6. Twenty minutes after the client has received a preoperative injection of atropine and midazolam (Versed), the client tells the nurse that he must be allergic to the medication because his mouth is dry and his heart seems to be beating faster than normal. What is the nurse’s best first action? A. Document the findings as the only action. B. Check the client’s pulse and blood pressure. C. Prepare to administer epinephrine and diphenhydramine (Benadryl). D. Explain to the client that these symptoms are normal responses to the medication.

ANS: B Although these are the expected physiologic responses to the preoperative medication, any time the client states that he or she can feel a change in normal cardiac function, the system should be assessed. If the client’s pulse and blood pressure are within normal limits, the nurse should More test answers on https://studyhippo.com/perioperative-nursing-practice-questions/

3. The nurse notices clear nasal drainage in a patient newly admitted with facial trauma, including a nasal fracture. The nurse should: A. test the drainage for the presence of glucose. B. suction the nose to maintain airway clearance. C. document the findings and continue monitoring. D. apply a drip pad and reassure the patient this is normal.

A. test the drainage for the presence of glucose. Clear nasal drainage suggests leakage of cerebrospinal fluid (CSF). The drainage should be tested for the presence of glucose, which would indicate the presence of CSF. More test answers on https://studyhippo.com/hesi-med-surg/

A nurse is performing an assessment on a client who is at 38 weeks gestation and notes that the FHR is 174/bpm. On the basis of this finding, the appropriate nursing action is to: 1. Notify the physician 2. Document the findings. 3. Check the mother’s heart rate 4. Tell the client that the FHR is normal.

1. Notify the physican Rational: The FHR depends on gestational age and ranges from 160-170/bpm in the 1st trimester, but slows with fetal growth to 120-160/bpm near or at term. Because the FHR is increased from the reference range, the nurse should notify the physican. More test answers on https://studyhippo.com/exam-1-ob-nclex-questions/

3 Nurses are mandated reporters of suspected child abuse. Significant bruising on a 2-year-old child’s head, arms, abdomen, and legs possibly indicate child abuse. It is not enough to document the findings, instruct the mother on safe handling of the child, or discuss the story with a colleague.

The home health nurse notices significant bruising on a 2-year-old child’s head, arms, abdomen, and legs. The patient’s mother describes the child’s frequent falls. Which is the best nursing action for the home health nurse to take? 1 Document the findings and treat the child. 2 Instruct the mother on safe handling of a 2-year-old child. 3 Contact a child abuse hotline. 4 Discuss this story with a colleague. More test answers on https://studyhippo.com/foundations-of-nursing-chapter-23-legal-implications-in-nursing-practice/

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Document The Finding Fluid Volume Excess Nursing

Cirrhosis case study – Flashcards 24 terms

Jamie Hutchinson

24 terms

Preview

Cirrhosis case study – Flashcards

question

Which information about cirrhosis should the nurse remember when responding to Frank's wife?

answer

There are several types of cirrhosis with differing causes.

question

Which question is most important for the nurse to include when assessing the client for etiologic factors related to cirrhosis?

answer

Have you been exposed to toxic substances where you work?

question

When nursing intervention is important prior to a paracentesis?

answer

Instruct the client to empty his bladder.

question

Maintaining bedrest for 24 to 48 hours is an important nursing intervention following which procedure?

answer

Angiography with portal pressure measurements.

question

In the client with cirrhosis, which lab value will be decreased from the normal value?

answer

Serum albumin.

question

Which clinical manifestation is likely to occur as the result of the prolonged APTT and PT/INR?

answer

Epistaxis.

question

Which other clinical manifestation(s) may occur with cirrhosis? (Select all that apply)

answer

-Fruity breath. -Clay colored stools.

question

Which medication places Frank at risk for hyperkalemia?

answer

Spironolactone (Aldactone)

question

Which action should the nurse perform?

answer

Continue the albumin infusion.

question

What is the best approach for the nurse to use when responding to Frank?

answer

Query Frank in a nonjudgmental manner about his use of rationalization.

question

What is the best response by the nurse?

answer

The type of liver damage that you have occurs after years of drinking, and that is what makes me think you are an alcoholic.

question

Who should the nurse notify of Frank's action?

answer

Frank's HCP.

question

In which situations is the use of physical restraints appropriate? (Select all that apply)

answer

-A client who is at high risk for injury to self for whom no other safety measures have been successful.

