EXIT HESI V1

A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?

"You seem quite frightened right now."

The nurses preparing a dose of 60 MCG of Leriparatide. The medication is labelled 750 MCG/2 .4 ML. how many ML should the nurse administer enter numerical value only if rounding is required, round to the nearest 10th. 0.2

0.2

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

0.75

A client who weighs 132 pounds receives a prescription for lorazepam 44 mcg/kg intravenously to be administer 20 minutes before a scheduled procedure. The medication is available in 2 mg/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

1.3

The healthcare provider prescribes Cytovene 375 mg q 12 hour to infuse over 90 minutes. The pharmacy delivers Cytovene 375 mg in a 150 mL IV bag. Using a microdrip system labeled, 60 microdrops/mL., how many microdrops/minute should the nurse regulate the infusion?

100 microdrops/minute

A client is receiving a Nitroglycerin IV infusion at 6 mL/hr. The IV bag contains nitroglycerin 50 mg in dextrose 5% in water 250 mL. How many mcg/min of Nitroglycerin should the nurse document in the EMR?

20mcg/min

A client receives a prescription for 1 liter of lactated Ringer's intravenously (IV) to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

21

A client who weighs 25 kg receives a prescription for Isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "Isoniazid Oral Solution, USP 50 mg/mL" How many mL should the nurse administer?

250ml

The nurse is caring for a client who receives a prescription for valproic acid in which the maximum safe dosage is 60 mg/kg/day. How many mg/day is the maximum safe dosage for a client who weighs 176 pounds? (Enter numerical value only.)

4800

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

A Bloody mesis

A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a Pa02 of 92 mm Hg. Which intervention should the nurse implement? Reference Range pH Reference Range: Adult/child: 7.35 to 7.45] PaCO2 [Reference Range: Adult/child: 35 to 45 mm Hg] HCO3 Reference Range: Adult/child: 21 to 28 mEq/L (21 to 28 mmol/L)] Pa02 [Reference Range: Adult/child: 80 to 100 mm Hg]

A Increase rate of ventilation.

The school nurse is preparing a teaching pamphlet in response to requests from parents regarding an outbreak of pinworms at the local preschool. Which information about the most commonly prescribed medication, mebendazole, should be included?

A Only children with perianal itching should take the medication.

The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father. Which intervention(s) should the nurse implement? (Select all that apply.)

A Provide the daughter with written instructions. Face client when speaking. Include the family in the discharge teaching.

After reviewing the Braden Scale findings of residents at a long-term facility, the charge nurse should tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client?

A older man whose sheets are damp each time he is turned.

The nurse caring for a 3-month-old infant who is one day after a pyloromyotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing both knees to the chest. Which action should the nurse take?

Administer a prescribed analgesic for pain

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Administer a prescribed opioid analgesic.

The nurse is assessing a client's breath sounds. Which medication from the client's prescriptions will have the most positive effect on this respiratory finding? (Please listen to the audio clip to select the option that applies. To repeat, click the play button again.)

Albuterol.

Which client is best to assign to the practical nurse (P) who is assisting the registered nurse (RN) with the care of a group of clients?

An adult who is one day postoperative for a laparoscopic cholecystectomy.

An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

Carry on with surgical preparation of the client without a signed informed consent

The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first?

Change the client's position.

The nurse is providing teaching to a client admitted with a blood glucose level of 580 mg/dL (32.22 mol/L) about preventing complications related to diabetes mellitus. Which response by the client indicates understanding? Reference Range Glucose [Reference Range: 0 to 50 years: 74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Check blood sugar levels every four to six hours every day.

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for inuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

Children usually resume their toileting behaviors when they leave the hospital.

The nurse is preparing to suction a client with an oral airway. Which action should the nurse include?

Apply a water soluble lubricant to the catheter.

An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. Which action should the nurse take?

Ask the wife to stop and assess the client's swallowing reflex.

A 10-year-old with acute decompensated heart failure has a 3 pound (1.4 kg) weight gain in the last 24 hours. Which intervention is most important for the nurse to implement?

Assess bilateral lung sounds.

