Medsurg HESI
The parents of fa newborn infant with hypospadias are concerned about when the surgical correction should occur . What information should the nurse provide ? a . Repair should be done by one month to prevent bladder infections . b . Repairs typically should be done before the child is potty - trained . c . Delaying the repair until school age reduces castration fears . d . To form a proper urethra repair , it should be done after sexual maturity.
B
The parents of fa newborn infant with hypospadias are concerned about when the surgical correction should occur . What information should the nurse provide ? a . Repair should be done by one month to prevent bladder infections . b . Repairs typically should be done before the child is potty - trained . c . Delaying the repair until school age reduces castration fears . d . To form a proper urethra repair , it should be done after sexual maturity .
B
d 12. The nurse formulates a nursing diagnosis of , " High risk for ineffective airway clearance " for a client with myasthenia gravis . What is the most likely etiology for this nursing diagnosis ? 3 a . Pain when coughing . b . Diminished cough effort . C. Thick dry secretions . d . Excessive inflammation .
B
4. A client is on a mechanical ventilator . Which client response indicates that the neuromuscular blocker tubocurarine chloride ( Tubarine ) is effective ? a . The client's expremities are paralyzed . b . The peripheral nerve stimulator causes twitching . c . The client clinches fist upon command . d . The client's Glagow Coma Scale score is 14
A
46. Because the census is currently low in the Obstetrics ( OB ) unit , one of the nurses is sent to work on a medical - surgical unit for the day , or until the OB unit becomes busy . Which client assessment is best for the charge nurse to assign to the OB nurse ? a . An adult who had a colon resection yesterday and has an IV . b . An older adult who has a fever of unknown origin . C. A woman who had an n acute brain attack ( stroke , CVA ) 6 hours ago . d . A teenager with a femoral fracture who is in traction .
A
52. Immediate postoperative nursing care for a client who has had a surgical repair of an abdominal aortic aneurysm should include which interventions ? a . Assessing pedal pulses frequently and monitoring the nasogastric drainage . b . Maintaining strict bedrest for 72 hours and assessing radial pulses . c . Monitoring an infusion of IV heparin and checking the PTT level daily . d . Assessing the right flank dressing and monitoring the suprapubic Foley catheter .
A
61. The community mental health nurse is planning to visit four clients with schizophrenia today Which client should the nurse see first ? a . The mother who took her children from school because aliens were after them . b . The young man who has a history of substance abuse and has no telephone . C. The newly diagnosed client who needs to be evaluated for medication compliance . d . The young woman who believes she is to blame for her recent miscarriage .
A
62. The nurse is caring for a client whose urine drug screen is positive for cocaine . What behavior is this client likely to exhibit during cocaine withdrawal ? A. . Intense cravings . b . Increased energy . C. Talkativeness . d . Euphoria
A
64. A 5 - year - old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis . Which intervention should the nurse implement first ? a . Initiate normal saline IV at 50 ml / hr . b . Administer a loading dose of penicillin IM . C. Obtain a culture of any sputum or wound drainage . d . Administer the initial dose of folic acid PO .
A
66. A client has 2nd degree electrical burns on both upper extremities The nurse is preparing to administer the first application of the topical antimicrobial agent mafenide acetate ( Sulfamylon ) to the burned area . Which intervention should the nurse implement first a a . . Premedicate the client prior to applying the medication . Ь Use sterile gloves when applying this medication . c Cleanse the burned area with sterile normal saline . d . Assess the client's most recent arterial blood gas test results
A
77. Following a motor vehicle collision , a 3 - year - old girl has a spica cast applied . Which toy is best for the nurse to provide for this 3 - year - old child ? a W . Set of cloth hand puppets . b . Barbie doll and clothes . c . Duck that squeaks . d . Hand - held video game .
A
60. A client with a cold is taking the antitussive benzonatate ( Tessalon ) . Which assessment data indicates to the nurse that the medication is effective ? a . Reports reduced nasal discharge . b . Denies having coughing spells . C. Able to sleep through the night . d . spe Expectorating bronchial secretions
B
80. A male Muslim client with pneumonia is scheduled to receive a dose of an intravenous antibiotic but refuses to allow the nurse to begin the medication , stating he cannot allow fluids to enter his body once he is cleansed for prayer . What action should the nurse implement ? a . Reschedule administration of the antibiotic until after he completes his prayers . b Instruct the client that the antibiotics must be given on time to be effective . c Notify the healthcare provider that the client has refused the scheduled d . Ask the pharmacist to supply an oral form of the antibiotic for the client.
A
84. A 25 - year - old male client has a diagnosis of epididymitis and a positive culture for Escherichia coli . What is the most important information for the nurse to include in the teaching plan ? a . Avoid penile contact with the rectal area . b . Epididymitis is a pre - cancerous condition c . Obtain an annual prostate digital exam . d . Surgical intervention is often indicated .
