HESI Exit Exam 2020
62. The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client complaint calls for immediate nursing action? A) Diaphoresis and shakiness B) Reduced lower leg sensation C) Intense thirst and hunger D) Painful hematoma on thigh
A
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of "suppression"? A) "I don't remember anything about what happened to me." B) "I'd rather not talk about it right now." C) "It's all the other guy's fault! He was going too fast." D) "My mother is heartbroken about this."
A
A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority? A) Remove protective arm devices one at a time for short periods with supervision B) Initiate by mouth feedings when alert, with the return of the gag reflex C) Introduce to the parents how to cleanse the suture line with the prescribed protocol D) Position the infant on the back after feedings throughout the day
A
A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse should A) Expose the cast to air and turn the child frequently B) Use a heat lamp to reduce the drying time C) Handle the cast with the abductor bar D) Turn the child as little as possible
A
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? * A) Bradycardia B) Lethargy C) Irritability D) Vomiting
A
A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse? A) Ask the client if he has noticed any bleeding or dark stools B) Tell the client to call 911 and go to the emergency department immediately C) Schedule a repeat Hemoglobin and Hematocrit in 1 month D) Tell the client to schedule an appointment with a hematologist
A
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the "evil eye." The nurse should communicate to other personnel that the appropriate approach is to A) Touch the baby after looking at him B) Talk very slowly while speaking to him C) Avoid touching the child D) Look only at the parents
A
A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness? A) Holistic healing B) Spiritual advising C) Herbal preparations D) Witchcraft potions
A
A child with Tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention to A) Assessment of oxygenation B) Observation for developmental delays C) Prevention of infection D) Maintenance of adequate nutrition
A
A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse? A) "Focus on your sons' needs during the first days at home." B) "Tell each child what he can do to help with the baby." C) "Suggest that your husband spend more time with the boys." D) "Ask the children what they would like to do for the newborn."
A
A client comes into the community health center upset and crying stating "I will die of cancer now that I have this disease." And then the client hands the nurse a paper with one word written on it: "Pheochromocytoma." Which response should the nurse state initially? A) Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid). B) This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline. C) Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor. D) You probably have had episodes of sweating, heart pounding and headaches.
A
A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse's best explanation of these findings? A) These side effects are common and should subside in a few days B) The client is probably having an allergic reaction and should discontinue the drug C) Taking the lithium on an empty stomach should decrease these symptoms D) Decreasing dietary intake of sodium and fluids should minimize the side effects
A
A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale? A) "Nursing will help contract the uterus and reduce your risk of bleeding." B) "Breastfeeding twins will take too much energy after the hemorrhage." C) "The blood transfusion may increase the risks to you and the babies." D) "Lactation should be delayed until the "real milk" is secreted."
A
A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note A) High protein B) Clear color C) Elevated sed rate D) Increased glucose
A
A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority? A) Elevate leg on 2 pillows B) Apply support stockings C) Apply warm compresses D) Maintain complete bed rest
A
A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to A) Insufficient oxygenation of the cardiac muscle B) Potential circulatory overload C) Left ventricular overload D) Electrolyte imbalance
A
A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse's immediate attention? A) Lethargy B) Agitation C) Ataxia D) Hearing loss
A
A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client A) Has increased airway obstruction B) Has improved airway obstruction C) Needs to be suctioned D) Exhibits hyperventilation
A
A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs? A) Weight gain of 2 pounds or more in a 48 hour period B) Urinating 4 to 5 times each day C) A significant decrease in appetite D) Appearance of non-pitting ankle edema
A
A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client's family is alarmed and calls the clinic when "his eyes rolled upward." The nurse recognizes this as what type of side effect? A) Oculogyric crisis B) Tardive dyskinesia C) Nystagmus D) Dysphagia
A