question

What if Frank's Glasgow Coma Scale rating obtained in this assessment?

answer

question

What is the primary underlying cause of hepatic encephalopathy?

answer

Increased serum ammonia.

question

Which outcome indicates to the nurse that the lactulose and neomycin are having the desired effect?

answer

Increased mental alertness.

question

Which activity level should be initiated during the acute phase of cirrhosis?

answer

Bedrest.

question

Which intervention should be implemented related to the diagnosis of fluid volume excess?

answer

Measure abdominal girth daily.

question

What intervention should the nurse implement first?

answer

Position Frank in the bed in a side lying position.

question

In what order should the nurse perform the following actions? (Place in numerical order from first action through last action.)

answer

1- Apply oxygen 2- Ensure patency of the IV 3- Notify the HCP 4- Transfer to critical care

question

Which lunch menu is the best choice for Frank?

answer

Turkey sandwich and a fruit smoothie.

question

Which instruction has the highest priority?

answer

Stop all alcohol consumption.

question

Which member of the interprofessional team is the best choice for the nurse to contact to help Frank meet this goal/

answer

Social worker.

question

What is the best response by the nurse?

answer

I really need you to find a way to help this client.

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Community Health Document The Finding Health Assessment Lower The Temperature Nursing

Hesi CS: Healthy Newborn – Flashcards 23 terms

Elizabeth Bates

23 terms

Preview

Hesi CS: Healthy Newborn – Flashcards

question

The nursery nurse places the infant under the radiant warmer and start to dry the infant quickly. What is the rationale for this action?

answer

Convective heat loss from evaporation is reduced.

question

Which action should the nurse take prior to drying the infant's back?

answer

Inspect the back for possible neurological defects. rationale: To prevent harm while drying the newborn, the back should always be inspected for possible neurological defects, like spinal bifida.

question

At 1 minute of age, the infant is crying and has a heart rate of 160 and a respiratory rate of 58. Both of the infant's arms and legs are flexed, and her hands and feet are cyanotic.

answer

9. rationale: One point is deducted for acrocyanosis.

question

Upon inspection of the umbilical cord, which finding should the nurse report to the healthcare provider?

answer

One artery and one vein are present. Rationale: two arteries and one vein should be present

question

The Carson baby's head is molded from the vaginal delivery. Upon seeing the baby, Ms. Carson says, "Oh, she is so beautiful, but something is wrong with her head." How should the nurse respond?

answer

"Her head has been molded from delivery through the birth canal, which is normal." Rationale: Molding commonly occurs in babies delivered vaginally, and the head will become more symmetrical over time.

question

The nurse checks the identification bands for both the baby and the mother upon admission to the nursery. One ID number is incorrect. What should the nurse do?

answer

Redo the identification bands with another nurse witnessing the process Rationale: Identification bands must be correct to ensure the safety and security of all hospitalized clients, especially newborns.

question

Upon admission to the transition care nursery, the Carson baby's axillary temperature is 97.4° F What action should the nurse take?

answer

Place the infant in a radiant warmer and monitor her temperature. Rationale: The baby's temperature is not within normal range (97.5°-99° F). The infant should remain in the radiant heat warmer until her temperature has stabilized.

question

While examining the infant's head, the nurse notes soft swelling of the scalp that extends across the suture lines of the fetal skull. What action should the nurse take?

answer

Document the finding in the record. Rationale: This finding indicates caput succedaneum, which commonly occurs after a vaginal birth.

question

The nurse notes a bluish discoloration of the skin across the infant's sacral area. What action should the nurse take?

answer

Document this finding Rationale: This bluish discoloration of the skin is a birthmark, commonly referred to as Mongolian spots. They are merely a dense collection of normal skin cells deep in the skin. This is a common finding, which should simply be noted in the baby's record

question

Which physical finding, if present, should the nurse report to the healthcare provider?

answer

Loose natal teeth that are not covered by the gums. Rationale: Natal teeth present at birth is an unusual occurrence that should be reported to the healthcare provider. Loose natal teeth are frequently removed to prevent aspiration.

question

When examining the baby's extremities, which finding would warrant additional assessment by the nurse?

answer

Limited hip abduction in the supine position. Rationale: Because this finding could indicate developmental dysplasia of the hip, formerly known as congenital hip dislocation, additional assessment is warranted.

