Wgu hesi rn D444 Adult health I exam
Total Questions : 55
Showing 25 questions, Sign in for moreWhich instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?
Explanation
Rationale:
A. Using salt tablets would exacerbate hypernatremia by increasing sodium levels in the body, which is not advisable.
B. Drinking plenty of water when thirsty helps to dilute the excess sodium and correct hypernatremia. Encouraging hydration is essential in managing this condition.
C. While monitoring urine output can provide information about renal function, it does not directly address the management of hypernatremia.
D. Reviewing food labels for sodium content may be helpful for long-term dietary changes, but immediate hydration is the priority for correcting hypernatremia.
A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?
Explanation
Rationale:
A. Hyperventilation leads to respiratory alkalosis, not acidosis, as it reduces carbon dioxide levels in the blood.
B. Respiratory acidosis is characterized by the accumulation of carbon dioxide in the blood, leading to a decrease in blood pH. This is the fundamental process underlying respiratory acidosis.
C. While the kidneys can help eliminate carbon dioxide through bicarbonate production, respiratory acidosis primarily results from respiratory failure rather than renal conversion.
D. Elevated blood oxygen levels do not stimulate the respiratory rate; rather, low oxygen levels typically prompt an increased respiratory effort.
A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
Explanation
Rationale:
A. While knowing the last dose of corticosteroids may be relevant, it does not address the immediate symptoms of confusion and vomiting.
B. Establishing a neurological baseline is important, but the priority is to manage the client's acute symptoms first.
C. Administering a PRN IV antiemetic is essential to manage the projectile vomiting, which can lead to further complications like aspiration or dehydration. This intervention directly addresses the client's current distress.
D. A complete head-to-toe neurological assessment is important for ongoing monitoring, but it should be conducted after stabilizing the client's immediate symptoms.
A client has been administered lactulose for several days. Which therapeutic response should the nurse expect for a client with hepatic encephalopathy?
Explanation
Rationale:
A. Lactulose typically increases the frequency of liquid stools as it helps to draw water into the intestines to facilitate bowel movements.
B. The primary therapeutic goal of lactulose in hepatic encephalopathy is to reduce ammonia levels in the blood, which should result in improved mental status and cognitive function.
C. While lactulose can affect fluid balance, an increase in urine output is not a direct therapeutic response associated with its use.
D. Although improvement in ambulation may occur as the client's mental status improves, it is not the primary expected outcome of lactulose treatment.
Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?
Explanation
Rationale:
A. Step-by-step verbal directions may be confusing for clients with Huntington's disease due to cognitive and motor difficulties.
B. Escorting the client to the cafeteria ensures safety and provides direct assistance, which is crucial given the potential for impaired judgment and coordination in Huntington's disease.
C. While using a map might help some clients, it may overwhelm or confuse others, particularly those with cognitive impairments associated with Huntington's disease.
D. Orienting the client to a color-coding system could also be confusing and may not be an effective method of navigation for someone with cognitive challenges.
A client who is newly diagnosed with erosive esophagitis secondary to gastroesophageal reflux disease (GERD) reports to the home health nurse that there has been only a minimal reduction in symptoms after taking lansoprazole PO for one full week. Which action should the nurse take?
Explanation
Rationale:
A. It is important for the nurse to educate the client that healing from erosive esophagitis can take several weeks, and symptoms may not improve immediately with medication.
B. While confirming medication administration timing is important, it may not directly address the client's concerns about symptom relief.
C. Notifying the healthcare provider about dosage change may be premature without first ensuring the client understands the typical healing timeline and reviewing medication adherence.
D. While assessing bowel sounds and abdominal girth is useful for gastrointestinal health, it is not directly relevant to evaluating the effectiveness of lansoprazole for esophagitis symptoms.
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?
Explanation
Rationale:
A. Topical corticosteroids are the first-line treatment for psoriasis as they help reduce inflammation and alleviate symptoms like burning and bleeding.
B. Topical analgesics may relieve pain but do not address the underlying inflammation or scaling associated with psoriasis.
C. Topical antifungals are used to treat fungal infections and are not appropriate for psoriasis.
D. Colloidal oatmeal-based lotion can provide soothing effects but does not treat the underlying condition effectively like topical corticosteroids do.
A client with open-angle glaucoma asks the nurse how long the prescribed eye drops will need to be used. Which response made by the nurse is accurate?
Explanation
Rationale:
A. Eye drops for glaucoma are not used for pain and swelling control but to manage intraocular pressure.
B. Open-angle glaucoma is not about restoring a smaller angle; it is managed primarily by controlling intraocular pressure.
C. Long-term use of eye drops is necessary for maintaining normal eye pressure and preventing optic nerve damage in clients with open-angle glaucoma.
D. While the drops may reduce excess pressure initially, lifelong treatment is generally required to maintain safe pressure levels and prevent further damage.
A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
Explanation
Rationale:
A. Increasing the intake of oral fluids is crucial as it helps to liquefy secretions, making it easier for the client to cough up thick mucus and improve breathing.
B. While anxiety reduction methods can be helpful, addressing the physical symptoms of respiratory distress is more immediate.