A
87. A male client asks the nurse how lo long his hospital stay will be following his scheduled surgery . Which resource provides the best guide for the nurse in responding to the client ? a . Critical pathway for the scheduled surgery . b . Diagnosis - related group ( DRG ) for the surgery . c . The client's preferred provider arrangement . d . Standards of clinical nursing practice .
A
93. During a home visit , the nurse should evaluate the adequacy of a client's treatment for COPD by assessing for which primary symptom ? a . Dyspnea b . Tachycardia . C. Unilateral diminished breath sounds . d . Edema of the ankles .
A
98. The charge nurse observes that a client with a nasogastric tube applied to low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel a . Remove the glass of water and speak to the UAP b . Discuss the incident with the UAP at the end of the day . C. Write an incident report and notify the healthcare provider . d Remind the client of the potential for electrolyte imbalance .
A
99. Which assessment is most important for the nurse to complete to determine a client's tolerance for ambulation ? a . Respiratory rate . b . Capillary refill . C. Pedal pulses . d . Skin turgor .
A
An outcome for treatment of peripheral vascular disease is , " The client will have decreased venous congestion . " What client behavior would indicate to the nurse that this outcome been met ? a . Avoids prolonged sitting or standing . b . Avoids trauma and irritation to skin . c . Wears protective shoes d . Quits smoking
A
In evaluating teaching of a client about wearing a Holter monitor which statement made by the client would indicate 10 to the nurse that the client understands the procedure ? a . " I must record any symptoms occurring with my activity . " b . " I am not looking forward to staying in bed for 24 hours . " c . " I really am dreading the frequent blood drawing . " d . " I know that I shouldn't get close to my microwave oven . "
A
The nurse is planning care for a 16 - year - old , who has juvenile rheumatoid arthritis ( JRA The nurse includes activities to strengthen and mobilize the joints and surrounding muscle . Which physical therapy regimen should the nurse encourage the adolescent to implement ? a . Exercise in a swimming pool . b . Splint affected joints during activity . c . Perform passive range - motion exercises twice daily . d . Begin a training program lifting weights and running .
A
54. A 65 - year - old female client arrives in the emergency department with shortness of breath and chest pain . The nurse accidentally administers 10 mg of morphine sulfate instead of 4 mg as prescribed by the healthcare provider . Later , the client's respiratory rate is 10 breaths / minute , oxygen saturation is 98 % , and she states that her pain has subsided . What the legal status of the nurse ? a . . The nurse is guilty of negligence and will be sued . b . The client would not be able to prove malpractice in court . C. The nurse is protected by the Good Samaritan Act . D. The healthcare provider should have given the morphine sulfate dose.
B
5. An elderly female client comes to the clinic for a regular check - up . The client tells the nurse that she has increased her daily doses of acetaminophen ( Tylenol ) for the past month to control joint pain . Based on this client's comment , what previous lab values should the nurse compare with today's lab report ? a . Look at last quarter's hemoglobin and hematocrit , expecting an increase today due to dehydration . b . Look for an increase in today's LDH compared to the previous one to assess for possible liver damage .
B
55. A client with which problem requires the most immediate intervention by the nurse ? a. Finger paresthesias related to carpal tunnel syndrome . b . Increasing sharp pain related to compartment syndrome . c . Increasing burning pain related to a Morton's neuroma . d . Increasing sharp pain related to plantar fascitis
B
56. The charge nurse should intervene when what behavior is observed ? a. Two staff members are overheard talking about a cure for AIDS outside a client's room . b. A hospital transporter is reading a client's history and physical while waiting for an elevator C. A UAP tells a client , " It's hard to quit drinking but Alcoholic Anonymous helped me. d . Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge .
B
50. An unlicensed assistive personnel ( UAP ) reports to the charge nurse that a client who delivered a 7 - pound infant 12 hours ago is complaining of a severe headache . The client's blood pressure is 110/70 , respiratory rate is 18 breaths / minute , heart rate is 74 beats / minute and temperature is 98.6 ° F. The client's fundus is firm and one fingerbreadth above the umbilicus . What action should the charge nurse implement first ? a . Notify the healthcare provider of the assessment findings . b . Determine if the client received anesthesia during delivery . 51. 1. C c . Assign a practical nurse ( PN ) to reassess the client's vital signs . D. Obtain a STAT hemoglobin and hematocritest tube due to a hemothorax
B
13. Following a CVA , the nurse assess that a client developed dysphagia , hypoactive bowel sounds and firm , distended abdomen . Which prescription for the client should the nurse question ? a . Continous tube feeding at 65 ml / hr via gastrostomy . b . Total parenteral nutrition to be infused at 125 ml / hour . tube connected to low intermittent suction .
