At a community health fair, a 50 yr old woman tells the nurse she has an annual physical exam that

HESI V4 FrmRN2u A 59 yr old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client’s condition?He is in a coma, and has a very poor prognosis At a community health fair, a 50 yr old woman tells the nurse she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?Ask the woman if she also performs monthly breast self-exams Which assessment finding should indicate to the nurse that a client with arterial HTN is experiencing a cardiac complication?Complaints of shortness of breath on exertion A college student who is Dx with a vaginal infection and vulva irritation describes the vaginal discharge as having a “cottage-cheese” appearance. Which prescription should the nurse implement first?Instill the first dose of nystatin (Mycostatin) vaginally per applicator A client in acute renal failure has a serum potassium of 7.5 mEq/L. Based on this finding the nurse should anticipate implementing which action?Administer a retention enema of Kayexalate The nurse manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?A 35 year-old with Lupus erythematosus A nurse is teaching a client postoperative breathing techniques using an incentive spirometer (IS). What should the nurse encourage this client to do to maintain sustained maximal inspiration?Inspire deeply and slowly over 3 to 5 seconds The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine (Clozaril). Which statement should the nurse provide?“the medication will help you think more clearly” A male client with diabetes mellitus takes Novolin 70/30 insulin before meals and azithromycin (Zithromax) PO daily, using medication he brought from home. When the nurse delivers his breakfast tray, he tells her that he took his insulin but forgot to take his daily dose of the Zithromax an hour before breakfast as instructed. Action?Instruct the client to eat his breakfast and take the Zithromax two hours after eating What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?Treat sexual partner(s) concurrently A primagravida at term comes to the prenatal clinical and tells the nurse that she is having contractions every 5 minutes. The nurse monitors the client for one hour, using an external fetal monitor, and determines that the client’s contractions are 7 to 15 seconds with mild intensity by palpation. Action?Send the client home and instruct her to call the clinic when her contractions occur 5 minutes apart for one hour HESI V4 FrmRN2u

Which instruction should the nurse provide to an elderly client taking an ACE inhibitor and a calcium channel blocker?Change positions slowly Assessment findings of a 3-hr old newborn include: axillary temperature of 97.7, HR of 140 with a soft murmur, and irregular RR 42. Based on these findings; action?Record the findings on the flow sheet A client admitted to the hospital for depression is escorted to a private room. Prior to leaving the room, what intervention is most important for the nurse to implement?Search all personal belongings An experienced nurse tells the nurse manager that working with a new graduate is impossible because the new grad will not listen to suggestions. The new grad comes to the nurse manager describing the senior nurses’ attitude as challenging and offensive. Action best for NM to take?Ask the nurses to meet with the nurse manager to identify ways of working together Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?Ineffective tissue perfusion The nurse offers diet teaching to a female college student who was Dx with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?Combine several legumes and grains such as beans and rice to form complete proteins The nurse is triaging clients from a train wreck. A client has multiple open wounds, a BP of 90/50, and Pulse of 112. Which triage tag color should the nurse place on this client?Red Which action should the nurse include in the plan of care for a client who is receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?Monitor serum creatinine levels A client receiving amlodipine (Norvasc), a calcium channel blocker, develops 1+ pitting edema around the ankles. It is most important for the nurse to obtain what additional client data?Breath sounds A male adult client is transferred to a psychiatric facility following release from the hospital for treatment of a self-inflicted gunshot wound. In attempting to develop a therapeutic relationship with the client, which information is most important?The nurses’ feelings about this client Which client requires careful nursing assessment for signs and symptoms of hypermagnesemia?A middle-aged male client in renal failure following an unsuccessful kidney transplant While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. Action?Measure the length of the apneic periods HESI V4 FrmRN2u

The nurse is preparing to administer the 0700 dose of 20 units of Humulin R to an 8-yr old girl Dx with type 1 diabetes. The mother comments that her daughter is a very picky eater and many times does not eat meals. Intervention?Ask the girl if she will be eating her breakfast this morning The nurse is caring for a 10-yr old who is Dx with acute glomerulonephritis. Which outcome is the priority for this child?Fluid balance maintained as evidenced by a urine output of 1 to 2 ml/kg/hr A 20-yr old male client is Dx with Ewing’s sarcoma following examination for a knee injury. Which instruction is most important for the nurse to provide the client?Seek treatment for the sarcoma immediately The nurse in the newborn nursery admits a baby from L & D who is suspected of having a congenital heart Dz. Which findings help to confirm this diagnosis?Centralized cyanosis and tachycardia when crying A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampoules containing 0.2 mg/ml. What is the max dosage in mg that the nurse should administer to this client?2 A male client admitted three days ago with respiratory failure is extubated and with 40% oxygen per face mask is initiated. Currently his temperature is 99, cap refill is less than 4 seconds, and respiratory effort is within normal limits. What outcome should the nurse evaluate to measure for successful extubation?Maintains effective breathing pattern A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the HCP and implement which intervention?Prepare for intubation with an endotracheal tube When caring for a laboring client whose contractions are occurring every 2 to 3 minutes, the nurse should document that the pump is infusing how many ml/hr?42 The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse she has a new man in her life, with whom she is having a sexual relationship, and they both smoke cigarettes. Information to provide?A diaphragm and condom provide effective contraception when used together An adult male admitted to the psych unit from ED because he is in the manic stage of bipolar disorder.He has lost 10 lbs in the last two weeks and has not bathed in a week because he has been “trying to start a new business” and is “too busy to eat.” He is alert and oriented to time, place, and person, but not situation. Dx?Imbalanced nutrition HESI V4 FrmRN2u

A client in the oliguric phase of acute renal failure (ARF) has a 24 hour urine output of 400ml. nurse should allow this client to have how much oral intake during the next 24 hours?Limit oral intake to 900 to 1000 ml A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client’s wrists and asks her what happened. She doesn’t respond. Next?Take the client to a room for supervision by staff What assessment technique should the nurse use to monitor a client for a common untoward effect of phenytoin (Dilantin)?Inspection of the mouth The nurse is preparing to administer an IM dose of Vitamin B1 (thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, “what do you think you’re doing?” Response?“this shot will help relieve the pain in your feet” When administering an intramuscular injection containing 3 ml of a painful medication, Intervention?Select a large, deep muscle mass Nurses working in L & D are demanding a change in policy because they believe they are required to float more often than nurses on other units. However, floating to L & D is not reciprocated because other nurses are not competent to provide highly specialized obstetrical skills. Action?Propose a method for self-staffing labor and delivery Locate the optic disk It is the really light area on the right The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. which action indicates the mother understands instructions?Positions the infant supine in the crib to sleep HCP prescribes amoxicillin (Amoxil) 1.5 grams PO daily, in equally divided doses to be administered every

• hours. The medication is available in a bottle labeled, “Amoxicillin (Amoxil) suspension 200mg/5ml.”

How many ml should nurse administer every 8 hours?

12.5 20 year old female client tells nurse her menstrual periods occur about every 28 days, and her breasts are quite tender when her flow is heavy. She also states that she performs her breast self-exam on the first day of every month. Action?Encourage the client to perform BSE 2-3 days after her menstrual period ends HESI V4 FrmRN2u