HESI Comprehensive Review for the NCLEX-RN Examination
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity
B. Right cephalic vein
An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client safely administered the injections. What is the nurse's best response? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home."
C. "When I watched you give yourself the injection, you did it correctly."
The nurse who is preparing to give a 14-year-old client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents.
C. Do not give the medication and document the reason.
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing action? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea.
D. Determine if pain is causing the client's tachypnea.
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time.
D. Discuss the client another time.
The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor.
D. Gently lower the client to the floor.
The health care provider diagnoses metastatic cancer and recommends a gastrostomy for an elderly client in stable condition. The client's adult child is concerned and states to the nurse, "I don't think my parent 'can handle' the cancer diagnosis." What information will guide the nurse's response? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the adult child has the right to waive informed consent for the parent. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.
D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.
How many mL will the nurse document on the client's intake and output record from the items listed? _____ mL 1200 mL water 4 ounce container of gelatin 8 ounces of orange juice 355 mL can of soda 1 cup of soup
2155 rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The postoperative client states to the nurse, "When I had surgery last year I got constipated. It was miserable. What can I do to avoid constipation after this surgery this time?" (Select all that apply.) A. "Drink approximately 3000 mL of non-caffeinated fluid per day." B. "I will make sure that you get out of bed an walk for 10 minutes, six times per day." C. "I will administer your pain medication even if you do not have any pain." D. "I will ask your healthcare provider for a prescription of docusate." E. "When you are on a regular diet, make sure you order plenty of fruits and vegetables." F. "When you are resting in bed, make sure you are flat on your back."
A. "Drink approximately 3000 mL of non-caffeinated fluid per day." B. "I will make sure that you get out of bed an walk for 10 minutes, six times per day." D. "I will ask your healthcare provider for a prescription of docusate." E. "When you are on a regular diet, make sure you order plenty of fruits and vegetables."
The client reports to the clinic nurse, "I sleep for about 2 hours and then I have to get up to use the bathroom. I repeat that pattern about three to four times per night." What questions will the nurse include in this client's assessment? (Select all that apply.) A. "How much fluid do you drink after 8:00 in the evening?" B. "Does your spouse wake up with you, and use the bathroom after you?" C. "What time of day do you take your water pill?" D. "Do you drink any alcoholic beverages in the evening?" E. "When did this pattern of urination start?" F. "Do you have any itching or burning when you urinate?"
A. "How much fluid do you drink after 8:00 in the evening?" C. "What time of day do you take your water pill?" D. "Do you drink any alcoholic beverages in the evening?" E. "When did this pattern of urination start?" F. "Do you have any itching or burning when you urinate?"
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult."
A. "How will this affect your present sexual activity?"
The nurse is at a teen event. Which teen's statement would cause the nurse to input some safety tips? (Select all that apply.) A. "My boyfriend and I fool around on occasion, but he never comes when he is inside me." B. "I hang around with my friends after the games, like football and baseball." C. "I work until 10:00 pm at a local fast-food restaurant." D. "I never use my seatbelt while I am driving. I hate the way it feels." E. "We often go and play beach volleyball when it is nice out."
A. "My boyfriend and I fool around on occasion, but he never comes when he is inside me." D. "I never use my seatbelt while I am driving. I hate the way it feels."
The nurse is performing an intake interview for a newly admitted client to the rehabilitation unit. Which questions will the nurse include in the interview? (Select all that apply.) A. "When do you usually go to bed? And, when do you usually wake up?" B. "Do you usually bathe/shower in the morning or in the evening?" C. "Do you have any intolerance to food that we need to know about?" D. "How long do you think you will be here on the rehabilitation unit?" E. "Do you urinate every hour, on the hour, when you are awake?"
A. "When do you usually go to bed? And, when do you usually wake up?" B. "Do you usually bathe/shower in the morning or in the evening?" C. "Do you have any intolerance to food that we need to know about?" D. "How long do you think you will be here on the rehabilitation unit?"