A confused client has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)? A) Assist the client with activities of daily living B) Monitor the clients physical safety C) Evaluate for basic comfort needs D) Document mental status and muscle strength
A
A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to A) Suggest 3 to 4 warm sitz baths per day B) Cleanse the genitalia twice a day with soap and water C) Spray warm water over genitalia after urination D) Apply heat or cold to lesions as desired
A
A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to A) A cerebral vascular accident B) Postoperative meningitis C) Medication reaction D) Metabolic alkalosis
A
A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning is A) Central nervous system damage B) Moderate anemia C) Renal tubule damage D) Growth impairment
A
An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age? A) Double the birth weight B) Triple the birth weight C) Gain 6 ounces each week D) Add 2 pounds each month
A
Following mitral valve replacement surgery a client develops PVC's. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc's of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute? A) 60 microdrops/minute B) 20 microdrops/minute C) 30 microdrops/minute D) 40 microdrops/minute
A
For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate? A) Institute seizure precautions B) Weigh the child twice per shift C) Encourage the child to eat protein-rich foods D) Relieve boredom through physical activity
A
The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. A priority maternal assessment by the nurse should be to ask about A) Alcohol use during pregnancy B) Usual nutritional intake C) Family genetic disorders D) Maternal and paternal ages
A
The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care? A) Reduce the environmental stimuli B) Offer formula every 2 hours C) Talk to the newborn while feeding D) Rock the baby frequently
A
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate? A) Unequal leg length B) Limited adduction C) Diminished femoral pulses D) Symmetrical gluteal folds
A
The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed? A) Extreme fatigue B) Increased appetite C) Intense itching D) Constipation
A
The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend A) Isometric B) Range of motion C) Aerobic D) Isotonic
A
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is A) "Eat a balanced diet for your age." B) "Increase your intake of protein and Vitamin A." C) "Decrease fatty foods from your diet." D) "Do not use caffeine in any form, including chocolate."
A
The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be A) Reduce fear and protect self-esteem B) Minimize anxiety and delay apprehension C) Avoid conflict and leave unpleasant situations D) Increase independence and communicate more often
A
The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report A) Loss of consciousness B) Feeding problems C) Poor weight gain D) Fatigue with crying
A
The nurse would teach a client with Raynaud's phenomenon that it is most important to A) Stop smoking B) Keep feet dry C) Reduce stress D) Avoid caffeine
A
The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that A) Circumcision is delayed so the foreskin can be used for the surgical repair B) This procedure is contraindicated because of the permanent defect C) There is no medical indication for performing a circumcision on any child D) The procedure should be performed as soon as the infant is stable
A
The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ("knocked out"). After recovering the tooth, the initial response should be to A) Rinse the tooth in water before placing it in the socket B) Place the tooth in a clean plastic bag for transport to the dentist C) Hold the tooth by the roots until reaching the emergency room D) Ask the child to replace the tooth even if the bleeding continues
A
When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority? A) Risk for injury: hemorrhage B) Risk for injury related to peripheral neuropathy C) Altered nutrition: less than body requirements D) Fluid volume excess: ascites
A
When teaching new parents to prevent Sudden Infant Death Syndrome (SIDS) what is the most important practice the nurse should instruct them to do? A) Place the infant in a supine or side lying position for sleep B) Do not allow anyone to smoke in the home C) Follow recommended immunization schedule D) Be sure to check infant every one hour
A
Which of these clients would the triage nurse request for the health care provider to examine immediately? A) A 5 month-old infant who has audible wheezing and grunting B) An adolescent who has soot over the face and shirt C) A middle-aged man with second degree burns over the right hand D) A toddler with singed ends of long hair that extends to the waist
A
Which of these statements by the nurse is incorrect to use to reinforce information about cancers to a group of young adults? A)You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods. B) Prostate cancer is the most common cancer in American men with results to threaten sexuality and life. C) Colorectal cancer is the second-leading cause of cancer-related deaths in the United States. D) Lung cancer is the leading cause of cancer deaths in the United States. Yet it's the most preventable of all cancers.
