EXIT HESI RN Used from 2021/22/23 all Semesters

49. A client with multiple sclerosis (MS) is receiving interferon beta-1b 0.1875 mg subcutaneously QOD. The nurse reconstitutes the vial by slowly injecting 1.2 ml of diluent into the interferon vial for a reconstituted solution of 0.25 mg/1 ml. How many ml should the nurse administer? (Enter numerical value only. If required, round to the nearest hundredth.)

0.75

78. A female client with chronic kidney disease and renal failure has an indwelling peritoneal catheter in ..... used for peritoneal dialysis. While bathing, her abdominal dressing becomes wet. What action should the nurse take? A) Change the dressing. B) Reinforce the dressing. C) Flush the peritoneal dialysis catheter. D) Scrub the catheter with povidone-iodine.

A) Change the dressing.

35. A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client? A) Dry roasted almonds. B) Cheddar cheese and crackers. C) Carrot and celery sticks. D) Beef bologna sausage slices.

A) Dry roasted almonds.

64. In early septic shock states, what is the primary cause of hypotension? A) Peripheral vasodilation. B) Cardiac failure. C) A vagal response. D) Peripheral vasoconstriction.

A) Peripheral vasodilation.

13. At 40 weeks gestation, a laboring client who is lying in a supine position tells the nurse that she has finally found a comfortable position. What action should the nurse take? A)Place a pillow under the client's head and knees. B) Place a wedge under the client's right hip. C) Encourage the client to turn on her left side. D) Explain to the client that her position is not safe.

B) Place a wedge under the client's right hip.

42. Following morning care, a client with a C-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which interventions should the nurse implement first? A) Assess the client's blood pressure every 15 minutes. B) Relieve any kinks or obstruction in the client's Foley tubing. C) Teach the client to response to symptoms of dyreflexia. D) Administer a prescribed PRN dose of hydrazine (Apresoline)

B) Relieve any kinks or obstruction in the client's Foley tubing.

69. A client presents to the clinic with concerns regarding her left breast. Which assessment findings are most important for the nurse to report to the healthcare provider? A) Multiple firm, round, freely moveable masses. B) A slight asymmetry of the breasts. C) A fixed nodular mass with dimpling of skin. D) Bloody discharge from the nipple.

C) A fixed nodular mass with dimpling of skin.

32. A young adult female presents at the emergency center with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider? A) History of irritable bowel syndrome (IBS) B) Pain scale rating of a "9" on a 0-10 scale. C) Last menstrual period 7 weeks ago. D) Reports white, curly vaginal discharge.

C) Last menstrual period 7 weeks ago.

34. A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine sulfate 4 mg IV. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care? A) Assess for back muscle aches. B) Obtain body weight daily. C) Monitor urinary output hourly. D) Record drainage from the drain.

C) Monitor urinary output hourly.

29. In early septic shock states, what is the primary cause of hypotension? A) A vagal response. B) Cardiac failure. C) Peripheral vasodilation. D) Peripheral vasoconstriction.

C) Peripheral vasodilation.

26. A client is admitted to a medical unit with a diagnosis of gastritis and chronic heavy alcohol abuse. What should the nurse administer to prevent the development of Wernicke's syndrome? A) Atenolol. B) Famotidine. C) Thiamine. D) Lorazepam.

C) Thiamine.

9. A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? A) Serum Calcium. B) Erythrocyte sedimentation rate. C) Osmolality. D) Hemoglobin.

D) Hemoglobin.

12. The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 ml to be influenced over 4 hours. The IV administration set delivers 10 gtt/ml. How many gtt/minute should the nurse regulate the infusion? ( round the nearest whole number.)

Flow rate(gtt/min) = volume(ml)/ time(min) × drop factor(gtt/mL). Flow rate=1000 ml/240 min×10 gtt/ml. Flow rate = 41.667gtt/min. Flow rate = 42 gtt/min.

16. The healthcare provider prescribes potassium chloride 25 mEq in 500ml D5W to infuse over 6 hours. The available 20ml vial of potassium chloride is labeled, "How many ml of potassium chloride should the nurse add to the IV fluid? (Round to the nearest tenth.)

Using the formula D / H X Q:25 mEq / 10 mEq x 5ml ꞊12.5ml

83. A client with multiple sclerosis is receiving baclofen 15mg PO three times daily. The drug is available in 10 mg tablets. How many tablets should the nurse administer in a 24-hour period? (Round to nearest tenth.)