The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and 8:00 pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan on drawing the test? A. 7:00 am B. 9:00 am C. 12:00 noon D. 2:00 pm
A. 7:00 am
The nurse is preparing to administer 0.32 mL of medication subcutaneously. What supplies will the nurse need to deliver the medication? (Select all that apply.) A. A 1 mL syringe B. A 3 mL syringe C. Alcohol prep pads D. Sterile gloves E. A 24-gauge ¾″ needle F. A 20-gauge 1″ needle
A. A 1 mL syringe C. Alcohol prep pads E. A 24-gauge ¾″ needle
The nurse is orienting a new graduate to the reporting regulations often seen in the emergency department. Which clients will the nurse need to report to the nurse manager/supervisor to alert the proper authorities? (Select all that apply.) A. A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the back in various stages of healing. B. An 88-year-old who states, "My child lives 5 minutes away no longer stops to visit. My days are long and lonely." C. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was shot in the shoulder." D. An 18-year-old who states, "Once I turned 18 my parents demanded I leave their home. I was no longer welcomed there." E. A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked that family. It is just that way."
A. A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the back in various stages of healing. C. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was shot in the shoulder." E. A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked that family. It is just that way."
The nurse is preparing an IV solution containing 10 mEq of potassium in 100 mL of normal saline. Which findings would concern the nurse? (Select all that apply.) A. A red and swollen peripheral IV site B. An order to infuse the solution at 50 mL/hr C. Starting the infusion without an infusion devise D. Inverting the potassium solution every 30 minutes while infusing E. The solution is a lemon-yellow color
A. A red and swollen peripheral IV site C. Starting the infusion without an infusion devise E. The solution is a lemon-yellow color
A client is laughing at a television program when the evening nurse enters the room. The client states, "My foot is hurting. I would like a pain pill." How should the nurse respond? A. Ask the client to rate the pain using a 1 to 10 scale. B. Encourage the client to wait until bedtime for the pill. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct the client in the use of deep breathing exercises for pain control.
A. Ask the client to rate the pain using a 1 to 10 scale.
The nurse is preparing to administer a bolus tube feeding. What steps must the nurse include prior to administering the feeding? (Select all that apply.) A. Aspirate the stomach contents. B. Assess bowel sounds. C. Position the client in semi-Fowler's position. D. Irrigate the lumen after the contents are replaced. E. Warm the feeding to room temperature. F. Assess the pH of the stomach contents.
A. Aspirate the stomach contents. B. Assess bowel sounds. E. Warm the feeding to room temperature. F. Assess the pH of the stomach contents.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. What is the priority nursing action for this client? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Request that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate.
A. Assist the client to walk to the bathroom and do not leave the client alone.
For the client with a sodium level of 128 mEq/L, which meal selections should the nurse suggest to the client? (Select all that apply.) A. Bacon, egg, and cheese biscuit B. Chinese chicken and vegetables, with rice and soy sauce C. Strawberry, spinach salad with yogurt-based blue cheese dressing D. Chicken salad stuffed fresh tomato with a side of celery sticks E. Grilled tilapia with a fresh green side salad F. Grilled hot dog on a bun with ketchup and mustard
A. Bacon, egg, and cheese biscuit B. Chinese chicken and vegetables, with rice and soy sauce F. Grilled hot dog on a bun with ketchup and mustard
The nurse is providing care to a client who had major abdominal surgery. Upon return from the recovery room, the client's vital signs were at the pre-operative baseline. The client was sleepy, but arousable, and the skin was warm and dry to the touch. At the 1 hour post admission assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and the skin is cool and clammy to the touch. What are the priority nursing actions? (Select all that apply.) A. Call the health care provider. B. Elevate the head of the bed. C. Observe for restlessness/confusion. D. Administer oxygen by re-breather mask. E. Observe the abdominal bandage.