C. Monitoring for medication side effects is important, but it is secondary to ensuring effective airway clearance and improving respiratory function.
D. Avoiding crowded areas is a preventive measure but does not address the current issue of managing mucus production and shortness of breath.
A client is being cared for in the emergency department with acute abdominal pain and a provisional diagnosis of pancreatitis. The nurse assesses the client and obtains the results from laboratory studies. Which information is most valuable in reporting the client's status to the healthcare provider?
Explanation
Rationale:
A. While H. pylori can be related to gastrointestinal issues, it is not the primary focus in pancreatitis management, and urine output is less critical than pancreatic enzyme levels.
B. Assessing bowel sounds and abdominal pain is important, but specific laboratory results provide more concrete information regarding the condition.
C. Chronic constipation and serum gastrin levels are not directly relevant to acute pancreatitis.
D. The severity of nausea and vomiting, along with serum amylase results, directly indicates the status of pancreatitis, as elevated amylase levels are typically associated with this condition. This information is vital for guiding treatment decisions.
The nurse is caring for a client with chronic obstructive pulmonary disease who develops an onset of dyspnea and tachypnea with coughing. After positioning the client upright, which action should the nurse take next?
Explanation
Rationale:
A. While attaching humidification can be beneficial for patients with respiratory issues, the immediate priority is to assess the client's oxygenation status.
B. Obtaining a pulse oximetry reading is crucial to determine the client's oxygen saturation level and guide further interventions.
C. Coaching through huff coughing is helpful, but it is more important to first assess oxygenation to understand the severity of the dyspnea.
D. Providing a nebulizer treatment can be an important intervention, but it should follow the assessment of the client's oxygen levels to determine if immediate treatment is necessary.
Which technique should the nurse use when assessing for early signs of rheumatoid arthritis?
Explanation
Rationale:
A. Observing the client's fingers is essential as early signs of rheumatoid arthritis often manifest in the small joints of the hands, including swelling, redness, and pain.
B. While lymph nodes may be palpated for other conditions, they are not directly indicative of rheumatoid arthritis.
C. Observing the skin for lesions is important for other conditions but is not a primary assessment technique for rheumatoid arthritis.
D. Palpating large joints for nodules is more relevant in later stages of the disease; early signs focus more on the small joints and their characteristics.
A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?
Explanation
Rationale:
A. Isolating the client is the most critical action to prevent the potential spread of COVID-19 to others, especially since the client is exhibiting symptoms consistent with the virus.
B. While counseling family members is important, it is secondary to ensuring the immediate safety of others in the healthcare setting.
C. Reporting results is necessary for public health tracking but does not take precedence over immediate isolation measures.
D. Teaching the client preventive measures is important, but again, it should follow ensuring isolation to mitigate any risk of exposure to others.
A client with emphysema is reporting difficulty in breathing and exhibiting audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?
Explanation
Rationale:
A. Uncontrollable shaking can be a side effect of albuterol, but it is not as critical as other potential cardiovascular concerns.
B. Increased anxiety is common with respiratory distress but is not immediately life-threatening.
C. Throat irritation may occur but is generally not a severe concern compared to cardiovascular effects.
D. An irregular rapid heart rate is a significant sign of potential adverse effects from albuterol, indicating possible toxicity or worsening of the client’s condition, which requires immediate intervention.
. The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?
Explanation
Rationale:
A. Raising hands above the head may not effectively improve gas exchange and could lead to discomfort in a client with dyspnea.
B. Laying down may not facilitate optimal breathing; instead, sitting upright is generally more effective.
C. Increasing the breathing rate can lead to hyperventilation and does not improve gas exchange.
D. Drawing air in through the nose and exhaling slowly through pursed lips helps maintain positive pressure in the airways, prevents airway collapse, and improves gas exchange by allowing for more effective expiration.
A client with chronic cirrhosis has esophageal varices. It is most important for the nurse to monitor the client for the onset of which problem?
Explanation
Rationale:
A. Clay-colored stool can indicate bile duct obstruction but is not the immediate concern with esophageal varices.
B. Brown, foamy urine may suggest liver dysfunction but does not pose an immediate life threat like variceal bleeding.
C. Hematemesis, or vomiting blood, is a critical complication of esophageal varices due to the risk of significant hemorrhage and requires immediate intervention.
D. Anorexia can occur in cirrhosis but is not as urgent as monitoring for potential bleeding from varices.
The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?
Explanation
Rationale:
A. While assessing body temperature is important, it is not the most critical action prior to administering vancomycin.
B. Auscultating bowel sounds can provide information about gastrointestinal function but is not specifically required before administering vancomycin.
C. Measuring oxygen saturation is important in assessing respiratory status but is not related to the administration of vancomycin.
D. Checking serum creatinine is essential because vancomycin can affect renal function, and assessing kidney function is critical before administration to prevent potential toxicity, especially in patients with a history of renal impairment.
A client who was admitted yesterday with bilateral pneumonia has congested breath sounds, an oxygen saturation of 94% on room air, and an oral temperature of 100° F (37.8° C). The client has a weak cough effort and is using accessory muscles to breathe. Which intervention should the nurse implement first?