A
Which of these tests with frequency would the nurse expect to monitor for the evaluation of clients with poor glycemic control in persons aged 18 and older? A) A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervals B) A glycosylated hemoglobin is to be obtained at least twice a year C) A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessment D) A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment
A
Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children? A) Sports and games with rules B) Finger paints and water play C) "Dress-up" clothes and props D) Chess and television programs
A
With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select? A) An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours ago B) An adolescent admitted the prior night with Tylenol intoxication C) A middle aged client with an internal automatic defibrillator and complaints of "passing out at unknown times" admitted yesterday D) A school age child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts
A
126. The nurse is caring for a client with status epileptics. The most important nursing assessment of this client is A) Intravenous drip rate B) Level of consciousness C) Pulse and respiration D) Injuries to the extremities
B
81. When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility? A) Digestive problems B) Amenorrhea C) Electrolyte imbalance D) Blood disorders
B
A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal? A) Hot dog, carrot sticks, gelatin, milk B) Soup, blenderized soft foods, ice cream, milk C) Peanut butter and jelly sandwich, chips, pudding, milk D) Baked chicken, applesauce, cookie, milk
B
A client is admitted for COPD. Which finding would require the nurse's immediate attention? A) Nausea and vomiting B) Restlessness and confusion C) Low-grade fever and cough D) Irritating cough and liquefied sputum
B
A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because it A) Reduces the potential for renal collapse B) Reduces the potential for shock C) Reduces the intensity of bladder spasms D) Prevents bladder atrophy
B
A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate? A) Determine that adequate mist is supplied B) Inspect the nares and ears for skin breakdown C) Lubricate the tips of the cannula before insertion D) Maintain sterile technique when handling cannula
B
A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the client A) "Be sure and eat a fat-free diet until the test." B) "Do not eat or drink anything but water for 12 hours before the blood test." C) "Have the blood drawn within 2 hours of eating breakfast." D) "Stay at the laboratory so 2 blood samples can be drawn an hour apart."
B
A couple asks the nurse about risks of several birth control methods. What is he most appropriate response by the nurse? A) Norplant is safe and may be removed easily B) Oral contraceptives should not be used by smokers C) Depo-Provera is convenient with few side effects D) The IUD gives protection from pregnancy and infection
B
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to A) A social worker from the local hospital B) An occupational therapist from the community center C) A physical therapist from the rehabilitation agency D) Another client with diabetes mellitus and takes insulin
B
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize A) They can expect the child will be mentally retarded B) Administration of thyroid hormone will prevent problems C) This rare problem is always hereditary D) Physical growth/development will be delayed
B
A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy? A) Intraventricular hemorrhage B) Retinopathy of prematurity C) Bronchial pulmonary dysplasia D) Necrotizing enterocolitis
B
A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider's diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first? A) Cardiopulmonary resuscitation B) Insertion of a chest tube C) Oxygen therapy D) Assisted ventilation
B
An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication? A) Determine third party payment plan for this treatment B) The client's manual dexterity C) Proximity to health care services D) Ability to use visual assistive devices
B
At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about preconception diet changes. Which of the statements made by the nurse is best? A) "Include fibers in your daily diet." B) "Increase green leafy vegetable intake." C) "Drink a glass of milk with each meal." D) "Eat at least 1 serving of fish weekly."
