Hesi
The nurse has conducted a cancer prevention community education program in evaluating the participants understanding of the carcinogens which statement indicates an accurate understanding
Substances that change a cell so that it becomes cancerous are potential sources of cancer
A client with a right ulnar fracture and cast placement reports an increase in arm pain which action should the nurse take next
Assess right radial pulse volume
A client experiences residual effects following an acute attack of meniere's disease and receives a new prescription for an antihistamine which assessment finding indicates that the medication is effective
Ambulates easily without vertigo
The nurse is caring for a client who had a cholecystectomy two days ago. The client is febrile, reporting upper abdominal pain radiating to the back and has had three episodes of vomiting in the last 8 hours. The nurse reviews the client's serum amylase and lipase level results which are twice the normal value. Based on these findings, the nurse should recognize the client is exhibiting symptoms of which condition?
Acute pancreatitis.
A client who is experiencing a first gouty arthritis attack reports excruciating pain in the right great toe. The nurse inspects the inflamed joint and administers ibuprofen 800 mg PO as prescribed. Which instruction should the nurse include in the discharge teaching?
Avoid the consumption of wine, beer, and coffee.
The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
Spinach salad.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
High pitched sound heard upon inspiration
A client reports to the nurse of recently visiting someone who has a shingles infection the client believes that having had chickenpox as a child will be protective against shingles how should the nurse respond SATA
Affirm that a person with shingles has a history of chickenpox infection
Distinguish the difference between herpes varicella and herpes zoster
The nurse is caring for a client with acute kidney injury (AKI) which assessment finding warrants immediate intervention
Dyspnea and sinus tachycardia
Which instruction should the nurse in the discharge teaching for a client who has gastroesophageal reflux
Teach the client to elevate the head of the bed on blocks
Following a motor vehicle collision a client with chest trauma receives a chest tube to relieve a hemothorax two hours following the chest tube insertion the nurse observes the water level in the water seal chamber is rising during inspiration and falling during expiration which action should the nurse implement
Continue to monitor drainage system
A client who was recently diagnosed with Raynaud's disease is concerned about pain management which nursing instruction should the nurse provide
Wearing gloves when handling cold items guards against painful spasms
The nurse is developing home care instructions for a client with peripheral artery disease (PAD) which intervention should the nurse include
Structured exercise
A client with an external fixation device for a fractured left femur is troubled with left foot pain which intervention should the nurse implement first
Assess peripheral pulses
The nurse is caring for a client diagnosed with psoriasis vulgaris who is receiving a psoralen and ultraviolet A light (PUVA) treatment which assessment finding indicates that the client has been overexposed to the treatment
Requires sunglasses because sunlight hurts eyes.
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA) which information should the nurse include in the discharge instructions
Restrict physical activities
A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
Confirmation of the autoimmune disease process
A client with chronic kidney disease on peritoneal dialysis exhibits redness tenderness and drainage around the catheter site of the abdominal wall while planning care the nurse is most concerned about preventing which complication related to these findings
Peritonitis
While caring for a client with full thickness burns covering 40% of the body the nurse observes purulent drainage from the wounds before reporting this finding to the healthcare provider the nurse should evaluate which laboratory value
Neutrophil count
The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan which behavior indicates that the client is adhering to the eating plan
Enjoys fat free yogurt as an occasional snack food
A client is hospitalized with an inflammatory bowel disease (IBD) exacerbation and is being treated with a corticosteroid the client develops a rigid abdomen with rebound tenderness which action should the nurse take
Obtain vital sign measurements
An adult client newly diagnosed with left ventricular dysfunction is admitted to the hospital with fine rales and wheezing when assessing this client which additional finding is the nurse likely to obtain