A. Call the health care provider. C. Observe for restlessness/confusion. D. Administer oxygen by re-breather mask. E. Observe the abdominal bandage.
In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? A. Daily black, sticky stool B. Daily dark brown stool C. Firm brown stool every other day D. Soft light brown stool twice a day
A. Daily black, sticky stool
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider.
A. Document that the client responds to painful stimulus.
The nurse is working with one LPN and two aides on a 20 bed unit. Which are the appropriate tasks to delegate to the appropriate person? (Select all that apply.) A. Feeding an elderly and confused client to the aide B. Toileting the client for the first time after surgery to the LPN C. Placing the bathroom supplies in the room of the new admission to the LPN D. Reinforcing the discharge teaching instructions to the LPN E. Administering a po pain medication to the LPN F. Performing the routine dressing change 5 days after surgery to the LPN
A. Feeding an elderly and confused client to the aide D. Reinforcing the discharge teaching instructions to the LPN E. Administering a po pain medication to the LPN F. Performing the routine dressing change 5 days after surgery to the LPN
The nurse is preparing to administer a new medication through an existing IV line containing a vasopressor. What action must the nurse take first? A. Flush the line with normal saline at the same rate as the vasopressor. B. Administer the medication at the prescribed IV rate. C. Start a second IV line to administer the new medication. D. Call the health care provider to change the order for the new medication to po.
A. Flush the line with normal saline at the same rate as the vasopressor.
The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level
A. Low serum albumin level
The nurse is concerned the client will develop a nosocomial infection. Which nursing action is best for the nurse to take when providing care for an incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers.
A. Maintain standard precautions.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit
A. Mode of transmission
A 75-year-old client states to the nurse, "I am just not hungry anymore." The client has lost 10 pounds/4.53 kg in the past 4 months. Which snacks will the nurse recommend to the client? (Select all that apply.) A. Nuts B. Milkshakes C. Chocolate candy bar D. Peanut butter and crackers E. Glass of whole fat milk
A. Nuts B. Milkshakes D. Peanut butter and crackers E. Glass of whole fat milk
The nurse is providing care to clients at a day treatment center. One of the clients who is usually talkative and eats well is now confused and did not eat lunch. The nurse learns these are new findings as of today. What are the next nursing actions? (Select all that apply.) A. Obtain a clean catch urine sample. B. Take the client's vital signs. C. Assess for the initiation of any new medications. D. Obtain an oxygen saturation. E. Call the client's children to report the confusion. F. Call the facility's bus service to return the client home.
A. Obtain a clean catch urine sample. B. Take the client's vital signs. C. Assess for the initiation of any new medications. D. Obtain an oxygen saturation.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which action should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift.
A. Perform range-of-motion exercises to prevent contractures.
A nurse is working in an occupational health clinic when an employee walks in and states, "I was walking outside and I believe I was just struck by lightning." The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury
A. Pulse characteristics
The nurse is providing care to a client immediately after a total right mastectomy. What steps will the nurse include when positioning the client? (Select all that apply.) A. Raise the head of the bed 30 to 45 degrees. B. Roll the client to her right side and place a pillow behind her back. C. Elevate her right arm under two pillows. D. Require the client to stay in bed for 72 hours post procedure. E. Place a sandbag on the incision.
A. Raise the head of the bed 30 to 45 degrees. C. Elevate her right arm under two pillows.
A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of respiratory compromise for this client. What will the nurse include in this client's plan of care? (Select all that apply.) A. Raise the head of the bed to no less than a 45 degrees angle. B. Have the client use an incentive spirometer 10 times every hour while awake. C. Limit total fluid intake to no more than 1000 mL/day. D. Have the client sit on the side of the bed instead of getting up and walking. E. Ask the client to take deep breaths and cough five times every hour while awake.
A. Raise the head of the bed to no less than a 45 degrees angle. B. Have the client use an incentive spirometer 10 times every hour while awake. E. Ask the client to take deep breaths and cough five times every hour while awake.