4.5

67. An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full-thickness burns to all surfaces of both lower extremities. What percentage of body surface area should the nurse document in the electronic medical record (EMR)? A) 36% B) 9% C) 45% D) 15%

A) 36%

99. A nurse who usually works on a step-down unit is moved to work a 12-hour shift in the critical care unit. Which client is best for the charge nurse to assign to this nurse? A) A ventilator dependent client with chronic obstructive pulmonary disease COPD. B) A client who has a new onset diabetic ketoacidosis (DKA) and is on an insulin drip. C) A client admitted for a narcotic overdose who is ventilated with respiratory alkalosis. D) A ventilated client admitted today with respiratory failure and respiratory acidosis.

A) A ventilator dependent client with chronic obstructive pulmonary disease COPD.

25. The nurse completed a dressing change for a client with partial thickness burns to both legs. After completing the dressing change, What intervention should the nurse implement? A) Administer a PRN dose of pain medication. B) Raise this head of bed to a 90 angle. C) Perform passive range of motion. D) Position ankles in a dorsiflexed position.

A) Administer a PRN dose of pain medication.

11. A client with peptic ulcer disease receives a prescription for intermittent suction via a SalemSump nasogastric tube (NGT). After inserting the NGT and obtaining coffee-ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit, the client complains of nausea. What action should the nurse implement first? A) Administering a prescribed antiemetic agent. B) Provide oral suction using a Yankauer tip. C) Connect the NGT to low intermittent suction. D) Irrigate the NGT with sterile normal saline.

A) Administering a prescribed antiemetic agent.

63. An adult female tells the nurse that her grandmother was diagnosed with colorectal cancer at age 75 and the client is implementing measures to reduce her own risk. Which of the client's plans indicates the need for additional information? A) Annual sigmoidoscopy screening. B) Increased intake of fresh fruits, vegetables, and whole grains. C) Reduced dietary intake of animal fat and protein. D) Yearly fecal occult blood testing.

A) Annual sigmoidoscopy screening.

72. An adult client's apical pulse is 110 beats per minute. What intervention should the nurse implement first? A) Assess the client's radial pulse and apical pulse at the same time. B) Assess the client to determine the reason why the pulse is elevated. C) Notify the charge nurse that the client's pulse is elevated. D) Attempt to calm the client and take the pulse again in one hour.

A) Assess the client's radial pulse and apical pulse at the same time.

62. A middle-aged female client tells the clinic nurse that she has lost an inch of height in the last year. What is the priority nursing intervention? A) Assist the client to schedule a bone density exam. B) Observe for the presence of a dowager's Hump. C) Advise the client to begin stretching exercises. D) Encourage the client to eat calcium-rich foods.

A) Assist the client to schedule a bone density exam.

82. An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation level is 62%. What action should the nurse take first? A) Begin manual ventilation immediately. B) Silence the alarm and call the technician. C) Monitor manual ventilation immediately. D) Call respiratory therapy.

A) Begin manual ventilation immediately.

79. The nurse is planning care for a client who admits to having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A) Begin to show signs of improvement in affect. B) Lacks interest in the activity of the family and friends. C) Express feelings of sadness and loneliness. D) Neglects personal hygiene and has no appetite.

A) Begin to show signs of improvement in affect.

14. A family member reports that the client who is bedridden has not been turned or repositioned all night and is sleeping on a special air mattress with no sheets. What information should the nurse provide to the family member? A) Clarify that an aerated support surface does not use sheets that often cause skin breakdown. B) Describe the night staff's plan of care to ensure the client's sleep is not disturbed. C) Explained that turning is only necessary to reposition the client during waking hours. D) Suggest that a family member turn the client during the night when someone is there.

A) Clarify that an aerated support surface does not use sheets that often cause skin breakdown.

48. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory values requires intervention by the nurse? A) Creatinine 4 mg/dl (354 micromol/L SI) B) Total calcium 9 mg/dl (2.25 mmol/L SI) C) Phosphate 4 mg/dl (1.293 mmol/L SI) D) Fasting glucose 95 mg/dl (5.3 mmol/L SI)

A) Creatinine 4 mg/dl (354 micromol/L SI)

56. The nurse is assessing a client with a closed head injury sustained in a motor vehicle collision. Which finding indicates the lowest neurologic functioning? A) Decerebrate posturing during position changes. B) Withdrawal from painful stimuli. C) Decorticate posturing during tracheal suctioning. D) Localization of a tactile stimulus.

A) Decerebrate posturing during position changes.