A
23. It is most important for the registered nurse ( RN ) who is working on a medical unit to provide direct supervision in which situation ? a . A graduate nurse needs to access a client's implanted port to start an infusion of Ringer's Lactate . Kingarst A postpartum nurse pulled to the unit needs to start a transfusion of packed red blood cells . c . A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside . d . An unlicensed assistive personnel is preparing to weigh an obese bedfast client using a bed scale .
A
25. A 10 - year - old child with meningitis is suspected of having diabetes insipidus . In evaluating the child's laboratory values , which finding is indicative of diabetes insipidus ? a. Decreased urine specific gravity . b . Elevated urine glucose . c . Decreased serum potassium . D. Increased serum sodium .
A
28. A client who has Type 1 diabetes and is at 10 - weeks gestation comes to the prenatal clinic complaining of a headache , nausea , sweating , feeling shaky , and being tired all the time . What action should the nurse take first ? a . Check the blood glucose level . b . Draw blood for a Hemoglobin AIC . C. Assess urine for ketone levels . d . Provide the client with a protein snack.
A
30. The nurse is planning care for a non - potty - trained child with nephrotic syndrome . Which intervention provides the best means of determining fluid retention ? a . Weigh the child daily . b . Observe the lower extremities for pitting edema . c . Measure the child's abdominal girth weekly . d . Weigh the child's wet diapers .
A
32. A client from a nursing home is admitted with urinary sepsis and has a single - lumen , peripherally - inserted central catheter ( PICC ) . Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule . Which medication should the nurse administer first ? a . Piperacillin / tazobactam ( Zosyn ) in 100 ml D , W , IV over 30 minutes q8 hours b L . Vancomycin ( Vancocin ) 1 gm in 250 ml D , W , IV over 90 minutes q12 hours d c . Pantoprazole ( Protonix ) 40 mg PO daily Enoxaparin ( Lovenox ) 40 mg subq q24 hours .
A
53. A nurse se is teaching a client postoperative breathing techniques using an incentive spirometer ( IS ) . What should the nurse encourage this client to do to maintain sustained maximal inspiration ? a Exhale forcefully into the tubing for 3 to 5 seconds . b . Inspire deeply and slowly over 3 to 5 seconds . C. Breathe into the spirometer using normal breath volumes . d . Perform IS breathing exercises every 6 hours .
B
100. A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals . Which intervention should the nurse implement first ? a . Provide a supportive , structured environment for meals . b . Assess weight , vital signs , potassium and other electrolytes . c . Discuss alternative strategies for binging and purging . d . Monitor the client after meals for possible vomiting .
B
11. The nurse is administering sevelamer ( RenaGel ) during lunch to a client with end stage renal disease ( ESRD ) . The client asks the nurse to bring the medication later . The nurse should describe which action of RenaGel as an explanation for taking it with meals ? a de . Prevents indigestion associated with ingestion of spicy foods . b . Binds with phosphorus in foods and prevents absorption . c . Promotes stomach emptying and prevents gastric reflux . d . Buffers hydrochloric acid and prevents gastric erosion .
B
20. A 9 - year - old female client was recently diagnosed with diabetes mellitus . Which symptom will her parents most likely report ? a . Refuses to eat her favorite meals a home . b . Drinks more soft drinks than previously . c . Voids only one or two times per day . d . Gained 10 pounds within one month .
B
21. The nurse is caring for four clients : Client A , who has emphysema and whose oxygen saturation is 94 % ; Client , with a postoperative hemoglobin of 8.7 mg / dl ; Client C , newly admitted with a potassium level of 3.8 mEq / L ; and Client D , scheduled for an appendectomy who has a white blood cell count of 15,000 mm³ . What intervention should the nurse implement ? a . Increase Client A's oxygen to 4 liters per minute via nasal cannula . b . Determine if Client B has two units of packed cells available in the blood bank . c . Ask the dietician to add a banana to Client C's breakfast tray . d Inform Client D that surgery is likely to be delayed until the infection is treated
B
27. A 38 - year - old male client collapsed at his outside construction job in Texas in July . His admitting vital signs to ICU are , BP 82/70 , heart rate 140 beats / minute , urine output 10 ml / skin cool to the touch . Pulmonary artery ( PA ) pressures are , PAWP 1 , PAP 8/2 , RAP -1 , SVR 1600. What nursing action has the highest priority ? a . Apply a hypothermia unit to stabilize core temperature . b . Increase the client's IV fluid rate to 200 ml / hr . C. Call the hospital chaplain to counsel the family . d . blood cultures x 3 to detect infection
B
29. A client in labor states , " I think my water just broke ! " The nurse notes that the umbilical cord is on the perineum . What action should the nurse perform first ? a . Administer oxygen via face mask . c . Notify the operating room team . b . Place the client in Trendelenburg . C. Administer a fluid bolus of 500 ml .