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention.
A. Record the amount on the client's fluid output record.
The nurse is talking with the spouse of a client admitted to the long-term care center. The client has end-stage renal cancer and is admitted for palliative care while awaiting hospice placement. The client often moans and groans, but is otherwise non-communicative and somnolent. What will the nurse include in the spouse's teaching regarding the care of the client? (Select all that apply.) A. Repositioning every 2 hours B. Round-the-clock pain medication administration C. Assessment for skin breakdown D. Back rubs three times a day E. Bathing twice a day
A. Repositioning every 2 hours B. Round-the-clock pain medication administration C. Assessment for skin breakdown D. Back rubs three times a day
The nurse is working at a community-based clinic. Which client's spiritual well-being concerns the nurse the most? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement
A. Roman Catholic woman considering an abortion
Which nonverbal action should the nurse implement to demonstrate active listening? A. Sit facing the client. B. Cross arms and legs. C. Avoid eye contact. D. Lean back in the chair.
A. Sit facing the client.
The postoperative nurse is reviewing the use of an incentive spirometer. Which instructions will the nurse include in the client's teaching plan? (Select all that apply.) A. Sit in an upright position. B. Cough deeply three times. C. Hold breath for 5 seconds after inhaling on the spirometer. D. Place mouth securely around the mouthpiece of the spirometer. E. Remove mouth from mouthpiece and exhale through the nose.
A. Sit in an upright position. C. Hold breath for 5 seconds after inhaling on the spirometer. D. Place mouth securely around the mouthpiece of the spirometer.
The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to take for this client? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate.
A. Stay with the client while the client is standing.
The nurse is preparing to change the bed of a client who is non-responsive, and receiving continuous enteral tube feedings. What step must the nurse take prior to changing the bed? A. Stop the feeding for 15 minutes prior to changing the bed. B. Obtain extra linens to absorb any feeding that leaks out of the mouth. C. Ask another nurse to help with changing the bed. D. Ask the client's spouse to leave the room during the bed change.
A. Stop the feeding for 15 minutes prior to changing the bed.
The clinic nurse is reviewing an antibiotic medication prescribed to a client with a urinary tract infection. What instructions will the nurse include in the client's teaching? (Select all that apply.) A. Take all of the medication as prescribed, especially when you start feeling better. B. Take the medication with 8 ounce/240 mL of water. C. Call poison control if you start itching, develop hives, or have difficulty breathing. D. Keep this medication out of the reach of small children, preferably in a locked cabinet. E. Call your healthcare provider (HCP) when your symptoms subside.
A. Take all of the medication as prescribed, especially when you start feeling better. B. Take the medication with 8 ounce/240 mL of water. D. Keep this medication out of the reach of small children, preferably in a locked cabinet.
The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is 128 mEq/L. The nurse should be alert for which findings? (Select all that apply.) A. Weakness in the hands and feet B. +1 reflexes to the patella C. Headache D. Muscle twitching E. Nausea F. Facial redness
A. Weakness in the hands and feet B. +1 reflexes to the patella C. Headache E. Nausea
A 65-year-old client who attends an adult daycare program and is wheelchair mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. "Take a vitamin supplement tablet once a day." B. "Change positions in the chair frequently" C. "Increase daily intake of water or other oral fluids." D. "Purchase a newer model wheelchair."
B. "Change positions in the chair frequently"
The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale."
B. "Compress the inhaler while slowly breathing in through your mouth."
The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When viewing the consent form, the nurse notes the surgeon's signature, but not the client's signature. What steps must the nurse take? (Select all that apply.) A. Call the surgeon. B. Ask the client, "Did your surgeon explain the procedure to you?" C. Have the client's spouse sign the form. D. Ask the client, "Do you have any questions?" E. Witness the signature. F. Obtain the consent.
B. Ask the client, "Did your surgeon explain the procedure to you?" D. Ask the client, "Do you have any questions?" E. Witness the signature.