An older client with a history of diabetes mellitus for 20 years is taking furosemide 40 mg by mouth daily. Which action should the nurse implement first?

Assess for muscle weakness, fatigue, or leg cramps.

The nurse is providing supplemental oxygen to a client who is experiencing a cluster headache. In evaluating the effectiveness of the oxygen therapy, which assessment is most important for the nurse to make?

Assess oxygen saturation.

A young adult is brought to the Emergency Department after taking a handful of drugs. The client is unresponsive, so an endotracheal tube (ETT) is inserted. How should the nurse determine if the ETT is correctly placed? (Select all that apply.)

Auscultate for presence of bilateral breath sounds. Obtain a portable chest x-ray to verify ETT location. Assess for symmetrical chest movement.

What instruction should the nurse include in the teaching plan for the family of a school-aged child with AIDS?

Avoid exposure to chickenpox

A male client with multiple myeloma is admitted with pneumonia and pancytopenia. The nurse reviews the complete blood cell count findings and identifies a platelet count of 20,000/mm? (20 × 109L). Which intervention should the nurse include in the client's plan of care? Reference Range Platelet [Reference Range: 150,000 to 400,000/mm3 (150 to 400 ×10°/L)] FIl Show calculator

Avoid intramuscular injections. Correct

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

Avoid large crowed areas during the colder months of the year.

A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching?

Avoid the consumption of wine, beer, and coffee.

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

B Musical and drumlike.

A client presents to the emergency department (ED) with complaints of abdominal pain. The nurse observes the client's right cheek and eye are bruised and suspects possible domestic violence. Which approach is best for the nurse to use when interviewing the client?c

Begin with questions that are less sensitive in nature.

A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely

C Hypokalemia.

An older client with heart failure (HF), coronary artery disease (CAD), and hypertension (HT), is receiving these daily prescriptions: atenolol, furosemide, and enalapril. Which assessments) should the nurse include in evaluating the effectiveness of the medications? (Select all that apply.)

Daily weight Blood pressure Heart sounds

The nurse on the medical-surgical unit is receiving a transfer report from the post-anesthesia care unit (PACU) nurse for a client who had an exploratory laparotomy. The PACU nurse provides the following information: "1000 mL normal saline is infusing at 125 mL/hr into the left wrist with 600 mL remaining. Ondansetron 4 mg intravenously every 8 hours is prescribed for nausea. The last dose was administered at 0700. The client is currently describing pain at a level 2 on a 0 to 10 pain scale. The client has a prescription for hydromorphone 1 mg intravenously every 2 hours as needed for pain. The last dose was administered at 1000." Which additional information should the PACU nurse report?

Declining to take ice chips for complaints of dry mouth.

A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (IN) is 1. Which protocol prescription should the nurse implement?

Decrease the heparin dose.

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Reference Range: Adult 4.5 to 5.6 mg/dL (1.05 to 1.3 mol/L)]

Determine apical pulse rate and rhythm.

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. What is the most likely source of contamination that the nurse should consider when interviewing the client about exposure?

Drinking water contaminated by sewage

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Elevated blood pressure must be anticipated and identified quickly.

The nurse notes that a client with depression has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Encourage the client to participate in group activities.

The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)?

Establish blood pressure parameters for client monitoring.

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Evaluate the newly hired UP's level of competency by observing the UAP deliver care

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having unprotected sex. Which response should the nurse provide? A Clarify that all STIs are transmitted through sexual intercourse.

Explain that reinfections occur from sex with untreated partners.

A client in the third trimester of pregnancy reports that she feels some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take?

Explain that this normal secretion can be assessed at the next visit.

A client who is admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) IIB IIIA inhibitor. Which assessment finding places the client at greatest risk?

Unresponsive to painful stimuli.

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (P)?

Use bladder ultrasound to detect urinary retention.

An older client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) bathe her, is becoming increasingly agitated and stating the UAP wants to hurt her and tie her up. Which approach should the nurse use with the client?

Use distraction and therapeutic communication skills.