Explanation
Rationale:
A. Obtaining arterial blood gases is important for assessing respiratory status but is not the immediate priority.
B. Administering an antipyretic can help reduce fever but does not address the immediate respiratory distress the client is experiencing.
C. Offering an analgesic can improve comfort but is not the priority intervention in this scenario.
D. Suctioning to clear secretions from the airway is the most critical intervention to improve the client’s respiratory status, especially given the weak cough effort and use of accessory muscles, indicating possible airway obstruction or ineffective clearance of secretions.
A client has a nasogastric (NG) tube placed during abdominal surgery. During postoperative convalescence, the nurse identifies that the client is manifesting a hand tremor, muscle twitching, and confusion. Which arterial blood gas values are consistent with metabolic alkalosis that the nurse should report to the healthcare provider?
Explanation
Rationale:
A. This value indicates metabolic acidosis rather than alkalosis due to a low pH and normal HCO3.
B. This value is indicative of metabolic alkalosis as the pH is elevated (7.49), the HCO3 is elevated (32 mEq/L), and the PCO2 is within normal range, reflecting a compensatory response.
C. While the pH is slightly elevated, the high PCO2 suggests respiratory compensation, making it less consistent with primary metabolic alkalosis.
D. This value indicates metabolic acidosis due to a low pH and normal HCO3 levels, not alkalosis.
A client with symptoms of influenza that started the previous day asks the clinic nurse about taking oseltamivir to treat the infection. Which response should the nurse provide?
Explanation
Rationale:
A. It is accurate that vaccination is most effective before symptoms appear, but this statement does not address the client's immediate need for treatment.
B. Oseltamivir (Tamiflu) is an antiviral medication that can be prescribed for influenza symptoms if taken within the first 48 hours of symptom onset, making it appropriate to refer the client for a prescription.
C. While over-the-counter medications may help alleviate some symptoms, they do not treat the underlying viral infection, and antiviral medications can be more effective.
D. This statement is true but does not directly answer the client's question about the treatment of influenza with oseltamivir.
The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
Explanation
Rationale:
A. Increasing the frequency of dressing changes is not necessary unless there is excessive drainage or signs of infection; it may disrupt the healing process.
B. Applying a hydrocolloidal gel dressing is appropriate for a stage 3 pressure injury with granulation tissue as it promotes a moist healing environment and helps facilitate healing.
C. A transparent dressing may not provide adequate moisture retention or protection for a stage 3 pressure injury compared to a hydrocolloidal dressing.
D. Leaving the dressing off could expose the wound to infection and is not advisable without further assessment and consultation.
To assess the quality of an adult client's pain, which approach should the nurse use?
Explanation
Rationale:
A. Observing body language and movement can provide clues about the client's pain but does not directly assess the quality of the pain experienced.
B. Identifying effective pain relief measures is important for managing pain but does not assess the quality of pain itself.
C. Asking the client to describe the pain directly assesses its quality, allowing the nurse to understand its characteristics, such as intensity, duration, and type (e.g., sharp, dull, throbbing).
D. Providing a numeric pain scale is useful for quantifying pain intensity but does not capture the qualitative aspects of the pain experience.
While changing a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?
Explanation
Rationale:
A. Culturing for sensitive organisms is essential in identifying the causative agent of the infection indicated by the purulent drainage, guiding appropriate antibiotic therapy.
B. Blood pH level is not directly relevant to assessing wound drainage or infection status.
C. C-reactive protein (CRP) can indicate inflammation but is not specific enough to provide immediate information regarding the infection at the wound site.
D. Serum blood glucose level is more relevant for assessing the client's overall metabolic status and risk for infections rather than directly correlating with the purulent drainage observed.
An adult client is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the client. Which instruction should the nurse provide to the UAP?
Explanation
Rationale:
A. While the nurse can perform oral care, it is essential for the UAP to assist where appropriate, and oral care should not be solely left for the nurse.
B. A soft-bristled toothbrush is the best option for the client with painful mouth ulcers, as it is gentle and reduces the risk of further irritation.
C. Offering mouthwash may not be appropriate, especially if it contains alcohol, as it could further irritate the ulcers; additionally, thorough cleansing is typically more effective with careful brushing rather than rinsing alone.
D. Wearing sterile gloves is unnecessary for oral care; standard precautions, including clean gloves, should be used, but sterile gloves are not required for this type of care.
A client with cholelithiasis has a gallstone lodged in the common bile duct and is unable to eat or drink without becoming nauseated and vomiting. Which finding should the nurse report to the healthcare provider?
Explanation
Rationale:
A. Belching is a common symptom and not an urgent finding in this context.
B. Yellow sclera indicates jaundice, which suggests bile obstruction due to the lodged gallstone in the common bile duct; this is a critical finding that requires immediate attention from the healthcare provider.
C. Flatulence can occur with gastrointestinal distress but does not indicate an immediate complication.
D. Amber urine may indicate dehydration or bilirubin presence, but it is less critical than the yellow sclera in this scenario, which directly indicates liver or bile duct involvement.
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