is disseminated intravascular coagulation (DIC). Bleeding at the sites of intravenous needle insertion or laboratory blood draws, nosebleeds, and spontaneous bruising may be early indicators of DIC; they should be reported and require further evaluation. Missed abortion is the term used to describe when a fetus dies during the first half of pregnancy but is retained in the uterus. When the fetus dies, the early signs/symptoms of pregnancy (e.g., nausea, breast tenderness, urinary frequency) disappear. The uterus stops growing and begins to shrink. Red or brownish vaginal bleeding may or may not occur. A client is receiving an intravenous infusion of oxytocin to stimulate labor. The nurse monitoring the client notes uterine hypertonicity. What does the nurse immediately do? Stop the oxytocin infusion Check the vagina for crowning Encourage the client to take short, deep breaths Increase the rate of the oxytocin infusion and call the primary health care provider - answers>Stop the oxytocin infusion Rationale: The nurse would immediately stop the oxytocin infusion and increase the rate of the nonadditive solution, position the client in a side-lying position, and administer oxygen with the use of a snug face mask at 8 to 10 L/min. If uterine hypertonicity or a nonreassuring fetal heart rate pattern is detected, the nurse must intervene to reduce uterine activity and increase fetal oxygenation. The nurse would also notify the primary health care provider. Oxytocin is a synthetic compound identical to the natural hormone secreted from the posterior pituitary gland. It is used to induce or augment labor at or near term. The nurse monitors uterine activity for the establishment of an effective labor pattern and for complications associated with the use of the medication. Checking the vagina for crowning; encouraging the client to take short, deep breaths; and increasing the rate of the oxytocin infusion are not the immediate actions. A nurse is monitoring a pregnant woman in labor and notes this finding on the fetal-monitor tracing (see figure). Which action should the nurse take as a result of this observation? Reposition the mother Document the finding Notify the nurse-midwife Take the mother's vital signs - answers>Document the finding Rationale: The nurse sees evidence of accelerations. Accelerations are transient increases in the fetal heart rate that often accompany contractions and are normally caused by fetal movement. Ths nurse should document the finding. Accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Repositioning the mother, notifying the nurse-midwife, and taking the mother's vital signs are all unnecessary actions. A client with cervical cancer is undergoing chemotherapy with cisplatin. For which adverse effect of cisplatin will the nurse assess the client? Nausea Bloody urine Hearing loss Electrocardiographic changes - answers>Hearing loss Rationale: Cisplatin is a platinum-based agent used to treat various types of cancer. One adverse effect of cisplatin is ototoxicity, and the nurse would monitor the client for tinnitus and hearing loss. Nausea occurs with the use of several chemotherapeutic agents and is not necessarily an adverse effect. Cyclophosphamide causes hemorrhagic cystitis, evidenced by bloody urine. Doxorubicin (Adriamycin) causes cardiotoxicity.
A nurse is monitoring a pregnant client with suspected partial placenta previa who is experiencing vaginal bleeding. Which finding would the nurse expect to note on assessment of the client? Painful vaginal bleeding Sustained tetanic contractions Complaints of abdominal pain Soft, relaxed, nontender uterus - answers>Soft, relaxed, nontender uterus Rationale: Partial placenta previa is incomplete coverage of the internal os by the placenta. One characteristic of placenta previa is painless vaginal bleeding. The abdominal assessment would reveal a soft, relaxed, nontender uterus with normal tone. Vaginal bleeding and uterine pain and tenderness accompany placental abruption, especially with a central abruption and blood trapped behind the placenta. In placental abruption, the abdomen feels hard and boardlike on palpation as the blood penetrates the myometrium, resulting in pain and uterine irritability. A sustained tetanic contraction may occur if the client is in labor and the uterine muscle cannot relax. A nurse assisting with a delivery is monitoring the client for placental separation after the delivery of a viable newborn. Which observation indicates to the nurse that placental separation has occurred? A discoid uterus Sudden sharp vaginal pain Shortening of the umbilical cord A sudden gush of dark blood from the introitus - answers>A sudden gush of dark blood from the introitus Rationale: Placental separation occurs when the placenta separates from the uterus. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and a change in uterine shape from discoid to globular. The client may experience vaginal fullness but sudden sharp vaginal pain is not usual. A nurse is conducting a preoperative psychosocial assessment of a client who is scheduled for a mastectomy. Which finding would cause the nurse to conclude that the client is at risk for poor sexual adjustment after the mastectomy? The client reports a history of sexual abuse by her father. The client reports irregular menses relationship with her spouse. The client reports a satisfying intimate relationship with her spouse. The client reports that her and her spouse have never been able to conceive children. - answers>The client reports a history of sexual abuse by her father. Rationale: Clients at risk for self-esteem problems and poor sexual adjustment after mastectomy include those who report a lack of support from a spouse or partner; the existence of an unhappy, unstable intimate relationship; or a history of sexual problems or of sexual abuse, such as rape or incest. Clients with problems involving intimate relationships and sexuality should be referred for counseling. The remaining options are unrelated to the problem of poor sexual adjustment. A nurse provides instructions to a client who is preparing for discharge after a radical vulvectomy for the treatment of cancer. Which statement by the client indicates a need for further instruction? "I can resume sexual activity in 4 to 6 weeks." "I need to avoid straining when I have a bowel movement." "I should wear support hose for 6 months and elevate my legs frequently."