Fatigue
The nurse determines that an adult client who is admitted to the postanesthesia care unit(PACU) following abdominal surgery has a tympanic temperature of 94.6 F a heart rate of 88 beats/min a respiratory rate of 14 breaths/min and a blood pressure of 94/68mmHg which action should the nurse implement
Raise the head of the bed to 60 - 90 degrees
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH) which information should the nurse provide
Increase physical activity
While completing a health assessment for a young adult female with acute appendicitis the client informs the nurse that there is a chance that she may be pregnant the operating team is preparing to take the client to surgery which intervention should the nurse implement immediately
Perform a bedside pregnancy test
Which nursing problem should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction
Risk for injury related to effects to adverse of thrombolysis
A client with a history of chronic indigestion is brought to the emergency department (ED) with acute abdominal pain and confusion the client reports constipation and frequent urination which of the client's serum laboratory value requires intervention by the nurse
Reference range:
Potassium (3.5-5.0)
Calcium 9 -10.5)(2.25-2.62 mmol/L)
Magnesium (1.3 - 2.1)( 0.65 to 1.05 mmol/L)
Hemoglobin (14-18) (8.7 to 11.2 mmol/L)
Calcium 12mg (3 mmol/L)
The nurse is admitting a client with possible tuberculosis (TB) the client is placed in a private room with airborne precautions pending diagnostic test results. Which diagnostic test should the nurse review to confirm the diagnosis of TB
Sputum culture positive for Mycobacterium tuberculosis
A client with metastatic cancer reports a pain level of 10 on a 0 to 10 scale twenty minutes after the nurse administers an IV analgesic the client states No pain relief yet which intervention is most important for the nurse to include in the client's plan of care
Frequently evaluates the client's pain
A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder which assessment finding should the nurse expect this client to exhibit
Profuse diaphoresis and severe pounding headache
Two weeks after returning home from traveling a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell the nurse obtains a nasal swab to test for covid -19 which action is most important for the nurse to take
Isolate the client from other clients family and healthcare workers not wearing proper PPE
The nurse is preparing an older client for a magnetic resonance imaging ( MRI) with contrast. Which laboratory value should the nurse report for the healthcare provider (HCP) before the scan is performed?
Reference range:
Glycosylated hemoglobin A!c (HbA1c) [Nondiabetic 4% to 5.9%]
Serum Creatinine [0.6 to 1.2 mg/dl)(53 to 106 umol/L)
Fasting blood sugar (70 - 110 mg/dL)(less than 6.1 mmol/L)
Blood Urea nitrogen (BUN)(10 - 20 mg/dL) (3.6 to 7.1 mmol?L)
Serum Creatinine of 1.9 mg/d/L (168 umol/L)
A family suspects that AIDS dementia is occuring in their adult child who is HIV positive. Which symptom confirms the suspicion?
A change has recently occurred in handwriting
The nurse is providing teaching to a client newly diagnosed with type 2 Diabetes mellitus about disease management. Which information stated by the client indicates understanding
Check blood sugar levels every 4 to six hours every day
When teaching a client with Parkinson's disease, which rationale for the prescription of Carbidopa Levodopa should the nurse include?
Increases the amount of dopamine available for muscles to function properly
A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?
Meningococcal meningitis
A client with oral cancer is receiving radiotherapy (RT) prior to surgery. Which intervention should the nurse teach the client to implement in managing mucositis related to RT?
Normal saline mouth rinses as swish and spit after meals and bedtime
A client who takes daily supplemental iron tablets for iron deficiency anemia reports feeling increasingly fatigued. Which laboratory value should the nurse review?
Complete Blood Count
Lactulose was prescribed two days ago for a client who was recently diagnosed with hepatic encephalopathy. The client is confused and experiencing frequent loose stools. Laboratory findings show an elevated serum ammonia (NH3) level of 200 mcg/dL (157.09 umol/L). WHich action should the nurse take?
Reference Range:
Ammonia [10 to 80 mcg/dL (6 to 47 umoL]
Hold the next dose of lactulose
A client with chronic kidney disease on peritoneal disease exhibits redness, tenderness and drainage around the catheter site on the abdominal wall. While planning care, the nurse is most concerned about preventing which complication related to these findings?
Peritonitis