100. During a postpartum assessment of a client who is 5 hours post vaginal delivery, the nurse determines the fundus is 3 finger breadths above the umbilicus and positioned to the client's side. Which action should the nurse implement first? A) Encourage the client to void. B) Massage the fundus until firm. C) Catheterize for residual urinary volume. D) Provide additional oral replacement fluids.

A) Encourage the client to void.

15. A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which action should the nurse implement? (Select all that apply.) A) Monitor stools for the presence of blood. B) Auscultate bowel sounds in all quadrants. C) Assess characteristics of pain. D) Review the last partial thromboplastin time results. E) Prepare to administer warfarin.

A) Monitor stools for the presence of blood. C) Assess characteristics of pain. E) Prepare to administer warfarin.

6. A male client with an antisocial personality disorder is admitted to an inpatient mental health unit for multiple substance dependency. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client's history is most likely to include which finding? A) Multiple convictions for misdemeanors and Class B felonies. B) Delusions of grandiosity and persecution. C) Suicidal ideations and multiple attempts. D) Photos and panic attacks when confronted by authority figures.

A) Multiple convictions for misdemeanors and Class B felonies.

54. A client who was splashed with a chemical has both eyes covered with bandages. When assisting the client with eating, which intervention should the nurse instruct the unlicensed assistive personnel (UAP) to implement? A) Orient the client to the location of the food on the plate. B) Ask to visit during mealtime to assist with feeding. C) Provide with only finger foods D) Feed the client the entire meal.

A) Orient the client to the location of the food on the plate.

91. The nurse finds a client at 33 weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? A) Position a firm wedge to support the pelvis and thorax at a 30-degree tilt. B) Apply oxygen by mask after opening the airway. C) Apply less compression force to reduce aspiration. D) Give continuous compression with a ventilation ratio at 20:3.

A) Position a firm wedge to support the pelvis and thorax at a 30-degree tilt.

93. An older client with a history of pernicious anemia has developed ataxia and paresthesia. In planning care, which nursing intervention has the highest priority? A) Provide assistance with ambulation. B) Keep the head of the bed elevated. C) Offer a PRN sleep aid at night. D) Instruct about healthy diet choices.

A) Provide assistance with ambulation.

85. The nurse enters the room of a client who is awaiting surgery for appendicitis. The unlicensed assistive personnel (UAP) has helped the client to a position of comfort with the right leg flexed and has applied a heating pad to the client's abdomen to relieve the client's pain. Which action should the nurse implement first? A) Remove the heating pad from the client's abdominal area. B) Determine if the consent form has been signed by the client. C) Evaluate the effectiveness of the heating pad in relieving pain. D) Confirm that the UAP has assisted the client to a position of comfort.

A) Remove the heating pad from the client's abdominal area.

1. After receiving IV fluids in the emergency department, an elderly client is admitted to the acute care unit with a medical diagnosis of dehydration. The client is receiving 0.9% normal saline at 125 ml/hour via saline lock and has a bounding pulse, tachycardia, and pedal edema. When contacting the healthcare provider, the nurse anticipates a prescription what intervention? A) Remove the saline lock from the client's arm. B) Increase the rate of the normal saline infusion. C) Decrease the rate of the normal saline infusion. D) Change the IV solution to 0.45% saline solution.

A) Remove the saline lock from the client's arm.

51. A nurse stops at the site of a motorcycle accident and finds a young adult male lying face down in the road in a puddle of water. It is raining, no one is available to send for help, and the cell phone is in the car about 50 feet away. What action should the nurse take first? A) Stabilize the victim's neck and roll over to evaluate his status. B) Return to the car to call emergency response 911 for help. C) Open the airway and initiate resuscitative measures. D) Examine the victim's body surfaces for arterial bleeding.

A) Stabilize the victim's neck and roll over to evaluate his status.

17. A male client reports to the on-call clinic nurse that he took Tadalafil 10 mg PO two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. What action should the nurse take? A) Tell the client to have someone bring him to an emergency department immediately. B) Advise the client to place one nitroglycerin tablet under his tongue as a precaution. C) Reassure the client that skin flushing is a common side effect of the medication. D) Instruct the client to increase his intake of oral until the skin flushing is relieved.

A) Tell the client to have someone bring him to an emergency department immediately.

3. The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? (Select all that apply) A) Wash the stump with soap and water. B) Avoid range of motion exercise. C) Apply alcohol to the stump after bathing. D) Inspect skin for redness. E) Use a residual limb shrinker.

A) Wash the stump with soap and water. D) Inspect skin for redness. E) Use a residual limb shrinker.