B
34. An elderly male client reports to the clinic nurse that he is experiencing increasing nocturia with difficulty initiating his urine stream . He reports a weak urine flow and frequent dribbling after voiding . Which nursing action should be implemented ? a . Obtain a urine specimen for culture and sensitivity . b . Encourage the client to schedule a digital rectal exam C. Advise the client to maintain a voiding diary for one week d . Instruct the client in effective techniques to cleanse the physical
B
37. In planning the turning schedule for a bedfast client , it is most important for the nurse to consider what assessment finding ? a . 4+ pitting edema of both lower extremities . b . A Braden risk assessment scale rating score of ten . c . Warm , dry skin with a fever of 100 ° F. d . Hypoactive bowel sounds with infrequent bowel movements . prescribes naproxen
B
40. A 60 - year - old male client is admitted to the hospital with the complaint of right knee pain the past week . His right knee and calf are warm and edematous . He has a history of diabetes and arthritis . Which neurological assessment action should the nurse perform for this client ? a . Glasgow coma scale . b . Pulses , paresthesia , paralysis distal to the right knee .. c . Pulses , paresthesia , paralysis proximal to the right knee . d md . Optic nerve using ains an an ophthalmoscope .
B
43. The nurse plans to educate a client about the purpose for taking the prescribed antipsychotic medication clozapine ( Clozaril ) . Which statement should the nurse provide ? a . " It will help you function better in the community . " b . " The medication will help you think more clearly . " c . " You will be able to cope with your symptoms . " d . " It will improve your grooming and hygiene . "
B
63. The nurse enters the room of a client with a history of seizure activity and observes that the unlicensed assistive personnel ( UAP ) is securing several pillows against the side rails to protect the client . What action should the nurse implement ? a . Ensure that the UAP has placed the pillows effectively to protect the client . b . Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows . C. Assume responsibility for placing the pillows while the UAP completes another task . d . Ask the UAP to use some of the pillows to prop the client in a side - lying position .
B
69. A client is hemiplegic following a cerebrovascular accident . To prevent this client from experiencing a painful shoulder , what intervention should the nurse include in the plan of care ? a ** . Exercise the affected shoulder by using it when assisting the client out of bed . b . Position the affected arm on pillows while the client is seated in a chair . c . Keep the client's affected arm elevated above the level of the heart . d . Avoid range of motion exercises on the affected shoulder until pain in the shoulder has passed .
B
71. While on the delivery table , a primipara tells the nurse that she wishes to breastfeed her infant . To assist the new mother with her goal , which intervention is best for the nurse to implement ? a . Permit privacy for the mother and infant to bond . b . Assist the mother to elicit a rooting reflex in the infant . c . Place a small amount of glucose water on the breast . d . Evaluate the infant's sucking reflex then give the infant to the mother
B
72. A male client diagnosed with gastroesophageal reflux ( GERD ) often wakes up at night experiencing heartburn . He tells the nurse that he sleeps with the head of the bed on blocks , and always drinks a glass of milk at bedtime to help him fall asleep . How should the nurse respond? a . " Milk does contain tryptophan , which helps many people fall asleep . " b . " Drinking milk before bedtime can increase your symptoms at night . "C " A warm drink , such as hot tea or cocoa should be substituted for the milk . " d . " Taking an antispasmodic medication with the milk will reduce the symptoms . "
B
74. The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake . Which evening snack contains the most folic acid ? a . Toasted white bread with butter . b . Whole grain cereal and milk . c . Hard - boiled egg and juice . d . Vanilla milkshake with protein supplement .
B
75. A 36 - year - old client is admitted to the ICU following a six - hour surgery to repair a fractured pelvis , and the estimated intraoperative blood loss ( EBL ) was 3,000 ml . Current client data include : BP 85/70 , heart rate 140 beats / minute , urine output 10 ml / hr , PAWP 2 , RAP - 3 , Het 20 % , Hgb 7 g / dl . What action should the nurse take at this time ? a . Administer propranolol ( Inderal ) to decrease the heart rate . b . Infuse blood and IV fluids to correct the hypovolemia . c . Start a dopamine ( Intropin ) infusion to raise the BP . d . Draw serum blood cultures to check for infection
B
76. An unresponsive female victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life . The client is accompanied by a close friend , but no family members are available . What action should the nurse take ? a . Notify the unit manager that an emergency court order is needed to allow the surgery . b . Continue o prepare the client for the surgery without a signed informed consent . C. Ask the woman's friend to sign the informed consent since the client is Ma unresponsive . d . Maintain continuous monitoring of the client until a family member can be located
B
78. While eating at a restaurant a gravid woman begins to choke and is unable to speak . What action should the nurse who witnesses the event take ? a . Call 911 immediately then begin cardiopulmonary resuscitation . b . The Heimlich maneuver using chest thrusts . C. The Heimlich maneuver using subdiaphragmatic thrusts . d . Cardiopulmonary resuscitation with uterine tilt .