Rationale: Most clients with CKD retain sodium. The client with CKD is instructed not to add salt at the table or during food preparation. Herbs and spices may be used as an alternative to salt to enhance the flavor of food. The client with advanced CKD is instructed to limit potassium intake. The client is also instructed to avoid salt substitutes, many of which are composed of potassium chloride, if oliguria is present. Processed foods are discouraged because they are high in sodium. A nurse provides dietary instruction to a hospitalized client with chronic obstructive pulmonary disease (COPD). Which menu selection by the client tells the nurse that the client understands the instructions? Coffee Broccoli Cheeseburger Chocolate milk - answers>Cheeseburger Rationale: The client with COPD is encouraged to eat a high-calorie, high-protein diet and to choose foods that are easy to chew and do not promote gas formation. Dry foods stimulate coughing, and foods such as milk and chocolate may increase the thickness of saliva and other secretions. The nurse advises the client to avoid these foods, as well as caffeinated beverages, which promote diuresis, contributing to dehydration, and may increase nervousness. Chlorpromazine has been prescribed to a client with Huntington's disease for the relief of choreiform movements (repetitive and rapid, jerky, involuntary movements that appear well-coordinated). Of which common side effect does the nurse warn the client? Headache Drowsiness Photophobia Urinary frequency - answers>Drowsiness Rationale: Chlorpromazine is an antipsychotic, antiemetic, antianxiety, and antineuralgia adjunct. Common side effects of chlorpromazine include drowsiness, blurred vision, hypotension, defective color vision, impaired night vision, dizziness, decreased sweating, constipation, dry mouth, and nasal congestion. Headache, photophobia, and urinary frequency are not specific side effects of this medication. A client who has sustained an acute myocardial infarction (AMI) is receiving intravenous reteplase. For which adverse effect of the medication does the nurse monitor the client? Diarrhea Vomiting Epistaxis Epigastric pain - answers>Epistaxis Rationale: Reteplase is a thrombolytic medication that promotes the fibrinolytic mechanism (i.e., conversion of plasminogen to plasmin, which destroys the fibrin in the blood clot). The thrombus, or blood clot, disintegrates when a thrombolytic medication is administered within 4 hours of an AMI. Necrosis resulting from blockage of the artery is prevented or minimized, and hospitalization may be shortened. Bleeding, a major adverse effect of thrombolytic therapy, may be superficial or internal and may be spontaneous. Epigastric pain, vomiting, and diarrhea are not adverse effects of this therapy. A home care nurse visits a mother who delivered a healthy newborn 4 days ago and assesses how the mother is doing breastfeeding her infant. What does the nurse ask the mother to do to permit assessment of whether the infant is receiving an adequate amount of milk? Count the number of times that the infant swallows during a feeding Weigh the infant every day and check for a daily weight gain of 2 oz (60 ml) Count wet diapers to be sure that the infant is having at least six to 10 each day
Pump the breasts, place the milk in a bottle, measure the amount, and then bottle-feed the infant - answers>Count wet diapers to be sure that the infant is having at least six to 10 each day Rationale: The mother should be taught to count wet and soiled diapers to help determine whether the infant is receiving enough milk. Generally an infant should have at least 6 to 10 wet diapers (after the first 2 days of life) and at least 4 stools each day. The mother may also assess the swallowing and nutritive suckling of the infant, but this would not provide the best indication of adequate milk intake. Counting the number of times that the infant swallows during a feeding is an inadequate indicator of milk intake. The mother is not usually encouraged to weigh the infant at home, because this focuses too much attention on weight gain. Infants generally gain approximately 15 to 30 g (0.5 to 1 oz) each day after the early months of life. Pumping the breasts, placing the milk in a bottle, measuring the amount, and then bottle-feeding the infant constitute an assessment of the mother's bottle- feeding technique. A child who has just been found to have scoliosis will need to wear a thoracolumbosacral orthotic (TLSO) brace, and the nurse provides information to the mother about the brace. Which statement by the mother indicates a need for further information? "My child will need to do exercises." "My child needs to wear the brace 18 to 23 hours per day." "Wearing the brace is really important in curing the scoliosis." "I need to check my child's skin under the brace to be sure it doesn't break down." - answers>"Wearing the brace is really important in curing the scoliosis." Rationale: Scoliosis is a lateral curvature of the spine. There is a need for further information when the mother says, "Wearing the brace is really important in curing the scoliosis." Bracing is not curative of scoliosis but may slow the progression of the curvature to allow skeletal growth and maturation. A brace needs to be worn 18 to 23 hours a day, but it may be removed at night for sleep if this is prescribed. To be more cosmetically acceptable, a brace is usually worn under loose-fitting clothing. Back exercises are important in maintaining and strengthening the abdominal and spinal muscles. The child's skin must be meticulously monitored for signs of breakdown. Ferrous sulfate is prescribed for a client. What does the nurse tell the client is best to take the medication with? Milk Water Any meal Tomato juice - answers>Tomato juice Rationale: Ferrous sulfate is an iron product. Absorption of iron is best promoted when the supplement is taken with orange juice or tomato juice another food source of vitamin C or ascorbic acid. Calcium and phosphorus in milk decrease iron absorption. Water has no effect on the absorption of vitamin C. Telling the client to take the medication with any meal of the day does not guarantee that the iron will be taken with a food source of vitamin C or ascorbic acid. Additionally, it is best to take the iron supplement between meals with a drink high in ascorbic acid. client diagnosed with type 1 diabetes mellitus has just been told that she is 6 weeks pregnant. The nurse provides information to the client about dietary and insulin needs. What comment by the client suggests an understanding of the information?"I know I will have to increase my insulin during this time period." "My insulin needs should decrease during the first trimester." "Needs for insulin will not change during the first 3 months of pregnancy." "I will have to double up on the insulin dose during this time span." - answers>"My insulin needs should decrease during the first trimester." Rationale: Insulin needs generally decrease during the first trimester of pregnancy because the secretion of placental hormones antagonistic to insulin remains low. An increase in insulin need, lack of change in insulin need, and doubling of insulin need are all incorrect.