The nurse is providing care to an 86-year-old admitted for a heart catheterization. The nurse determines the client does not have an advance directive (AD) on file. What are the nurse's next steps? (Select all that apply.) A. Ask the client's cardiologist to come to the hospital and obtain the AD. B. Ask the client, "Have you considered completing the paperwork for an AD?" C. Ask the client's spouse to complete the AD. D. Tell the client, "An AD helps the staff provide care according to your wishes." E. Call the client's clergy member to make the final decisions for the client.
B. Ask the client, "Have you considered completing the paperwork for an AD?" D. Tell the client, "An AD helps the staff provide care according to your wishes."
Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse take next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.
B. Assess the client's neurologic status.
The client 12 hours after a laparotomy reports to the nurse a pain rating of 7 to 10. The nurse reviews the medication orders and it is another hour before the client can have another dose of pain medication. What actions can the nurse take to assist the client? (Select all that apply.) A. Administer the IV pain medication an hour early. B. Assist the client into side-lying, curled position. C. Obtain a warm pack to apply to the site of the incision. D. Suggest to the client taking 10 deep breaths, in through the nose and out through the mouth. E. Help the client with sustained concentration of a personally pleasant topic.
B. Assist the client into side-lying, curled position. C. Obtain a warm pack to apply to the site of the incision. D. Suggest to the client taking 10 deep breaths, in through the nose and out through the mouth. E. Help the client with sustained concentration of a personally pleasant topic.
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake
B. Broiled fish, green beans, and an apple
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality.
B. Explain the relationship to the charge nurse and ask for reassignment.
The nurse is evaluating measures implemented for the non-responsive client. Which findings indicate the effectiveness of the care delivered? (Select all that apply.) A. Footboard at the end of the bed B. Heals without redness bilaterally C. Skin intact on the back D. Sheepskin booties in place E. Elbow joint fully flexes and extends. F. Ankle joint rotates 360 degrees freely.
B. Heals without redness bilaterally C. Skin intact on the back E. Elbow joint fully flexes and extends. F. Ankle joint rotates 360 degrees freely.
The client states to the nurse, "This medication makes my mouth so dry." What are the nurse's suggestions to quench the client's thirst? (Select all that apply.) A. Drink 2, 8 ounce glasses of lemon-lime soda every day. B. Infuse your water with fresh citrus fruits to quench your thirst. C. Freeze strawberries and water together in popsicle mold. D. Add ginger ale to your daily glass of juice every day. E. Keep a few pieces of hard candy with you to suck on.
B. Infuse your water with fresh citrus fruits to quench your thirst. C. Freeze strawberries and water together in popsicle mold. E. Keep a few pieces of hard candy with you to suck on.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will the nurse take next? (Select all that apply.) A. Place the client in the bed next to the nurse's station. B. Instruct the client not to get out of bed. C. Place the call bell within the client's reach. D. Place the side rails up, according to institutional policy. E. Assist the client to the bathroom.
B. Instruct the client not to get out of bed. C. Place the call bell within the client's reach. D. Place the side rails up, according to institutional policy.
The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts were made prior to obtaining the sample with the tourniquet in place for nearly 5 minutes. Which laboratory finding would the nurse suspect is inaccurate related to the prolonged tourniquet placement? A. Na 148 mEq/L B. K 5.3 mEq/L C. Cl 102 mEq/L D. Ca 9.3 mg/dL
B. K 5.3 mEq/L Rationale:Prolonged tourniquet placement can cause accumulation of potassium, skewing the result upward. The sodium level is also high, but that is not related to the blood draw. The chloride and calcium levels are normal.
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that apply.) A. Compress the chest once between the nipples with two fingers. B. Note any obstruction or absence of breathing. C. Deliver five backslaps between the shoulder blades. D. Place the infant over the nurse's arm. E. Perform a blind finger sweep.
B. Note any obstruction or absence of breathing. C. Deliver five backslaps between the shoulder blades. D. Place the infant over the nurse's arm.