65. Four clients arrive on the labor and delivery unit at the same time. Which client should the nurse assess first? A) A 3-week multigravida with a prescription for serial blood pressure. B) A 39-week primigravida with a biophysical profile score of 5 out of 8. C) A 38-week primigravida who reports contractions occurring every 10 minutes. D) A 41-week multigravida who is scheduled induction of labor today.

B) A 39-week primigravida with a biophysical profile score of 5 out of 8. The results of the biophysical profile are added for a score between zero and 10. A score 8 - 10 is considered normal. A lower score may suggest a possible problem that could call for more evaluation. A score of four or less may call for pregnancy monitoring or inducement of labor.

60. The nurse enters the room of a client with Parkinson's disease who is taking Carbidopa- Levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take? A) Demonstrate how to help the client move more efficiently. B) Affirm that the client should arise slowly from the chair. C) Tell the UAP to assist the client in moving more quickly. D) Offer a PRN analgesic to reduce painful movement.

B) Affirm that the client should arise slowly from the chair.

87. While receiving a male postoperative client's staples the nurse observe that the client's eyes are closed and his face and hands are clenched. The client states, "I just hate having staples removed". After acknowledgment the client's anxiety, what action should the nurse implement? A) Reassure the client that this is a simple nursing procedure. B) Attempt to distract the client with general conversation. C) Encourage the client to continue verbalize his anxiety. D) Explain the procedure in detail while removing the staples.

B) Attempt to distract the client with general conversation.

5. A client with bleeding esophageal varices receives vasopressin IV. What should the nurse monitor for during the IV infusion of this medication? A) Vasodilatation of the extremities. B) Chest pain and dysrhythmia. C) Hypotension and tachycardia. D) Decreasing GI cramping and nausea.

B) Chest pain and dysrhythmia.

59. A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first? A) Obtain equipment for gastric lavage. B) Determine type of chemical exposure. C) Assess child for altered sensorium. D) Call poison control emergency number.

B) Determine type of chemical exposure.

20. The nurse is preparing to administer an oral antibiotic to a client with unilateral weakness, ptosis, mouth drooping, and aspiration pneumonia. What is the priority nursing assessment that should be done before administering this medication? A) Ask the client about soft food preferences. B) Determine which side of the body is weak. C) Obtain and record the client's vital signs. D) Auscultate the client's breath sounds.

B) Determine which side of the body is weak.

28. A male client with cirrhosis has jaundice and pruritis. He tells the nurse that he was been soaking in hot baths at night with no relief of his discomfort. What action should the nurse take? A) Explain that the symptoms are caused by liver damage and cannot be relieved. B) Encourage the client to use cooler water and apply calamine lotion after soaking. C) Obtain a PRN prescription for an analgesic that the client can use for symptom relief. D) Suggest that the client take brief showers and apply oil-based lotion after showering.

B) Encourage the client to use cooler water and apply calamine lotion after soaking.

2. A client who is admitted to the care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first? A) Patch one eye. B) Evaluate swallow. C) Reorient often. D) Range of motion.

B) Evaluate swallow.

43. The nurse is planning care for a young adult client with acromegaly. It is most important for the nurse to monitor which of the client's serum laboratory test results? A) White blood cell count. B) Glucose. C) Hemoglobin. D) Partial thromboplastin time.

B) Glucose.

47. A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A) Referral for social services for the child and family. B) Instruction about how much fluid the child should drink daily. C) Signs of addiction to opioid pain medications. D) Information about non-pharmaceutical pain relief measures

B) Instruction about how much fluid the child should drink daily.

61. When should the nurse conduct an Allen's test? A) When pulmonary artery pressures are obtained. B) Just before arterial blood gasses are drawn peripherally. C) Prior to attempting a cardiac output calculation. D) To assess for presence of a deep vein thrombosis in the leg.

B) Just before arterial blood gasses are drawn peripherally.

86. While assisting a client who recently had a hip replacement onto the bedpan, the nurse noticed that there is a small amount of bloody drainage on the surgical dressing, the client's skin is warm to touch, and there is a strong odor from the urine. Which action should the nurse take? A) Remove dressing and assess surgical. B) Measure the client's oral temperature. C) Insert an indwelling urinary catheter. D) Obtain a urine sample from the bedpan.

B) Measure the client's oral temperature.

30. A 17-year-old adolescent is brought to the Emergency Department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? A) Assess the client's temperature. B) Place a mask on the client's face. C) Determine the client's blood pressure. D) Obtain a chest x-ray per protocol.

B) Place a mask on the client's face.