To prevent infection by autocontamination during the acute phase of recovery from multiple burns, which intervention is most importTo prevent infection by autocontamination during the acute phase of recovery from multiple burns, which intervention is most important for the nurse to implement?

Use gown, mask, and gloves with dressing change.

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the educational materials include which characteristics)? (Select all that apply.)

Uses common words with few syllables. Contains a list with definitions of unfamiliar terms. Uses pictures to help illustrate complex ideas.

A client with a history of a bilateral adrenalectomy is admitted with a weak, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse?

Ventricular arrhythmias.

The nurse is caring for four clients: Client A, who has emphysema and whose oxygen saturation is 94%; Client B, with a postoperative hemoglobin of 8.2 mg/dL (82 g/L) ; Client C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mol/L); and Client D, scheduled for an appendectomy who has a white blood cell (WBC) count of 14,000 mm° (14 × 10ºL). Which intervention should the nurse implement? Reference Range Hemaglobin [Reference Range: Male: 14 to 18 g/dL (140 to 180 g/L)] Potassium [Reference Range: 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)] White Blood Cells [Reference Range: 5000 to 10,000/mm3 (5 to 10 × 10°/L)]

Verify that Client B has two units of packed cells available.

The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?

Vitamin supplements for high-risk pregnant women.

An adult male who fell from a roof and fractured his left femur is admitted for surgical stabilization after having a soft cast applied in the emergency department. Which assessment finding warrants immediate intervention by the nurse?

Weak palpable distal pulses

A client is receiving ophthalmic drops preoperatively for a cataract extraction and asks the nurse why the healthcare provider has prescribed all these medications. Which information should the nurse included when responding to this client? (Select all that apply.)

• B Pupillary dilation is necessary to access the eye chamber for lens removal. • C The iris must be paralyzed during surgery to prevent it from reacting to light. E One of the medications is used to anesthetize the corneal surface.

The healthcare provider prescribes the antibiotic cefdinir 300 mg by mouth every 12 hours for a client with a postoperative wound infection. Which foods should the nurse encourage this client to eat?

• B Yogurt or buttermilk.

An adult client presents to the clinic with large draining ulcers on both lower legs that are characteristic of Kaposi's sarcoma lesions. The client is accompanied by two family members. Which action should the nurse take?

• C Send family to the waiting area while the client's history is taken.

The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. Which intervention should the nurse should perform in the immediate management of the client?

Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment.

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted.

Recommend using a breast shield.

The nurse is caring for a client with a binge eating disorder. Which goal should the nurse first establish with the client?

Regulate food portions.

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? (Select all that apply.)

Remove resuscitation equipment from the room. Place a small pillow under the head. Gently close the eyes

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Replace fluids intravenously based on intake and output.

Six weeks after the birth of a child with Trisomy 21, the parents return to the prenatal clinic for a follow-up visit. They have spoken with a genetic counselor, but are still unsure about the risk of having another child with Trisomy 21. The couple brings literature from the counselor with them, and asks the nurse to explain it. Which action should the nurse take?

Review the literature and answer any questions the nurse is able to answer.

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

Review the need for the UP to wear a face mask while in close contact with the client.

The nurse determines the client is in pain. Which pain scales would be appropriate for this client? Select all that apply.

Riley Infant Pain Scale Poker Chip Tool FLACC Postoperative Pain Scale

The nurse documents that an adult male client who is depressed sleeps until lunch time and refuses to take telephone calls from his family. Which assessment is most accurate for the nurse to include in the nursing notes in the EMR?

Socail Isolation

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider?

Somnambulism

The nurse is caring for an adolescent who fell 20 feet (6.1 meters) 5 months ago while climbing the side of a cliff and has been in a sustained vegetative state since the accident. Which intervention should the nurse implement?

Talk directly to the adolescent while providing care

An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?

Tell the client to discuss the medication side effects with the healthcare provider.

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Test the fluid on the dressing for glucose

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.)

The client is lying in a supine position in bed. A bedside commode is positioned near the bed.

The nurse is developing a postoperative plan of care for a client with type 2 diabetes who will need to begin insulin after colostomy placement surgery for diverticular disease. Which outcome statement should the nurse use in the in the planning stage of the nursing process for this client?