B
In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test? A) Increased edema and weight gain B) Unchanged urine specific gravity C) Rapid protein excretion D) Decreased blood potassium
B
On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse's initial response should be to A) Give the client orientation materials and review the unit rules and regulations B) Introduce him/herself and accompany the client to the client's room C) Take the client to the day room and introduce her to the other clients D) Ask the nursing assistant to get the client's vital signs and complete the admission search
B
On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the RN anticipate finding? A) Periorbital edema, absent light reflex and translucent tympanic membrane B) Irritability, rhinorrhea, and bulging tympanic membrane C) Diarrhea, retracted tympanic membrane and enlarged parotid gland D) Vomiting, pulling at ears and pearly white tympanic membrane
B
Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure togetherwith pulmonary capillary wedge pressure with a pulmonary artery catheter. This action by the nurse will assess A) Right ventricular pressure B) Left ventricular end-diastolic pressure C) Acid-Base balance D) Coronary artery stability
B
The community health nurse has been following the care for an adolescent with a history of morbid obesity, asthma, hypertension and is 22 weeks in to a pregnancy. Which of these lab reports sent to the clinic need to be called to the teens health care provider within the next hour? A) Hemoblobin 11 g/L and calcium 6 mg/dl B) Magnesium 0.8 mEq/L and creatinine 3 mg/dl C) Blood urea nitrogen 28 and glucose 225 mg/dl D) Hematocrit 33% and platelets 200,000
B
The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the "unfreezing" phase of change. With this approach and phase the nurse manager should A) Discuss with the staff how to deal with any defensive behavior B) Explain to the unit staff why change is necessary C) Assist the staff during the acceptance of the new changes D) Clarify what the changes mean to the community and hospital
B
The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model? A) An appointed board oversees any administrative decisions B) Nursing departments share responsibility for client outcomes C) Staff groups are appointed to discuss nursing practice and client education issues D) Non-nurse managers supervise nursing staff in groups of units
B
The nurse is assigned to a client with Parkinson's disease. Which findings would the nurse anticipate? A) Non intention tremors and urgency with voiding B) Echolalia and a shuffling gait C) Muscle spasm and a bent over posture D) Intention tremor and jerky movement of the elbows
B
The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best response by the nurse should be that A) A child's bone is more flexible and can be bent 45 degrees before breaking B) Bones of children are more porous than adults and often have incomplete breaks C) Compression of porous bones produces a buckle or torus type break D) Bone fragments often remain attached by a periosteal hinge
B
The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins? A) B, D, and K B) A,D,andK C) A, C, and D D) A, B, and C
B
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data? A) Impaired gas exchange related to acute infection and sputum production B) Ineffective airway clearance related to sputum production and ineffective cough C) Ineffective breathing pattern related to acute infection D) Anxiety related to hospitalization and role conflict
B
The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport? A) Crackles in the lungs B) Confusion and restlessness C) Distended neck veins D) Use of accessory muscles
B
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions? A) Administration of cough suppressants B) Increasing oral fluid intake to 3000 cc per day C)Maintaining bed rest with bathroom privileges D) Performing chest physiotherapy twice a day
B
To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would A) Assist the client to use the bedside commode B) Administer stool softeners every day as ordered C) Administer anti dysrhythmics prn as ordered D) Maintain the client on strict bed rest
B
To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to the A) Finger and toenail quicks B) Eyes C) Perianal area D) External ear canals
B
Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt? A) "Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior." B) "What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?" C) "Don't focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs." D) "You've caused a great deal of pain to your family and close friends, so it will take time to undo all the things you've done."
B
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action? A) Check vital signs B) Massage the fundus C) Offer a bedpan D) Check for perineal lacerations
B
You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which indicates further teaching may be needed by the client? A) "I will be receiving continuous doses of medication." B) "I should call the nurse before I take additional doses." C) "I will call for assistance if my pain is not relieved." D) "The machine will prevent an overdose."