38.A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement? A) Provide typed instructions for healthy diet selections. B) Reinforce the need for adequate hydration. C) Explain exercises daily regimen. D) Demonstrate specific strengthening exercises.

B) Reinforce the need for adequate hydration.

24. The nurse enters the room of a client who is awaiting surgery for appendicitis. The unlicensed assistive personnel (UAP) has helped the client to a position of comfort with the right leg flexed and has applied a heating pad to the client's abdomen to relieve the client's pain. Which action should the nurse implement first? A) Determine if the consent form has been signed by the client. B) Remove the heating pad from the client's abdominal area. C) Confirm that the UAP has assisted the client to a position of comfort. D) Evaluate the effectiveness of the heating pad in relieving pain.

B) Remove the heating pad from the client's abdominal area.

23. The nurse is supervising an unlicensed assistive personnel (UAP) who will be providing personal care for a client with watery diarrhea caused by Clostridium difficile. Which action by the nurse takes priority? A) Remind the UAP to keep the client's water pitcher filled. B) Review use of personal protective equipment with the UAP. C) Provide barrier cream for application to the perineal area. D) Instruct the UAP to record the number of bowel movements.

B) Review use of personal protective equipment with the UAP.

7. An older client is admitted for repair of a broken hip. To reduce the risk for infection postoperative period., which nursing care intervention should the nurse include the client's plan of care? (Select all that apply) A) Administer low molecular weight heparin as prescribed. B) Teach client to use incentive spirometer every 2 hours while awake. C) Remove urinary catheter as soon as possible and encourage voiding. D) Maintain sequential compression devices while in bed. E) Assess pain level and medicate PRN as prescribed.

B) Teach client to use incentive spirometer every 2 hours while awake. C) Remove urinary catheter as soon as possible and encourage voiding.

71. When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? A) To promote retraction of the intercostal accessory muscles. B) To reduce abdominal pressure on the diaphragm. C) To decrease pressure on the medullary center which stimulates breathing. D) To promote bronchodilation and effective airway clearance.

B) To reduce abdominal pressure on the diaphragm.

8. The nurse is preparing a 50 ml dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication? A. Dilute the dextrose in one liter of 0.9% Normal Saline solution. B. Push undiluted slowly though the currently infusing IV. C. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml. D. Ask the pharmacist to add the Dextrose to a TPN solution.

B. Push undiluted slowly though the currently infusing IV.

10. A client with bacterial meningitis is receiving phenytoin. Which assessment finding indication to the nurse that the client is experiencing a therapeutic response to the phenytoin? A) Increased time of ambulation between periods of rest. B) Decrease in intracranial pressure and cerebral edema. C) Absence of seizure activity for the duration of treatment. D) Normal electroencephalogram after drug administration.

C) Absence of seizure activity for the duration of treatment.

75. A male client in the final stages of terminal cancer tells his nurse that he wishes he could just be allowed to die. The client states that he is tired of fighting his illness and is only continuing treatments because his family wants him to live. Which action should the nurse take? A) Notify the family that treatments have been discontinued. B) Arrange a meeting with the family, physician, and client. C) Ask the chaplain to discuss death issues with the client. D) Request a consultation with the hospital social worker.

C) Ask the chaplain to discuss death issues with the client.

68. While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take? A) Remind the client that a rescue inhaler might save his life. B) Gently touch the client then continue with the teaching. C) Ask the client what he is thinking about at this time. D) Leave the client alone so that he can grieve his illness.

C) Ask the client what he is thinking about at this time.

50. A client who had a percutaneous coronary intervention (PCI) two weeks ago returns to the clinic for a follow-up visit. The client has a postoperative ejection fraction of 30%. Today the client has links which are clear, +1 pedal edema, and a 5-pound weight gain. Which intervention should the nurse implement? A) Insert saline lock for IV diuretic therapy. B) Arrange transport for admission to the hospital. C) Assess compliance with routine prescriptions. D) Instruct the client to monitor daily caloric intake.

C) Assess compliance with routine prescriptions.

19. The healthcare provider prescribed furosemide for a 4-year old child who has a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective? A) Urinary output decrease of 5 ml/hour. B) Urine specific gravity change from 1.021 to 1.031 C) Daily weight decreases of 2 pounds (0.9 kg) D) Blood urea nitrogen (BUN) increase from 8 to 12 mg/dL (2.9 to 4.3 mmol/L)

C) Daily weight decreases of 2 pounds (0.9 kg)

37. The nurse is complaining an admission assessment for a male client with paranoid schizophrenia. The client tells the nurse that the staff dislikes him. What action should the nurse take? A) Assess the client's speech pattern for a flight of class. B) Observe the client for obsessive activities such as repeated hand washing. C) Determine if the client has formulated any plans regarding the staff. D) Ask the client if he has a plan to harm himself.