B
81. The nurse learns that a newly admitted adult client has a six month history of recurring somatic pain . During the admission interview , it is most important for the nurse to question the client about what problem ? a . Episodes of tremors . b . Feelings of depression . C. Periods of restlessness . d . Nausea and vomiting .
B
82. The nurse administers nalbuphine ( Nubain ) to a postoperative client . What etiology , secondary to the medication's effects , places the client at risk for injury ? a . Bleeding complications . b . Adverse CNS effects . c . Electrolyte imbalance . d . Immune system suppression .
B
83. A client who has end - stage renal disease ( ESRD ) continues to be despondent after receiving the biologic response modifier ( BRM ) epoetin alfa ( Epogen , Procrit ) for 3 weeks . Which parameters should the nurse assess when evaluating the effectiveness of this BRM ? a . WBCs , neutrophil and T , count . b . RBCs , hemoglobin , and hematocrit . c. Blood pressure , heart rate , and temperature . d . Serum potassium , calcium , and phosphorus .
B
91. When is the best time for the nurse to assess a client for residual urine ? a . When the client's bladder is distended . b . Immediately after the client voids . c . Just prior to the client voiding . d . After draining the urinary catheter bag .
B
96. The nurse observes that a client has received 250 ml of 0.9 % normal saline through the IV line in the last hour . The client is now tachypneic , and has a pulse rate of 120 beats / minute , with a pulse volume of +4 . Min In addition to reporting the assessment findings to the healthcare provider , what action should the nurse implement ? a . Discontinue the IV and apply pressure at the site . b . Decrease the saline to a keep - open rate . c . Increase the rate of the current IV solution . d . Change the IV fluid to 0.45 % normal saline at the same rate .
B
97. A client who participates in a health maintenance organization ( HMO ) needs a bone marrow transplant for treatment of breast cancer . The client tells the nurse that she is concerned that her HMO may deny her claim . What action by the nurse best addresses the client's need this time ? a . Have the client's healthcare provider write a letter to the HMO explaining the need for the transplant . b . Help the client place a call to the HMO to seek information coverage . c . Encourage the client to call a lawyer so that a lawsuit can be filed against the HMO if necessary . d . Have the social worker call the state board of insurance to register complaint against the HMO .
B
17. An 85 - year - old male resident of an extended care facility reaches for the hand of the unlicensed assistive personnel ( UAP ) and tries to kiss her hand several times morning care . The UAP reports the incident to the charge nurse . What is the best assessment of the situation ? a . This is sexual harassment and needs to be reported to the administration immediately . b . The UAP needs to be reassigned to another group of residents , preferably females only . only . C. The client may be suffering from touch deprivation and needs to know appropriate ways to express his need . d . The resident needs to know the rules concerning unwanted touching of the staff and the the consequences .
C
22. A recently widowed middle - aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has " little reason to live . " She describes one previous suicidal gesture and admits to having a gun in her home . To maintain the client's confidentiality and to help ensure her safety , which action is best for the nurse to implement ? a . Encourage the client to remove the gun from her possession . b . Notify the client's healthcare provider of the availability of the weapon . C. Contact a person of the client's choosing to remove the weapon from the home . d . Call the local police department and have the weapon removed from the home .
C
35. The nurse is performing an admission physical assessment of a newborn who is small for gestational age ( SGA ) . Which finding should the nurse report immediately to the pediatric healthcare provider ? a . Heel stick glucose of 65 mg / dl . b . Head circumference of 35 cm ( 14 inches ) . C. Widened , tense , bulging fontanel . d . High - pitched ingir - practica : shrill cry .
C
39. A nurse is interested in studying the incidence of infant death in a particular city and wants to compare that city's rate to the state's rate . What state resource is most likely to provide this information ? a . Disease registry . b . Department of Health . C. Bureau of Vital Statistics .. d . Census data .
C
42. What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum ? a . Soft , spongy fundus . b . Saturating two perineal pads per hour . c . Pulse rate of 56 BPM . d . Unilateral lower leg pain .
C
47. A primipara at 38 - weeks gestation is admitted to labor and delivery for a biophysical profile ( BPP ) . The nurse should prepare the client for what procedures ? a . Chorionic villi sampling under ultrasound . b . Amniocentesis and fetal monitoring . c . Ultrasonography and nonstress test . d . Oxytocin challenge test and fetal heart rates .