B
7. A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse? A) Arrange to change client care assignments B) Explain that this behavior is expected C) Discuss the appropriate use of "time-out" D) Explain that the child needs extra attention
B: Explain that this behavior is expected
The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first? A) Clear the area of any hazards B) Place the child on the side C) Restrain the child D) Give the prescribed anticonvulsant
B: Place the child on the side
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client? A) Compulsive behavior B) Sense of impending doom C) Fear of flying D) Predictable episodes
B: Sense of impending doom
5. A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to A) Administer pain medication B) Suction excessive tracheobronchial secretions C) Assist client to turn, deep breathe and cough D) Monitor oxygen saturation
B: Suction excessive tracheobronchial secretions
While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age? A) They are able to make simple association of ideas B) They are able to think logically in organizing facts C) Interpretation of events originate from their own perspective D) Conclusions are based on previous experiences
B: Think logically in organizing facts
A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which task? A) Loss of control B) Insecurity C) Dependence D) Lack of trust
C
A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize? A) Acceptance of the pregnancy B) Focus on fetal development C) Anticipation of the birth D) Ambivalence about pregnancy
C
A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to A) Gently rub the skin with a cotton swab to relieve itching B) Place the favorite books and push-pull toys in the crib C) To check every few hours for the next day or 2 for swelling in the baby's feet D) Turn the baby with the abduction stabilizer bar every 2 hours
C
A 6 year-old female is diagnosed with recurrent urinary tract infections (UTI). Which one of the following instructions would be best for the nurse to tell the caregiver? A) Increase bladder tone by delaying voiding B) When laundering clothing, rinse several times C) Use plain water for the bath, shampooing hair last D) Have the child use antibacterial soaps while bathing
C
A 67 year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infraction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is A) Constipation related to immobility B) High risk for infection C) Impaired gas exchange D) Fluid volume deficit
C
A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to assess for A) Rebound tenderness B) Left lower quadrant dullness C) Rounded swelling above the pubis D) Urinary discharge
C
A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure? A) Playing with toys in a back yard flower garden B) Eating small amounts of grass while playing "farm" C) Playing with cars on the pavement near burning leaves D) Throwing a ball to a neighborhood child who has poison ivy
C
A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would A) Instruct the client to maintain a regular diet the day prior to the examination B) Restrict the client's fluid intake 4 hours prior to the examination C) Administer a laxative to the client the evening before the examination D) Inform the client that only 1 x-ray of his abdomen is necessary
C
A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to A) Convince the client that the hospital staff is trying to help B) Help the client to enter into group recreational activities C) Provide interactions to help the client learn to trust staff D) Arrange the environment to limit the client's contact with other clients
C
A client was admitted with a diagnosis of pneumonia. When auscultating the client's breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect? A) Flushed skin B) Bradycardia C) Mental confusion D) Hypotension
C
A client who is terminally ill has been receiving high doses of an opiod analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli, what orders would the nurse expect from the health care provider? A) Decrease the analgesic dosage by half B) Discontinue the analgesic C) Continue the same analgesic dosage D) Prescribe a less potent drug
C
A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child's constantly saying "no" and his refusal to follow her directions. The nurse explains this is normal for his age, as negativism is attempting to meet which developmental need? A) Trust B) Initiative C) Independence D) Self-esteem
C
A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care? A) Pain related to periosteal injury B) Impaired mobility related to bleeding C) Parental anxiety related to knowledge deficit D) Injury related to inter cranial hemorrhage
C
A newly appointed nurse manager is having difficulties with time management. Which advice from an experienced manager should the new manager do initially? A) Set daily goals and establish priorities for each hour and each day. B) Ask for additional assistance when you feel overwhelmed. C) Keep a time log of your day in hourly blocks for at least 1 week. D) Complete each task before beginning another activity in selected instances.
C
A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned to this nurse is which child? A) Congenital cardiac defects B) An acute febrile illness C) Prolonged hypoxemia D) Severe multiple trauma
C
A priority goal of involuntary hospitalization of the severely mentally ill client is A) Re-orientation to reality B) Elimination of symptoms C) Protection from harm to self or others
C
A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify information? A) This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in my lower belly also may be removed. B) I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and preserved (cryopreserved) before chemotherapy. C) If I have cancer at stage 3 it means I have less involvement of the cancer. D) After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This artificial implant has the weight and feel of a normal testicle.