C) Determine if the client has formulated any plans regarding the staff.

55. An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? A) Prepare the client for an echocardiogram. B) Limit the client's fluids. C) Document in the client's record. D) Notify the healthcare provider.

C) Document in the client's record.

66. A male client with cirrhosis has jaundice and pruritis. He tells the nurse that he has been soak in hot baths at night with no relief of his discomfort. What action should the nurse take? A) Suggest that the client take brief showers and apply oil-based lotion after showering. B) Explain that the symptoms are caused by liver damaged and cannot be relieved. C) Encourage the client to use cooler water and apply calamine lotion after soaking. D) Obtain a PRN prescription for an analgesic that the client can use for symptom relief.

C) Encourage the client to use cooler water and apply calamine lotion after soaking.

95. The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. What action should the nurse take? A) Recommend a complete bath to cleanse the perineal area more fully. B) Instruct the PN that this technique promotes infection in elderly females. C) Evaluate the effectiveness of this measure to stimulate client voiding. D) Suggest contacting the healthcare provider for a prescription for Cather insertion.

C) Evaluate the effectiveness of this measure to stimulate client voiding.

33. A client is admitted to the intensive care unit with diabetes insidious due to a pituitary gland tumor. Which potential complication should the nurse monitor closely? A) Ketonuria. B) Peripheral edema. C) Hypokalemia. D) Elevated blood pressure.

C) Hypokalemia.

52. Following a cardiac catheterization, an adult client is sent to the cardiovascular unit. The nurse instructs the client to keep the affected leg immobile. Which intervention should the nurse plan to include in the client's plan of care? A) Apply a sequential compression device. B) Ambulate once vital signs are stable. C) Monitor telemetry of dysrhythmias. D) Maintain NPO until bowel sounds return.

C) Monitor telemetry of dysrhythmias.

40. When caring for a client with a traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours, the client's GCS score has been 14. What does this GCS finding indicate about this client? A) Rehabilitative prognosis is an expected full recovery. B) Insertion of an ICP monitoring device is necessary. C) Neurologically stable without indications of an increased ICP. D) Risk for irreversible cerebral damage related to increased ICP.

C) Neurologically stable without indications of an increased ICP.

84. An adult client with a broken femur is transferred to the medical-surgical unit to await surgical internal fixation after the application of an external traction device to stabilize the leg. An hour after an opioid analgesic was administered, the client reports muscle spasm and pain at the fracture site. While waiting for the client to be transported to surgery, which action the nurse implement? A) Reduce the weight on the traction device. B) Administer PRN dose of a muscle relaxant. C) Observe for signs of deep vein thrombosis. D) Check client's most recent electrolyte values.

C) Observe for signs of deep vein thrombosis.

98. A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately? A) Stomal output of 40 ml in last hour. B) Liquid brown drainage. C) Red edematous stomal appearance. D) Mucous strings floating in the drainage.

C) Red edematous stomal appearance.

41. While caring for a client's postoperative dressing the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without daring. Which is the most important action for the nurse to take? A) Determines if the drainage has an unpleasant B) Cleanse the wound with a sterile saline solution. C) Request a culture and sensitivity of the wound. D) Monitor the client's white blood cell count (WBC).

C) Request a culture and sensitivity of the wound.

74. The nurse is planning discharge teaching for a client who had an evacuation of gestational trophoblastic disease (GTD) two days ago. Which information is most important for the nurse to include in this client's teaching plan? A) Location and times for a local support group. B) Rho(D) immune globulin to prevent isoimminuization. C) Schedule a follow-up visit with the healthcare provider. D) Oral contraceptive use for at least one year.

C) Schedule a follow-up visit with the healthcare provider.

36. When administering ceftriaxone sodium intravenously to a client before surgery, which assessment finding requires the most immediate intervention by the nurse? A) Headache. B) Pruritis. C) Stridor. D) Nausea.

C) Stridor.

80. The nurse is developing a plan of care for an older male client with type 2 diabetes who reports blurred vision. Which outcome shows a plan of care for this client? A) The client will express acceptance of his changing health status. B)The client's family will state the signs and symptoms about the disease. C) The nurse will demonstrate the procedure for accurate eye care. D) The client's daily blood pressure will be less than 140/80 mmHg this month.