question

Which finding by the nurse is consistent with an infant born at 39 weeks gestation? Select all that apply

answer

Plantar creases covering the entire sole of foot Head and neck are 25% of body's surface Incorrect: Presence of abundant lanugo hair across face and back. Slightly soft, curved pinna with slow recoil Skin is smooth and pink with visible veins.

question

A nursing student is assisting the RN in caring for the infants in the nursery. The RN questions the student about vitamin K (Aqua MEPHYTON) as preparations are made for administration Which response by the student indicates an understanding of the purpose for administering this drug?

answer

"This drug is given to the newborn to prevent and/or treat hemorrhagic disease." Rationale: Because this vitamin does not cross the placenta and there is very little in breast milk, supplemental vitamin K should be given to newborns at birth to help clot the blood. Therefore, this is an accurate response by the student and no further client teaching is needed.

question

The nurse is preparing to give the infant her first bath. Which assessment data indicates that it is safe for the baby to be given her bath at this time?

answer

Axillary temperature of 98. Rationale: A bath may potentially lower the temperature, which will not be harmful because the core temperature is near 99° F.

question

At 2400 hours the infant is crying, her skin is mottled, and her hands are shaking. What action should the nurse take first?

answer

Monitor the blood glucose level. Rationale: Since it has been 2 hours since delivery, the infant may be experiencing hypoglycemia.

question

The nurse checks on Ms. Carson and the baby at 0200 hours. Both are asleep in the bed, with the baby lying beside Ms. Carson. What action should the nurse take?

answer

Remind Ms. Carson about infant safety and assist her to place the infant in the crib. Rationale: This action protects the baby while reinforcing teaching to the mother

question

When returning the baby to the crib, the nurse notices that the blanket covering the baby is loose, and the cap is off her head. The nurse takes the baby's temperature, which is 97.6° F. What action should the nurse take?

answer

Show Ms. Carson how to wrap the baby for warmth and apply the cap to her head. Rationale: This action not only protects the baby, but also involves and teaches the mother.

question

The nurse checks on Ms. Carson and her baby every 2 hours throughout the night. The baby is breastfed at 0300 and 0600 hours without difficulty. After the change of shift report at 0700 hours, the day nurse assesses the mother and baby. Ms. Carson states that the baby had a bowel movement after breastfeeding. She tells the nurse that she attempted to change the diaper, but had difficulty doing so. What action should the nurse take?

answer

Observe Ms. Carson as she performs a diaper change. *This approach helps the nurse evaluate the problems Ms. Carson is experiencing so the most effective teaching can be provided. Advise Mrs. Carson that classes to teach infant care are available on the unit.

question

When Ms. Carson removes the diaper, the nurse notices that the baby has caked powder in the inguinal leg folds and vulva areas.

answer

Instruct Ms. Carson to use plain water instead of powder. Rationale: Until the baby is 4 days old, only plain warm water is recommended (after the initial bath) because soaps, ointments, powders, lotions, and baby wipes can disrupt the acid mantle on the skin and provide a medium for bacterial growth. Ointments are prescribed only if a rash develops in the first few days of life. Use of powder also places the infant at risk for fine particle aspiration.

question

While changing the diaper, Ms. Carson notices blood-tinged mucous in the vulva area and asks the nurse what is causing this with her baby. What explanation should the nurse give?

answer

Withdrawal of maternal hormones is the usual cause of this occurrence." Rationale: This is called pseudomenstruation, which is due to the effects of maternal hormones.

question

At two days post birth, Ms. Carson and her baby are doing well and preparing for discharge. The baby's weight at birth was 7 lb 15 oz (3600 gms), and today she weighs 7 lb 3 oz (3300 gms). Ms. Carson expresses her concern to the nurse when she realizes that her baby has lost almost a pound since birth. How should the nurse respond?

answer

"Don't be concerned. Your baby's weight loss is in the typical range for all babies." Rationale: Babies may lose up to approximately 10% of their birth weight.

question

Ms. Carson is told that a neonatal screening test needs to be done before they are discharged When asked the reason for including the PKU test in the screening, which information should the nurse provide?

answer

A problem converting the protein, phenylalanine, may be present, which can lead to mental retardation if not found and treated early. Rationale: PKU testing is done to detect the level of phenylalanine in the baby's blood.

question

How should the nurse collect the blood needed for PKU screening?

answer

Puncture the lateral heel after warming and collect blood samples on the designated lab form. Rationale: The heel should be warmed, cleaned with alcohol, and dried with gauze. After puncturing the heel with a microlancet, blood is collected on a special neonatal screening form.