C
An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should the nurse perform first? A) Review the client's weight pattern over the year B) Ask the mother to record her diet for the last 24 hours C) Encourage her to talk about her view of herself D) Give her several pamphlets on postpartum nutrition
C
An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for trachea esophageal fistula. The mother asks:"When can the tube can be used for feeding?" The nurse's best response would be which of these comments? A) Feedings can begin in 5 to 7 days. B) The use of the feeding tube can begin immediately. C) The stomach contents and air must be drained first. D) The incision healing must be complete before feeding.
C
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem? A) "I have constant blurred vision." B) "I can't see on my left side." C) "I have to turn my head to see my room." D) "I have specks floating in my eyes."
C
During the beginning shift assessment of a client with asthma and is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding? A) Pulse oximetry reading of 89% B) Crackles at the base of the lungs on auscultation C) Rapid shallow respirations with intermittent wheezes D) Excessive thirst with a dry cracked tongue
C
In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next? A) Take the client's respirations, blood pressure (BP), temperature and then pupillary responses B) Place the client into the bed and administer the ordered PRN analgesic C) Check the client for bladder distention and the client's urinary catheter for kinks D) Turn the television off and then assist client to use relaxation techniques
C
In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability in A) Hearing, speech, and sight B) Endurance, strength, and mobility C) Learning, creativity, and judgment D) Balance, flexibility, and coordination
C
The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information? A) "The infant will get the hepititis B vaccine (HepB) and the hepatitis B immune globulin within 12 hours at birth at separate injection sites." B) "The second dose can be given at 1 to 2 months of age." C) "The third dose should be given at least 16 weeks from the second dose." D) "The last dose in the series is not to be given before age 24 weeks."
C
The nurse is assessing a 12 year-old who has Hemophilia A. Which finding would the nurse anticipate? A) An excess of red blood cells B) An excess of white blood cells C) A deficiency of clotting factor VIII D) A deficiency of clotting factors VIII and IX
C
The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding? A) Rapid respirations B) Diaphoresis C) Swelling of lower extremity D) Positive Babinski's sign
C
The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect? A) Expiratory wheezes B) Blurred vision C) Acites D) Dilated pupils
C
The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse responds A) "The complaints of at least 3 common findings." B) "The absence of any opportunistic infection." C) "CD4 lymphocyte count is less than 200." D) "Developmental delays in children."
C
The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate postoperative period? A) Raise the head of the bed at least 30 degrees B) Encourage ambulation within 24 hours C) Maintain in a flat position, logrolling as needed D) Encourage leg contraction and relaxation after 48 hours
C
The nurse is caring for a 5 year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity? A) Kicking balloons with right leg B) Playing "Simon Says" C) Playing hand held games D) Throw bean bags
C
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect? A) Confusion B) Loss of half of visual field C) Shallow respirations D) Tonic-clonic seizures
C
The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by A) Inserting a fenestrated catheter with a whistle tip without suction B) Completing suction pass in 30 seconds with pressure of 150 mm Hg C) Hyper oxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass D) Minimizing suction pass to 60 seconds while slowly rotating the lubricated catheter
C
The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation? A) Ask family members to dress the client B) Encourage the client to dress more quickly C) Allow the client the time needed to dress D) Demonstrate methods on how to dress more quickly
C
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure? A) Place pillows under the knees B) Use elastic stockings continuously C) Encourage range of motion and ambulation D) Massage the legs twice daily
C
The nurse is planning care for a client with increased intracranial pressure. The best position for this client is A) Trendelenberg B) Prone C) Semi-Fowlers D) Side-lying with head flat
C
The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching? A) Change the pillow covers every month B) Wash bed linens in warm water with a cold rinse C) Wash and rinse the bed linens in hot water D) Use air filters in the furnace system
C
The nurse is teaching a 27 year-old client with asthma about management of their therapeutic regime. Which statement would indicate the need for additional instruction? A) "I should monitor my peak flow every day." B) "I should contact the clinic if I am using my medication more often." C) "I need to limit my exercise, especially activities such as walking and running." D) "I should learn stress reduction and relaxation techniques."