The client will demonstrate ability to change the ostomy bag in two days

A client who delivered vaginally 2 days ago states that she wants to resume using her diaphragm for birth control. What information should the nurse share with her?

The diaphragm must be refitted after childbirth

A week after admission to intensive care for a bowel obstruction, a client is confused to time and place. The nurse frequently attempts to reorient the client but the client remains confused. Which intervention should the nurse implement for the client's safety?

Increase direct observation times.

The nurse is performing tracheostomy care for a client who underwent a laryngectomy for laryngeal cancer. During the procedure, the client begins to cough and is unable to clear the secretions. After the nurse suctions the airway, which finding indicates the intervention was

Increase in respiratory rate.

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the client's care?

Confusion.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Continue with the blood pressure assessment

The nurse is assessing a 3-month-old infant who had a pyloromyotomy yesterday. This child should be medicated for pain based on which findings)? (Select all that apply.)

Increased respiratory rate. Clenched fists. Restlessness Increased pulse rate.

A client who received and open reduction and internal fixation (ORIF) of the right femur after experiencing a fall at home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare provider using BAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

Increasing confusion of the client.

The nurse is caring for a client after a thoracentesis that drained 50 mL of clear fluid from the left lung. Which assessment finding should the nurse report to the healthcare provider immediately?

Mediastinal shift to the right.

By using correct handwashing technique between client contact, the nurse is affecting which link in the chain of infection?

Mode of transmission.

The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

Names 3 home safety hazards to be resolved immediately

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

Nitroglycerin.

The nurse is entering demographic and client history information in the electronic medical record (EMR) of a newly admitted client when the computer system shuts down. Which action should the nurse take first?

Notify information services department of the situation

The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge instructions?

Notify your healthcare provider if you start having abdominal pain.

A client is admitted to the intensive care until (ICU) with a spinal cord injury (SCI) following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Nurse case manager.

A male client who is admitted with bipolar disorder, manic psychosis, is placed in seclusion after unsuccessful attempts to de-escalate him during a sudden mood swing from laughter to jumping and screaming threats while waving a plastic dinner knife. The client is given haloperidol 5 mg intramuscularly STAT prior to seclusion. Which intervention is most important for the nurse to implement immediately after seclusion?

Observe for extrapyramidal symptoms, such as dystonia.

The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.)

Obtain blood glucose level. Verify the insulin prescription. Draw insulin into insulin syringe. Cleanse the selected site.

The nurse is reviewing the assessment data. What are the 3 most likely reasons that the infant is crying?

Pain Hypovolemia Hypoxia

Question 4 of 130

Picking up the second glove.

An older client is preparing for discharge following a myocardial infarction (MI). The nurse is reviewing the prescribed cardiac diet and exercise instructions with the client. Which action should the nurse implement while teaching?

Provide handouts written at a 12th grade reading level.

The nurse is preparing an older male adult for discharge who does not read and has bilateral hearing loss. The client's daughter who lives close to her father tells the nurse that she will stop by daily to check on her father. Which intervention(s) should the nurse implement?

Provide the daughter with written instructions.

A clinical trial is recommended for a female client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond?

Explore the client's decision to refuse treatment and offer support.

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? (Select all that apply.)

Fruits without sauce. Fresh or frozen vegetables without sauce. Cottage cheese

When developing a teaching plan for a client with newly diagnosed Type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Give a dose of regular insulin as prescribed.

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

High-Fowler's position.

The nurse is preparing to administer a formula feeding by nasogastric tube to a 2-month-old. Which intervention should the nurse implement?

Hold the infant with head and shoulders slightly elevated

A 38-week gestational age infant of a diabetic mother (IDM) is admitted to the newborn nursery weighing 8 pounds and 2 ounces, and is transitioning without respiratory distress. Within the first hours of transition after birth, what priority nursing assessment is necessary for this infant?

Hypoglycemia.

A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, "My favorite nurse is on duty now. Which response is best for the nurse to provide to this client's dichotomous tendency?

I am happy that you are getting better and will be able to go home."