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Advise The Client Document The Finding Fluid Volume Excess Nursing

HESI Case Study- Cirrhosis – Flashcards 24 terms

Roman Peck

24 terms

Preview

HESI Case Study- Cirrhosis – Flashcards

question

PN's response?

answer

There are several types of cirrhosis with differing causes

question

What additional questions should PN ask?

answer

-Have you ever been told that you have Hep C? -Have you been exposed to toxic substances at work? -Have you ever been diagnosed with Hep B? -Do you have any cardiovascular disorders?

question

What action should PN take prior to paracentesis?

answer

Instruct the client to empty the bladder

question

PN will maintain the client on bedrest for 24-48hrs following what procedure?

answer

Angiography with portal measurements

question

PN will look for decrease from the normal value in what laboratory test for a client with cirrhosis?

answer

serum albumin

question

PN should observe for which clinical manifestations as the result of the prolonged APTT and PTT/INR?

answer

epistaxis

question

PN knows which other clinical manifestation is a result of cirrhosis?

answer

fruity breath

question

PN should observe for hyperkalemia because of which med Roberta is taking?

answer

Spironolactone

question

Which action?

answer

document the finding in the client's record

question

What approach should the PN use?

answer

challenge Roberta about her denial in a nonjudgemental manner

question

What response?

answer

The type of liver damage that you have occurs after years of drinking, and that is what makes me think you are an alcoholic

question

Who should the PN notify regarding Roberta's action to leave AMA?

answer

Client's HCP

question

What action?

answer

Document that the client left the hospital AMA

question

What is the primary underlying cause of hepatic encephalopathy?

answer

increased serum albumin

question

Which outcome indicates to the PN that the lactulose and neomycin are having desired effect?

answer

increased mental altertness

question

PN initiates which activity-level during the acute phase of Roberta's cirrhosis?

answer

bedrest

question

What intervention?

answer

measure abdominal growth daily

question

What intervention?

answer

position Roberta in the bed with her feet slightly elevated

question

What action?

answer

apply O2

question

When should NS be completed?

answer

4:30PM

question

What selections?

answer

-baked chicken sandwich and fruit smoothie -grilled fish, spinach salad, apple, and iced tea

question

Lifestyle management choices?

answer

-stop alcohol consumption -stop aspirin containing meds -talk to HCP before taking OTC meds

question

Best choice for PN to contact?

answer

social worker

question

How should PN respond?

answer

I really need you to find a way to help the client

STUDY

Document The Finding Health Science Nursing

HESI Case Study-Healthy Newborn – Flashcards 23 terms

Sean Hill

23 terms

Preview

HESI Case Study-Healthy Newborn – Flashcards

question

ID bands of mother and infant do not match, what is the priority match?

answer

Report the discrepancy of the ID bands to the RN in charge

question

Infant feels cold, what should PN implement first?

answer

Obtain infant's axillary temp

question

PN places infant under warmer, what should PN do next?

answer

Take off all the infants clothes except the diaper

question

"Why is my baby's head messed up?"

answer

The molding of the head from delivery through the birth canal is normal

question

Soft swelling of scalp along suture line

answer

Document finding

question

Bluish spots on infant's sacral area?

answer

Mongolian spots

question

Physical finding that should be reported to RN

answer

Natal teeth not covered by gum

question

Finding in extremities that warrants additional assessment

answer

hip abduction limited in the supine position

question

Findings consistent with an infant born at 40w gestation

answer

-plantar creases covering entire soles of the feet -palpable anterior and posterior fontanelles

question

Why injection?

answer

prevent/treat hemorrhagic diseases

question

What would postpone bath?

answer

RR 64

question

Action the PN should take?

answer

Obtain infant's blood glucose level

question

PN best response?

answer

Remind of safety, help place in crib

question

What action?

answer

Place cap on infant, demonstrate how to swaddle

question

What action?

answer

Observe change diaper

question

What action?

answer

Review the recommendation of using plain water instead of powder

question

What action?

answer

Report missing consent to RN

question

How should PN respond?

answer

It's ok to nurse infant

question

How should PN respond?

answer

Amount of weight loss is typical for FT infants

question

What problem can be detected with PKU test?

answer

The lack of liver enzyme that converts proteins can lead to intellectual disability if not found and treated early

question

PN action for PKU test?