C) The nurse will demonstrate the procedure for accurate eye care.

73. Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form? A) The client is illiterate but verbalizes understanding and consent for the procedure. B) A 15-year-old primigravida who has been self-supporting for the past 6 months. C) The obstetrician explained a procedure that a neurologist will perform. D) The client was meditated for pain with a narcotic IM 6 hours ago.

C) The obstetrician explained a procedure that a neurologist will perform.

53. Following a gunshot wound, an adult client has a hemoglobin level of 4 grams/dl (40 mmol/L SI). The nurse prepares to administer a unit of blood for an emergency transfusion. The client has AB negative blood type and the blood bank sends a unit of Type A Rh negative, reporting that there is no Type AB negative blood currently available. Which intervention should the nurse implement? A) Administer normal saline solution until Type AB negative is available. B) Obtain additional consent for administration of Type A negative blood. C) Transfuse Types A negative blood until Type AB negative is available. D) Recheck the client's hemoglobin, blood type, and Rh factor.

C) Transfuse Types A negative blood until Type AB negative is available.

77. An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (If rounding required, round to the nearest tenth.)

Calculate using the formula, desired dose (220,000 units) over dose on hand (600,000 units) x the volume of the available dose (1 ml). 220,000 / 600,000 x 1 ml = 0.36 mL = 0.4

81. A client presents at the emergency department reporting a raspy voice, cold intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating hormone (TSH) and low T3 and T4 levels. After the client is admitted to the telemetry unit, which intervention is most important for the nurse to implement? A) Offer additional blankets and a warm drink. B) Assess for the presence of non-pitting edema. C)Note the client's most recent hemoglobin level. D) Administer prescribed dose of levothyroxine.

D) Administer prescribed dose of levothyroxine.

76. When administering brompheniramine maleate, an extended-release antihistamine tablet, the nurse is told by the male client that he cannot swallow tablets. Which intervention should the nurse implement? A) Document the client's refusal to take the medication. B) Crush tablet and mix with small amount of pudding. C) Document that the client cannot take the prescription. D) Ask the pharmacist to send it in liquid form.

D) Ask the pharmacist to send it in liquid form.

92. A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement? A) Recommend he avoid fast food restaurants until he is familiar with his prescribed diet. B) Advise him to take his own food with him when going to fast food restaurants with his friends. C) Encourage him to find activities to do with his friends that do not involve eating. D) Assist him in identifying popular fast foods that are within his meal plan for diabetes.

D) Assist him in identifying popular fast foods that are within his meal plan for diabetes.

46. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendations for hypertension? A) Grilled steak, baked potato with sour cream, green beans, and coffee. B) Beef stir fry, fried rice, egg drop soup, Diet Coke, and pumpkin pie. C) Tomato soup, grilled cheese sandwich, pickles, skim milk, and lemon menage pie. D) Baked pork chop, applesauce, corn on the cob, 1% milk, and key lime pie.

D) Baked pork chop, applesauce, corn on the cob, 1% milk, and key lime pie.

90. A 6-year-old child who had surgery yesterday absolutely refuses to use the incentive spirometer. Which intervention should the nurse implement? A) Ask the mother to assist when it is time to use the spirometer. B) Allow child to choose when to perform incentive spirometry. C) Contract with the child to use spirometer only after meals. D) Blow out lights, blow bubbles, and encourage child's laughing.

D) Blow out lights, blow bubbles, and encourage child's laughing.

94. The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100ml less than the input flow. Which actions should the nurse implement first? A) Continue to monitor intake and output with the next exchange. B) Check the client's blood pressure and serum bicarbonate. C) Irrigate the dialysis catheter. D) Change the client's position.

D) Change the client's position.

97. A client with persistent low back pain has received a prescription for electronic stimulator (TENS) unit. After the nurse applies the electrodes and turns on the power, the client reports feeling a tingling sensation. How should the nurse respond? A) Remove electrodes and observe for skin redness. B) Decrease the strength of the electrical signals. C) Check the amount of gel coating on the electrodes. D) Determine if the sensation feels uncomfortable.

D) Determine if the sensation feels uncomfortable.

22. A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A) Provide information about survival rates women who have this genetic mutation. B) Gather additional information about the client's family history for all types of cancer. C) Offer assurance that there are a variety of effective treatments for breast cancer. D) Explain that counseling will be provided to give her information about her cancer risk.

D) Explain that counseling will be provided to give her information about her cancer risk.

