When preparing to administer a prescribed medication to a homeless client at a community psychiatric clinic. The client tells the nurse that the usual dosage taken is different from the dose the nurse is giving. Which action should the nurse take?
A) Inform the client that he may refuse the med...
caring for neurologically
HESI RN 2024 compromised clients. Which client
EXIT EXAM with which change in status is best to
assign to the PN?
QUESTIONS AND
ANSWERS A) Subdural hematoma whose blood
pressure changed from 150/80 to
170/60.
When preparing to administer a B) Viral meningitis whose
prescribed medication to a homeless temperature change from 101 S to
client at a community psychiatric 102F.
clinic. The client tells the nurse that
C) Diabetic keto acidosis who is
the usual dosage taken is different
Glasgow coma scale score changed
from the dose the nurse is giving.
from 10 to 7.
Which action should the nurse take?
D) Myxedema, whose blood pressure
change from 80/50 to 70/40. - B) Viral
A) Inform the client that he may meningitis whose temperature change
refuse the medication and document from 101 S to 102F.
whether or not the client takes it.
B) Withhold the medication until the
The nurse is caring for a client with
dosage can be confirmed.
pneumonia who now develops initial
C) Explain to the client that the signs of septic shock and multi organ
dosage has been changed. failure. The healthcare provider
D) Tell the client to take the prescribes a sepsis protocol. Which
medication then verify the dosage at intervention is most important for the
the next healthcare team meeting. - B) nurse to include in the plan of care?
Withhold the medication until the
dosage can be confirmed.
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
The charge nurse is making
C) Excess warmth of extremities.
assignments for one practical nurse
and three registered nurses who are
,D) Monitor blood glucose level. - A)
Maintain strict intake and output.
NGN: The client is a 49-year-old male
who reports flu like symptoms
including fever and chest congestion
And adolescent client is admitted to
for four days. He came to the
the hospital because of writing a
emergency department last night
suicide note to a teacher at school. On
when he was having more difficulty
the second day of hospitalization, the
breathing he has a history of 1/2 pack
nurse asked the client to meet with the
a day cigarette smoking for 20 years.
treatment team. After the team
He has no significant medical or
meeting, the client leaves in tears and
surgical history.
goes to their room. Which nursing
intervention is best? Which two orders should the nurse
complete first?
A) Let the client rest quietly in their
room for a while. A) Sputum culture.
B) Explore the clients goals and B) Start oxygen 3 L per minute via
desire for treatment. nasal cannula.
C) Ask the treatment team about the C) Place the client on a cardio
clients behavior. respiratory monitor.
D) Go to the clients room and ask D) Chest x-ray.
what happened. - D) Go to the clients
E) Acetominophen 350 mg PO every
room and ask what happened.
six hours for temperature control.
F) Run 0.9% sodium chloride IV
The healthcare provider prescribes infusion at 150 mL per hour.
dalteparin 200 units per kilogram
G) Start peripheral IV.
subcutaneous once a day for a client
who weighs 154 pounds. The H) NPO. - B) Start oxygen 3 L per
medication is available and 25,000 minute via nasal cannula.
units per milliliter vial. How many C) Place the client on a cardio
milliliters should the nurse respiratory monitor.
administer? (Enter numerical value
only. If rounding is required, round to
the nearest 10th.) - 0.6
,NGN: 0330: place the client on a
cardio respiratory monitor, NPO,
(for each body system click to specify
sputum culture, start a peripheral IV
the assessment findings that indicates
infusion, start oxygen 3 L per minute
hypoxia)
via nasal cannula, begin 0.9% sodium
chloride IV infusion at 150 mL per
hour, acetaminophen 350 mg PO Cardiovascular: heart rate 100 bpm,
every six hours for temperature. capillary refill for seconds, blood
To start the client on oxygen as pressure 145/89.
ordered which items should the nurse Neurological: anxious, awake and
collects from the supply room? SATA alert, restless.
A) humidifier bottle. Respiratory: oxygen saturation 90%
B)Suction canister. on room air, respiratory rate 28 bpm,
productive cough. - Cardiovascular:
C)Sterile water.
capillary refill for seconds, blood
D) Nasal cannula. pressure 145/89.
E) Flow meter. Neurological: anxious, restless.
F) Lambs wool. Respiratory: oxygen saturation 90%
on room air, respiratory rate 28 bpm.
G) Tape. - D) Nasal cannula.
E) Flow meter.
NGN: The client is a 49-year-old male
who reports flu like symptoms
NGN: states, I am feeling extremely including fever and chest congestion
anxious right now. The client has for four days. He came to the
decreased breath sounds in the left emergency department last night
lower low. His mucus membranes are when he was having more difficulty
dry. He has a productive cough with breathing he has a history of 1/2 pack
thick, yellow secretions. His capillary a day cigarette smoking for 20 years.
refill is four seconds. Vital signs, He has no significant medical or
temperature 100.2. Heart rate 101 surgical history.
bpm, respiratory rate 28 breaths per
minute, blood pressure 145/89,
oxygen saturation 90% on room air. The nurse should place the client in a
_______________ position to
, promote _____________. - Semi- -The mask should cover only the
Fowler , lung expansion. mouth and leave the nose open for
expiration.
-I should place the mask first over the
NGN: Orders: 0330: place the client
nose and then cover the mouth. - -I
on a cardio respiratory monitor, NPO,
should clean the facemask once per
sputum culture, start a PIV, start
shift. (UNDERSTANDING)
oxygen 3L via nasal cannula, normal
saline 150 ML per hour, -The client should take a 1 to 2
acetaminophen 350mg PO every six minute break from the facemask each
hours for temp greater than 101F, hour. (NOT UNDERSTANDING)
chest x-ray.
-I should put gauze under the elastic
0500: Oxygen 8Lvia simple straps over the ears. (NOT
facemask, titrate to keep oxygen UNDERSTANDING ????)
saturation greater than 94%.
-I can adjust the oxygen level on the
flow meter to keep the clients oxygen
saturation greater than 94%.
(mark whether the statements by the
(UNDERSTANDING)
new grad nurse indicate
understanding or no understanding of -The mask should cover only the
the use of facemask in the care of this mouth and leave the nose open for
client) expiration. (NOT
UNDERSTANDING)
-I should place the mask first over the
-I should clean the facemask once per
nose and then cover the mouth.
shift.
(UNDERSTANDING)
-The client should take a 1 to 2
minute break from the facemask each
hour. NGN: Nurses Notes: 0400, the client
is awake and alert but restless. He
-I should put gauze under the elastic
states I am feeling extremely anxious
straps over the ears.
right now. The client has decreased
-I can adjust the oxygen level on the breath sounds in the left lower lobe.
flow meter to keep the clients oxygen His mucus membranes are dry. He has
saturation greater than 94%. a productive cough with thick, yellow
secretions. His capillary refill is four
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