answer

-Apply glove before obtaining specimen from newborn -Cuddle and comfort infant after specimen is obtained -Apply pressure to site with dry gauze after -Puncture outer aspect of heel no deeper the 2.0 mm -Warm the heel 5-10 minutes before obtaining

question

Vaccines at 2 months?

answer

-Second dose of hepatitis B (HepB) vaccine -First dose of rotavirus vaccine (RV) -First dose of Haemophilus influenzae typer b (Hib) -Pneumococcal conjugate vaccine (PCV) -Inactivated poliovirus vaccine (IPV)

question

Rationale for burping?

answer

Regurgitation

STUDY

Document The Finding Foundations Of Professional Nursing Health Assessment Nursing

HESI abdominal assessment case study – Flashcards 25 terms

Ewan Knight

25 terms

Preview

HESI abdominal assessment case study – Flashcards

question

Observe the color of the emesis.

answer

Which assessment should the RN complete first?

question

Observe for excessive dryness of the mucus membranes.

answer

Which assessment takes priority while the RN provides oral care?

question

Any difficulty with defecation.

answer

For the RN to learn about the client's bowel patterns, what information is most important to obtain from Mr. Dunner?

question

What happens when the client eats spicy foods.

answer

The nurse asks Calvin if there are any foods he cannot eat. He reports that he can't eat spicy foods. What information should the nurse obtain next?

question

Put on the room lights and ensure that the room temperature is comfortable. Encourage the client to empty his bladder.

answer

The RN prepares Calvin for the physical assessment of the abdomen. Before assisting him to a supine position, what action should the RN take? (Select all that apply.)

question

Inspect for masses or bulges.

answer

To assess the symmetry of the abdomen, what action should the nurse take?

question

Protuberant abdominal contour.

answer

The RN does not observe any pulsations of the abdominal aorta. The RN recognizes that this is consistent with what other assessment finding?

question

Past medical history of ascites. Change in body mass index (BMI).

answer

While inspecting Calvin's abdomen, the RN observes silvery white striae on the lower abdomen. In response to this finding, what information should the nurse obtain? (Select all that apply.)

question

Inspection Auscultation Percussion Palpation

answer

To ensure the most accurate assessment of peristalsis, what action should the nurse RN take? (Place in order from first action through last action.)

question

Note how frequently the sounds occur before moving to another quadrant.

answer

What action should the RN take next?

question

Left quadrants. Right quadrants. Right upper and lower quadrants.

answer

It is essential for the RN to listen for bowel sounds in which area(s)? (Select all that apply.)

question

Normal bowel sounds.

answer

How should the nurse document the assessment?

question

Document this normal finding on the client's assessment record. continue to monitor

answer

What action should the RN take in response to this finding? (Select all that apply.)

question

Observe the area for bladder distention.

answer

A dull sound is heard when the RN percusses over the suprapubic area. What action should the RN take in response to this finding?

question

Note this location as the border of the liver.

answer

What follow-up action should the RN take?

question

Lightly palpate the abdominal surface.

answer

The RN's goal in palpating the client's abdomen is to screen for any masses or tenderness. to achieve this goal, what action should the RN take first?

question

Observe the muscles while the client exhales.

answer

What action should the RN take?

question

The time the client received an antiemetic.

answer

Which information is most important to report to the RN assuming responsibility for Calvin's care?

question

Color and volume.

answer

During the report, the RN also describes the clients earlier emesis. The RN should describe the emesis in terms of which characteristics?

question

Push down on the left side of the abdomen.

answer

When completing the pain assessment, how should the RN assess for rebound tenderness?

question

Notify the healthcare provider of the findings.

answer

After observing the presence of rebound tenderness, the RN notes the onset of involuntary rigidity of the client's abdomen. Which action should the nurse implement.

question

Ask the client where he is experiencing pain.

answer

In response to the client's statement that he "hurts a lot," what action should the RN take first?

question

answer

After completing the pain assessment, the RN prepare to administer a prescribed opioid analgesic. Hydrocodone 10 mg by mouth every 6 hours is prescribed. Hydrocodone 5 mg tablet is available. How many tablets should the RN administer?

question

The client denies any lessening of his pain.

answer

Which finding provides the most useful data about the effectiveness of the medication?

question

Encourage the client to use a numeric pain scale to rate his pain.

answer

To learn about the intensity of the client's pain, what action should the RN take?

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