The nurse is preparing the room for a client after a laparotomy with a 5 inch midline abdominal incision. The nurse plans on teaching the client how to splint the wound when coughing or deep breathing. What extra item will the nurse place in the client's room? A. Pillow case B. Pillow C. Sheet D. Blue absorbent pad
B. Pillow
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly.
B. Put bed rails up on the side of bed opposite from the nurse.
During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.
B. Remind the client to walk carefully down the stairs until reaching a lower floor.
Which action should the nurse implement when providing wound care instructions to a client who does not speak English? A. Ask an interpreter to provide wound care instructions. B. Speak directly to the client, with an interpreter translating. C. Request the accompanying family member to translate. D. Instruct a bilingual employee to read the instructions.
B. Speak directly to the client, with an interpreter translating.
The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months
B. Taking anticoagulants for the past year
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about thoughts and feelings about death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility.
B. Talk with the client about thoughts and feelings about death.
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse to intervene with the UAP's approach? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity.
B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What action has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns
B. Use of careful handwashing technique
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate will the nurse document? A. 14 B. 16 C. 17 D. 28
B. 16
The clinic nurse is conducting an assessment of a 2-year-old. The nurse asks the mother, "What is your child playing with now?" Which response indicates to the nurse that further teaching is needed? (Select all that apply.) A. "We color together using jumbo crayons." B. "Finger paints in the kitchen are a favorite pastime." C. "A marble run race track is set up in the playroom." D. "When outside, the wagon filled with soccer balls is the preferred toy." E. "We got a golf set because my other children play golf."
C. "A marble run race track is set up in the playroom." E. "We got a golf set because my other children play golf."
A client with frequent urinary tract infections (UTIs) asks the nurse to explain a friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A. "Orange juice has vitamin C that deters bacterial growth." B. "Apple juice is the most useful in acidifying the urine." C. "Cranberry juice stops pathogens' adherence to the bladder." D. "Grapefruit juice increases absorption of most antibiotics."
C. "Cranberry juice stops pathogens' adherence to the bladder."
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You"
C. "Decreasing Cholesterol Levels Through Diet"
The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL. What delivery devise will the nurse select to prepare the medication? A. 30 mL medication cup B. 10 mL medication spoon C. 3 mL needleless syringe D. 5 mL medicine dropper
C. 3 mL needleless syringe
The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A. Dilute each of the medications with sterile water prior to administration. B. Mix the medications in one syringe before opening the feeding tube. C. Administer water between the doses of the two liquid medications. D. Withdraw any fluid from the tube before instilling each medication.
C. Administer water between the doses of the two liquid medications.
A client in a long-term care facility reports to the nurse, "I have not had a bowel movement in 2 days." What is the nurse's first action? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.
C. Assess the client's medical record to determine the client's normal bowel pattern.
After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A. Ask the client to remain quiet so the procedure can be performed safely. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure.
C. Calmly reassure the client that the discomfort will be temporary.
When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.
C. Leave the catheter in place and reattempt with another catheter.
Which action is most important for the nurse to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway.
C. Use aseptic technique to change the dressing. Rationale:Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.
In the middle of running a resuscitation for a cardiac arrest the LPN states to the nurse, "What can I do for your other patients?" The nurse says to the LPN, "Go ahead and start that blood on the client in 434B. It is primed and ready to go. You have seen me do it a million times. You can do it." What is the LPN's best response? A. "No way am I starting the blood on that client!" B. "I am going to tell the manager you asked me to start blood." C. "Sure, no problem. I can do that. I have done it before." D. "I can take over compressions so you can start the blood."
D. "I can take over compressions so you can start the blood."
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 8:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before."
D. "This is a new pill I have never taken before."
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports, "I am still unable to sleep, despite following the same routine every night." Which action should the nurse take next? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine he is currently following.