70. A male client is admitted to the hospital due to multiple fractures following a motor vehicle collision that occurred when he ran his car into his ex-spouse's home. When the client becomes angry and starts throwing objects at the staff, which PRN prescription should the nurse implement? A) Apply soft wrist restraints if needed for client safety. B) Consult with the chaplain for emotional support. C) Hydromorphone (Dilaudid) 2mg IV. D) Haloperidol (Haldol) 1mg IM.

D) Haloperidol (Haldol) 1mg IM.

39. The nurse is teaching a mother of a newborn with a cleft lip how to bottle feed her baby using a Medela Haberman feeder, which has a valve to control the release of milk and a slit nipple opening. The nurse discusses placing the nipple's elongated tip in the back of the oral cavity. What instruction should the nurse provide the mother about feedings? A) Alternate milk with water during the feedings. B) Squeeze the nipple base to introduce milk into the mouth. C) Position the baby in the left lateral position after feeding. D) Hold the newborn in an upright position.

D) Hold the newborn in an upright position.

44. A client with a history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain. Vital signs are: temperature 102 F (38.9 C) heart rate 138 beats/minute, blood pressure 80/60 mmHg. Which intervention should the nurse implement first? A) Obtain an analgesic prescription. B) Cover the client with the cooling blanket. C) Administer PRN oral antipyretic. D) Infuse an intravenous fluid bolus.

D) Infuse an intravenous fluid bolus.

96. The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. Which information about the most commonly prescribed medication, mebendazole, should be taken? A) Insert the medication as a rectal suppository. B) A second dose of medication should be given in two weeks. C) It is safe for children of all ages to take this medication. D) Only children with perianal itching should take the medication.

D) Only children with perianal itching should take the medication.

4. After 2 days of treatment for dehydration, a child continues to vomit and have diarrhea. Normal saline is infusing and the child's urine output is 50ml/hour. During morning assessment, the nurse determines that the child is lethargic and difficult to arouse. Which should the nurse implement? A) Increase the IV fluid flow rate. B) Review 24-hour intake and output. C) Obtain arterial blood gases. D) Perform a finger stick glucose test.

D) Perform a finger stick glucose test.

21. The nurse is demonstrating correct transfer procedures to the unlicensed assistance personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. What action should the nurse recommend? A) Apply a gait belt around the client's waist once a standing position has been assumed. B) Pull the client into position by reaching from the opposite side of the bed. C) Hold the client at arm's length while transferring to better distribute the body weight. D) Place the client's locked wheelchair on the client's strong side next the bed.

D) Place the client's locked wheelchair on the client's strong side next the bed.

27. Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. What action should the nurse take? A) Apply bilateral eye shields to reduce photosensitivity. B) Begin postoperative prophylactic antibiotics. C) Administer an antiemetic to prevent vomiting. D) Report the complain of eye pain to the surgeon.

D) Report the complain of eye pain to the surgeon.

89. An older adult male is admitted with complications related to Chronic Obstructive Pulmonary Disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? A) Limit the intake of high-calorie foods. B) Maintain a low protein diet. C) Eat meals at the same time daily. D) Restricts daily fluid intake.

D) Restricts daily fluid intake.

31. The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? A) White blood cell count of 12,000 mm^3 (12 x 10^9/L SI) B) Serum sodium of 145 men/L (145 mm/L SI) C) Urine culture positive for MRSA. D) Serum creatinine of 4.5mg/dl (398 mom/L SI)

D) Serum creatinine of 4.5mg/dl (398 mom/L SI)

18. The nurse is performing a peritoneal dialysis exchange on a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the healthcare provider? A) The client complains of abdominal fullness and cramping during installation. B) The client complains of a slight shortness of breath during installation. C) The amount of the returning dialysis fluid is greater than the amount instilled. D) The appearance of the returning dialysate fluid is cloudy.

D) The appearance of the returning dialysate fluid is cloudy.

57. Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? A) Balance and posture. B) Pressure sore risk. C) Risk for disuse syndrome. D) Upper body muscle strength.

D) Upper body muscle strength.

58. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? A) Administer antiemetic as needed. B) Initiate IV fluid replacement. C) Evaluate intake and output ratio. D) Withhold food and fluid intake.

D) Withhold food and fluid intake.

88. What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms? A) Avoid using heat or ice to injured muscles while taking this medication. B) Use cold and allergy medications only as directed by a healthcare provider. C) Take the medication on an empty stomach. D) Discontinue all non-steroidal anti-inflammatory medications.

Use cold and allergy medications only as directed by a healthcare provider.