C
48. A male client who is in the day room becomes increasingly angry and aggressive when he is denied a day - pass . Which action should the nurse implement ? A. Tell him he can have a day pass if he calms down . b . Put the client's behavior on extinction . C. Decrease the volume on the television set . d . Instruct the client to sit down and be quiet .
C
57. Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy ? a . Client denies allergies to contrast media . b . Skin prep to insertion site completed . c . On - call sedation administered . d . Oxygen at 2 L / minute per nasal cannula
C
59. An 89 - year - old male client complains to the nurse that people are whispering behind his back and mumbling when they talk to him . What age - related condition is likely to be occurring with this client ? a . Delirium b . Presbyopia c . Presbycusis d Cerebral dysfunction .
C
6. Aspirin is prescribed for a 9 - year - old child with rheumatic fever to control the inflammatory process , promote comfort , and reduce fever . What intervention is most important for the nurse to implement ? a . Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath . b . Administer the aspirin with at least two ounces of water or juice . c . Notify the healthcare provider if the child complains of ringing in the ears . d . Advise the parents to question the child about seeing yellow halos around objects .
C
65. A client t with a compound fracture of the left ankle is being discharged with a below - the - knee cast . Before being discharged , the nurse should provide the client with what instruction ? a . Keep the left leg in a dependent position . b . Apply heat to the left leg cast . auch C. Do not attempt to scratch atch the the skin under the cast . d . Apply a cold pack to any " hot spots " on the cast .
C
67. The community health nurse must provide a primary prevention program in the community Which type of program addresses this need ? a . Provide a nurse - practitioner to prescribe medications for clients with heart disease . b . Arrange cardiac - prudent diets to be delivered to individuals using Meals on Wheels . c . Incorporate an exercise program at a local Hispanic community center . d . Conduct a weekly blood pressure screening at the Hispanic senior citizen center .
C
70 . The pharmacist enters the wrong dose of a medication when transcribing prescriptions to a client's medication administration record ( MAR ) . Which action should the nurse take to prevent a medication error from occurring ? a . Compare the medication label with the medication administration record ( MAR ) . b . Check the client's identification bracelet prior to administering the medication . c C. Compare the medication administration record ( MAR ) to the prescription . d . Verify the room number on the medication administration record ( MAR ) .
C
73. A client diagnosed with Type 1 diabetes is NPO for a diagnostic test . The nurse is preparing to administer 24 units of 70/30 insulin . Which intervention should the nurse implement first ? a . Administer the insulin subcutaneously in the client's abdomen . b. Administer the insulin when the client returns from the test . C. Contact the healthcare provider to adjust the insulin dose . d . Call the department and request that this client's test be done first .
C
79. After placing a 36 - week - gestation newborn in an isolette and drying the infant with several blankets , what should the nurse implement next ? a . Open the isolette door to assess the infant's vital signs b . D Place erythromycin opthalmic ointment in both eyes . c . Remove the wet blankets and linens from the isolette . d . Administer the vitamin K ( AquaMEPHYTON ) injection .
C
85. A client is admitted to the hospital with a serum sodium level of 128 mEq / L , distended neck veins , and lung crackles . What intervention should the nurse implement ? a . Increase the intake of salty foods . b . Administer NaCl supplements . c . Restrict oral fluid intake . d . Hold the client's loop diuretic
C
86. A young adult male is brought to the emergency room with multiple gunshot wounds in the chest , abdomen , and head . After collecting the client's blood - saturated clothing as forensic evidence for the medical examiner , which action should the nurse implement ? a . Fold clothing in a large specimen container and send to the pathology lab . b . Roll the clothing in a towel and cover it with an impermeable drape . C. Place the clothes in a paper bag and transfer bag to a red biohazard bag . d . Drop the clothes in a red plastic bag and maintain blood - borne precautions .
C
90. Prior to o obtaining an axillary temperature , the nurse should perform which action ? a . Check the last oral temperature reading . b . Ask the client when he last ate or drank . c . Place a protective sheath over the thermometer . d . Position the client's arm theart level .
C
95. When assessing a male client who is receiving a unit of packed red blood cells ( PRBCs ) , the nurse notes that the infusion was started 30 minutes ago , and 50 ml of blood is left to be infused . The client's vital signs are within normal limits . He reports feeling " out of breath " but denies any other complaints . What action should the nurse take at this time ? a . Administer a PRN prescription for diphenhydramine ( Benadryl ) . b . Start the normal saline attached to the Y - tubing at the same rate . C. Decrease the intravenous flow rate of the PRBC transfusion . d . Ask the respiratory therapist to administer PRN albuterol ( Ventolin . ) .