D. Ask the client to describe the routine he is currently following.
During a routine assessment, an obese 50-year-old client states, "I feel so unlovable because of my weight." Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns.
D. Ask the client to talk about specific concerns.
At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at 1845. The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at 1915 and notes there is less than 50 mL left in the IV bag. What is the nurse's next action? A. Contact the healthcare provider on call. B. Call in the off going nurse and request an explanation. C. Tell the client that 950 mL of fluid just accidentally infused. D. Auscultate the client's lungs.
D. Auscultate the client's lungs.
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the health care provider to renew the prescription for the medication.
D. Contact the health care provider to renew the prescription for the medication.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's concern? A. The occurrence of any episodes of sleep apnea B. The child's blood pressure, pulse, and respirations C. Length of rapid eye movement (REM) sleep that the child is experiencing D. Description of the family's home environment
D. Description of the family's home environment
When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle.
D. Discard the saline solution and obtain a new unopened bottle.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise.
D. Encourage the client to call the clinic nurse or health care provider if any questions arise.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which nursing action is best for this client? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client.
D. Review the schedule of outdoor breaks with the client.
Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium
D. Sodium
The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse take first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying.
D. Talk to the client and attempt to find out why the client is crying.
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client.
D. Teach the importance of personal hygiene during menstruation with the client.
A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device.
D. Turn off the intermittent suction device.
The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? _____ mL (Round to the nearest tenth.) there is 10mg/2ml
0.8
The goal is for the client to take in 1500 calories/day administered through by a feeding tube. The concentration of the feeding is 1.5 calories/mL. How many mL per hour will the nurse need to set the infusion pump to deliver the feeding over 18 hours? _____ Enter a whole number.
56 ml/hr 1ml/1.5cal * 1500cal/18 hr = 55.55 = 56 ml/hr
The postoperative client is placed on a clear liquid diet. Which selections will the nurse select for the client? (Select all that apply.) A. Apple juice B. Popsicles C. Vanilla pudding D. Tomato soup E. Gelatin F. Black coffee
A. Apple juice B. Popsicles E. Gelatin F. Black coffee
In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels.
A. Check the bath water temperature.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which nursing actions are correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Explain that placement of the tube is painless. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx.
A. Place the client in a high Fowler position. D. Instruct the client to swallow after the tube has passed the pharynx.
The nurse evaluates the insertion site of an IV catheter and suspects the IV is infiltrated. Which findings support the evaluation? (Select all that apply.) A. The area around the insertion site is swollen. B. There is bruising 1 inch below the insertion site. C. The insertion site is cool to the touch. D. The client complains of a burning pain at the site. E. Redness is noted in the area of the insertion site. F. Blood is noted in the IV tubing when the IV bag is lowered.
A. The area around the insertion site is swollen. C. The insertion site is cool to the touch. D. The client complains of a burning pain at the site. E. Redness is noted in the area of the insertion site.
The nurse is teaching a group of young adults with families about preparing their underground shelter in the event of a tornado. What instructions will the nurse include in teaching plan for these families? (Select all that apply.) A. Place two electric lights in the shelter. B. Plan for 1 gallon of water per family member for at least 3 days. C. Don't forget a can opener with the supply of canned food. D. Make sure you include a first aid kit in the shelter. E. Pack shoes with sturdy soles and they must completely cover the feet.
B. Plan for 1 gallon of water per family member for at least 3 days. C. Don't forget a can opener with the supply of canned food. D. Make sure you include a first aid kit in the shelter. E. Pack shoes with sturdy soles and they must completely cover the feet.
The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the nurse bring to the attention of the healthcare provider? A. Temperature: 97.5°F/36.4°C B. Pulse: 80 beats/min C. Respirations: 26 breaths/min D. Blood pressure: 90/53 mm Hg
B. Pulse: 80 beats/min Rationale:A normal pulse rate for a 1-year-old is 90 to 130. This child's heart beat is below the normal range. The remaining vital signs are within the normal limits for a 1-year-old.