C
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart? A) Right ventricle, left ventricle, right atrium, left atrium B) Left ventricle, right ventricle, left atrium, right atrium C) Right atrium, right ventricle, left atrium, left ventricle D) Right atrium, left atrium, right ventricle, left ventricle
C
The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best? A) "What is your reason for wanting such a plan?" B) "Have you talked with your health care provider about this?" C) "Let us discuss your rights as a couple." D) "Write your ideal plan for the next class."
C
The nurse knows that a PTCA is the A) Surgical repair of a diseased coronary artery B) Placement of an automatic internal cardiac defibrillator C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow D) Non- invasive radiographic examination of the heart
C
The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager? A) Confront the nurse about the suspicions in a private meeting B) Schedule a staff conference, without the nurse present, to collect information C) Consult the human resources department about the issue and needed actions D) Counsel the employee to resign to avoid investigation
C
The nurse uses the DRG (Diagnosis Related Group) manual to A) Classify nursing diagnoses from the client's health history B) Identify findings related to a medical diagnosis C) Determine reimbursement for a medical diagnosis D) Implement nursing care based on case management protocol
C
The nurse would expect which eating disorder to have the greatest fluctuations in potassium? A) Binge eating disorder B) Anorexia nervosa C) Bulemia D) Purge syndrome
C
Which finding would be the most characteristic of an acute episode of reactive airway disease? A) Auditory gurgling B) Inspiratory laryngeal stridor C) Auditory expiratory wheezing D) Frequent dry coughing
C
Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require intervention by the nurse manager? A) To help an elderly client to the bathroom. B) To empty a foley catheter bag. C) To bathe a woman with internal radon seeds. D) To feed a 2 year-old with a broken arm.
C
While caring for a child with Reye's Syndrome, the nurse should give which action the highest priority? A) Monitor intake and output B) Provide good skin care C) Assess level of consciousness D) Assist with range of motion
C
The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to A) Reports of difficulty falling and staying asleep B) Expression of persistent suicidal thoughts C) Lack of enjoyment in usual pleasures D) Reduced senses of taste and smell
C: Lack of enjoyment in usual pleasures
A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is A) Progressive failure to adapt B) Feelings of anger or hostility C) Reunion wish or fantasy D) Feelings of alienation or isolation
D
A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a A) Chest x-ray B) Blood culture C) Sputum culture D) PPD intradermal test
D
A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosis A) Low serum albumin B) High serum cholesterol C) Abnormally low white blood cell count D) Elevated creatinine phosphokinase (CPK )
D
A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse? A) Call a chaplain B) Deny the feelings C) Cite recovery statistics D) Listen to the client
D
A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is A) High risk for infection related to vomiting B) Altered family processes related to chronic illness C) Fluid volume deficit related to vomiting D) Risk for aspiration related to loss of consciousness
D
A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse's contribution and begins to find objections to the suggestion. The nurse manager's best response is to A) Let's move on to a new action that deals with the problem. B) I think you need to reserve judgment until after all suggestions are offered. C) Very well thought out. Your analytic skills and interest are incredible. D) Let's move to the 'what if...' as related to these objections for an exploration of spin off ideas.