C
C 16. A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision . She states she is very angry at the person who hit her car . What is the best nursing response ? a . " You are lucky to be alive . Be grateful no one was killed . " b . " I understand your car was not seriously damaged . " c . " You are upset that this incident has brought you here . " d . " Have you ever been in the emergency department before ? "
C
C 68. The nurse is conducting assessments at the beginning of the shift . Which client s most likely to have an increased blood pressure since the last set of vital signs was recorded four hours ago ? a . A young female with increased urinary output following administration of IV furosemide ( Lasix ) . b . A middle - aged male receiving prazosin hydrochloride ( Minipress ) . C. An elderly male who received two units of packed red blood cells ( RBCs ) . d . An adolescent who is receiving azathioprine Imuran ) following a cardiac transplant .
C
In developing a care plan for a client that has a chest tube due to a hemothorax the nirse should reconize that which intervention is essential? a . Keep the arm and shoulder of the affected side immobile at all times b . Ensure that there is no fluctuation in the water - seal chamber . c . Encourage the client to breathe deeply and cough at frequent intervals . d . Maintain the Pleuravac® slightly above the chest level .
C
ing mg . . 3. In assessing a client with preeclampsia who is receiving magnesium sulfate , the nurse determines that her deep tendon reflexes are 1+ ; respiratory rate is 12 breaths / minute ; urinary output is 90 ml in 4 hours ; magnesium sulfate level is 9 mg / dl . Based on these findings , what intervention should the nurse implement ? a a . . Continue the magnesium sulfate infusion as prescribed . b . Decrease the magnesium sulfate infusion by one - half . c . Stop the magnesium sulfate infusion immediately d . Administer calcium gluconate immediately
C
posture and balance during ambulation . The healthcare provider prescribes 15 mg / kg of Streptomycin for an infant weighing 4 pounds . The drug is diluted in 25 ml of D - W to run over 8 hours . How much Streptomycin will the infant receive ? a 9 mg . b . 18 mg . C. 27 mg . d . 36 ing mg
C
36. Which client's laboratory value requires immediate intervention by a nurse ? A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams B A client with pancreatitis who has a fasting glucose of 190 mg / dl had 160 you ing mg / dl yesterday . C. A client with hepatitis who is jaundiced and has a bilirubin level that the normal value . d . A client with cancer who has an absolute count of neutrophils < 500 today and had 2,000 yesterday . client , it is most important
D
or answers the question While assessing a client with diabetes mellitus , the nurse observes an absence of hair growth on the client's legs . What additional assessment provides further data to support this finding a . Palpate for the presence of femoral pulses bilaterally . b . Assess for the presence of a positive Homan's sign . C. C. Observe the appearance of the skin on the client's legs . d Watch the client's posture and balance during ambulation
C. Observe the appearance of the skin on the client's legs .
15. In assessing a 70 - year - old female client with Alzheimer's disease , the nurse notes that she has deep inflamed cracks at the corners of her mouth . What intervention should the nurse include in this client's plan of care ? a . Scrub the lesions with warm soapy water . b . Encourage the client to drink orange juice for added vitamin C. c . Notify the healthcare provider of the need for oral antibiotics . d . Ensure that the client gets adequate B vitamins in foods or supplements .
D
24. A nurse is completing the health history for a 25 - year - old male client who reports that he is allergic to penicillin . Which question should the nurse ask after receiving this information ? a . " Are you allergic to any other medications ? " b . " How often have you taken penicillin in the past ? " C C. " Is anyone else in your family allergic to penicillin ? " a d . " What happens to you when you take penicillin ? "
D
26. A client with myelogenous leukemia is receiving an autologous bone marrow transplantation ( BMT ) . What is the priority intervention that the nurse should implement when the bone marrow is repopulating ? a . Administer sargramostim ( Leukine , Prokine ) . b . Infuse PRBC and platelet transfusions . c . Give parental prophylactic antibiotics . d. Maintain a protective isolation environment .
D
31. The mother of a 9 - month - old who was diagnosed with respiratory syncytial virus ( RSV ) yesterday calls the clinic to inquire if it will be all right to take her infant to the first birthday party of a friend's child the following day . What response should the nurse provide this mother ? a . The child can be around other children but should wear a mask at all times b . The child will no longer be contagious , no need to take any further precautions c . Make sure there are no children under the age of 6 months around the infected child . d . Do not expose other children . RSV is very contagious even without direct oral contact contact .
D
33. Which action should the nurse implement to reduce the risk of vesicant extravasation in the client who is receiving intravenous chemotherapy ? a . Administer an antiemetic before starting the chemotherapy . b . Instruct the client to drink plenty of fluids during the treatment . c . Keep the head of the bed elevated until the treatment is completed . d . Monitor the client's intravenous site hourly during the treatment .