D
A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse? A) Para 2, Gravida 1 B) Nulligravida 2, Para 1 C) Primagravida 1, Para 1 D) Gravida 2, Para 1
D
At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially A) Allow the staff to change assignments B) Clarify reasons for current assignments C) Help staff see the complexity of issues D) Facilitate creative thinking on staffing
D
During the care of a client with Legionnaire's disease, which finding would require the nurse's immediate attention? A) Pleuritic pain on inspiration B) Dry mucus membranes in the mouth C) A decrease in respiratory rate from 34 to 24 D) Decrease in chest wall expansion
D
Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: "We just don't know how he caught the disease!" The nurse's response is based on an understanding that A) AGN is a streptococcal infection that involves the kidney tubules B) The disease is easily transmissible in schools and camps C) The illness is usually associated with chronic respiratory infections D) It is not "caught" but is a response to a previous B-hemolytic strep infection
D
On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, "I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with all those people who smoke last night." Which nursing diagnoses would be most important for this client? A) Anxiety related to hospitalization B) Ineffective airway clearance related to potential thick secretions C) Altered health maintenance related to preventative behaviors associated with asthma D) Impaired gas exchange related to broncho constriction and mucosal edema
D
The RN is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application? A) Infant will experience minimal pain B) Muscle spasms will be relieved C) Mobility will be managed as tolerated D) Tissue perfusion will be maintained
D
The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is to A) Begin cardiopulmonary resuscitation B) Prepare for immediate defibrillation C) Notify the "Code" team and health care provider D) Assess airway breathing and circulation
D
The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up? A) A 13 month-old unable to walk B) A 20 month-old only using 2 and 3 word sentences C) A 24 month-old who cries during examination D) A 30 month-old only drinking from a sip cup
D
The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately? A) 3 episodes of vomiting in 1 hour B) Periodic crying and irritability C) Vigorous sucking on a pacifier D) No measurable voiding in 4 hours
D
The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate? A) Offer ice cream every 2 hours B) Place the child in a supine position C) Allow the child to drink through a straw D) Observe swallowing patterns
D
The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time? A) Altered tissue perfusion B) Risk for fluid volume deficit C) High risk for hemorrhage D) Risk for infection
D
The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention? A) Rapid bounding pulse B) Temperature of 38.5 degrees Celsius C) Profuse Diaphoresis D) Slow, irregular respirations
D
The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child has A) Achieved developmental milestones at an erratic rate B) Delay in musculoskeletal development C) Displayed difficulty with speech development D) Delay in achievement of most developmental milestones
D
The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. Which of these should be emphasized to the client to avoid? A) Large indoor gatherings B) Exposure to sunlight C) Active physical exercise D) Foods rich in vitamin K
D
The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? A) Weight reduction B) Stress management C) Physical exercise D) Smoking cessation
D
Which behavioral characteristic describes the domestic abuser? A) Alcoholic B) Over confident C) High tolerance for frustrations D) Low self-esteem
D
Which of the following measures would be appropriate for the nurse to teach the parent of a nine month- old infant about diaper dermatitis? A) Use only cloth diapers that are rinsed in bleach B) Do not use occlusive ointments on the rash C) Use commercial baby wipes with each diaper change D) Discontinue a new food that was added to the infant's diet just prior to the rash
D
Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes? A) Give written pre and post tests B) Ask questions during practice C) Allow another diabetic to assist D) Observe a return demonstration
D
Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective? A) "I may experience seizures if I stop the medication apruptly." B) " I may experience an increase in my heart rate for a few weeks." C) " I can expect to feel nervousness the first few weeks." D) " I can have a heart attack if I stop this medication suddenly."
D
Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathing A) "This action of my lips helps to keep my airway open." B) "I can expel more when I pucker up my lips to breathe out." C) "My mouth doesn't get as dry when I breathe with pursed lips." D) "By prolonging breathing out with pursed lips the little areas in my lungs don't collapse."
D
While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality? A) Flexion of lower extremities B) Negative Ortlani response C) Lengthened leg of affected side D) Irregular hip symmetry
D
The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis? A) Nutrition B) Elimination C) Activity D) Safety
D. Safety
A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client? A) Prone B) Dorsal recumbent C) Semi-Fowler D) Supine
c
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately? A) Jaundice evident at 26 hours B) Hematocrit of 55% C) Serum bilirubin of 12mg D) Positive Coomb's test
c
While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication? A) Positive Homan's sign B) Fever and chills C) Dyspnea and cough D) Sensory impairment
c