D
38. The healthcare provider prescribes naproxen ( Naprosyn ) 500 mg PO twice a day for a client with osteoarthritis . During a follow - up visit one month later , the client tells the nurse , " The pills don't seem to be working . They are not helping the pain at all . " Which factor should influence the nurse's response a . Noncompliance is probably affecting optimum medication effectiveness . b . Drug dosage is inadequate and needs to be increased to four times a day . C. The drug needs 4 to 6 weeks to reach therapeutic levels in the bloodstream . d . NSAID response is variable and another NSAID may be more effective.
D
41. A highly successful businessman presents to the community mental health center complaining of sleeplessness and anxiety over his financial status . What action should the nurse take to assist this client in diminishing his anxiety ? a . Encourage him to initiate daily rituals . b . hPainfore Reinforce the reality of his financial situation . C. Direct him to drink a glass of red wine at bedtime . d . Teach him to limit sugar and caffeine intake.
D
49. A client is discussing feelings related to a recent loss with the nurse . The nurse remains silent when the client says , " I don't know how I will go on . " What is the most likely reason for the nurse's behavior ? a . The nurse is stating disapproval of the statement . b . The nurse is respecting the client's loss . c Silence is reflecting the client's sadness . d . Silence allows the client to reflect on what was said
D
88. A client diagnosed with dementia is disoriented , wandering , has a decreased appetite , and is having trouble sleeping . What is the priority nursing problem for this client ? a . Disturbed thought processes . b . Altered sleep pattern . C. Imbalanced nutrition : less than d . Risk for injury .
D
89. The nurse preceptor is orienting a new graduate nurse to the critical care unit . The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client . What findings should the new graduate nurse identify ? a . Warm skin , hypertension , and constricted pupils . b . Bradycardia , hypotension , and respiratory acidosis . C. Mottled skin , tachypnea , and hyperactive bowel sounds . d . Tachycardia , mental status change , and low urine output .
D
92. Which finding should raise the greatest concern for a nurse who is performing an ENT examination ? a A painful ulcerated mucosal area inside the cheek for 1 day . b . Stippled gingival margins that adhere firmly to the teeth . c . A number of small yellowish - white and raised lesions on the buccal mucosa . d . An ulceration under the tongue that has been present for the last three weeks .
D
94. The community health nurse is working in multi - ethnic health center . In what situation should the nurse intervene ? a . An Asian - American mother reports using cupping to treat infection , resulting in a pattern of red round marks on her toddler's back . b . A Hispanic pregnant client who is often late for appointments , arrives late for today's appointment C. A Native - American who is being interviewed will not make direct eye contact when asked about violence in the home . d . An African - American infant who is spitting up milk has lost ounces since last week's clinic visit .
D
A client's telemetry monitor indicates the sudden onset of ventricular fibrillation. Which assessment finding should the nurse anticipate? A. Bounding erratic pulse. B. Regularly irregular pulse. C. Thready irregular pulse. D. No palpable pulse.
D
A male client is admitted to the neurological unit . He has just sustained a C - 5 spinal cord injury . Which assessment finding of this client warrants immediate intervention by the nurse a . Is unable feel sensation in the arms and hands . b . Has flaccid r upper af and and lower extremities . c . Blood pressure is 110/70 and the apical pulse is 68 . ... d . Respirations are shallow , labored , and 14 breaths / minute
D
A male infant born 30 weeks gestation at an outlying hospital is being prepared for transport to a Level IV neonatal facility . His respirations are 90 / min , and his heart rate beats per minute . Which drug is the transport team most likely to administer to this infant a . Ampicillin ( Omnipen ) 25 mg / kg slow IV push . b . Gentamicin sulfate ( Garamycin ) 2.5 mg / kg IV . c . Digoxin ( Lanoxin ) 20 micrograms d . Beractant ( Survanta ) 100 mg / kg per endotracheal tube .
D
Which signs or symptoms are characteristic of an adult client diagnosed with Cushing's syndrome ? a . Husky voice and complaints of hoarseness . b . Warm , soft , moist , salmon - colored skin . C. Visible swelling of the neck , with no pain . d . Central - type obesity , with thin extremities .
D
8. A charge nurse agrees to cover another nurse's assignment during a lunch break . Based on the status report provided by the nurse who is leaving for lunch , which client should be checked first by the charge nurse ? The client A . admitted yesterday with diabetec ketoacidosis whose blood glucose level is now 195 mg / dl . B with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch . C. post - triple coronary bypass four days ago who has serosanguinous drainage in the ch t tube . D. with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90 % .
d . with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90 % .