HESI Exit Practice

50. When caring for a client on a ventilator, which finding provides the greatest indication that the client has an open airway? a) The client has asymmetrical chest expansion b) Bilateral breath sounds can be auscultated c) The client has been turned q2h. d) Prescribed ventilator settings are being maintained

Bilateral breath sounds can be auscultated

147. A female college student is brought to the Emergency Department by her roommates who report that she was brought home about 4 hours ago by a group of fraternity brothers who reported that she was drunk. Her friends tell the nurse that when she began to awaken she stated, "I can't believe I let them do that to me. I should have resisted. It was my fault it happened. I was so stupid." How should the nurse respond? a) "Do you think the boys had reason to believe they could take advantage if you?" b) "Do you remember what you had to drink last night?" c) "DID you know the boys who brought you home last night?" d) "I am sorry you made some bad choices in terms of your safety."

"Do you remember what you had to drink last night?"

109. The healthcare provider prescribes Morphine Sulfate Oral Solution 38 mg PO q4 hours for a client who is opiod-tolerant. The available 30 mL bottle is labeled, 100 mg/5 mL (20mg/mL), and is packaged with a calibrated oral syringe to provide to provide accurate dose measurements. How many mL should the nurse administer? (enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.9

105. A client currently receiving an infusion labeled Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 mL at 14 mL/hour. A prescription is received to change the rate of the infusion to 900 units of Heparin per hour. The nurse should set the infusion pump to deliver how many mL/hour? (Enter numeric value only).

20

128. During the admission assessment, the nurse auscultates heart sounds for a client with no history of cardiovascular disease. Where should the nurse listen when assessing the client's point of maximal impulse (PMI)? (Click the chose location).

5th intercostal space

144. At shift change in the emergency room several pediatric clients arrive within minutes of each other. Which child requires the most immediate intervention by the nurse? a. A crying 5 year old with a scalp wound whose father is holding a blood soaked towel to the head. b. A year old with Down syndrome who is pale and is sleeping in the mother's arms c. A 4 year old with a barking cough and a flushed appearance who is sitting between both parents d. A 2 year old with an audible stridor who is drooling and sitting up in the mother's arms.

A 2 year old with an audible stridor who is drooling and sitting up in the mother's arms.

120. A client had a subtotal parathyroidectomy two days ago, and is now preparing for discharge. Which assessment finding is most important for the nurse to provide to the healthcare provider prior to client discharge? a) Afebrile with a normal pulse b) No bowel movement since surgery c) No appetite for breakfast d) A positive Chvostek's sign

A positive Chvostek's sign

125. A woman at 24-weeks gestation who has a fever, body aches, and had been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which prescription has the highest priority? a) Vital signs q4 hours b) Obtain specimens for culture c) Ringers Lactate IV 125 mL/8hours d) Assign private room

Assign private room

119. A client who does not appear to be pregnant comes to the antepartal clinic and tells the nurse that she thinks she may be "about two months pregnant". If the client is pregnant, which sign may the nurse expect her to exhibit? a) Lightening b) Quickening c) Edema of the feet d) Amenorrhea

Amenorrhea

127. The nurse observes an adolescent client prepare to administer a prescribed corticosteroid medication using a metered dose inhaler as seen in the picture. What action should the nurse take? a) Remind the client to hold his breath after inhaling the medication b) Confirm that the client has correctly shaken the inhaler c) Affirm that the client has correctly positioned the inhaler d) Ask the client if he has a spacer to use for this medication

Ask the client if he has a spacer to use for this medication

140. The nurse is preparing an older client for discharge following cataract extractions. Which instructions should be included in the discharge teaching? a. Limit exposure to sunlight during the first 2 weeks when the cornea is healing b. Do not read without direct lighting for 6 week. c. Avoid straining at stool, bending or lifting heavy objects d. Irrigate conjunctiva with ophthalmic saline prior to initiating antibiotic ointment

Avoid straining at stool, bending or lifting heavy objects

136. After a routine physical examination, the healthcare provider admits a woman with a history of SLE to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment findings warrant immediate intervention by the NURSE? a) Blood pressure 170/98. b) Joint and muscle aches. c) Urine output 300ml/hour. d) Dark, rust colored urine.

Blood pressure 170/98.

123. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering? a) Corticosteroids b) Bronchodilators c) Beta blockers d) Beta-adrenergics

Bronchodilators

134. A frail elderly woman fell at home and broke her hip. Because of her advanced age, which postoperative assessment is most important for the NURSE to include in the client's plan of care? a) Daily hemoglobin and hematocrit. b) Cognitive acuity and level of orientation c) Bowel sounds and bowel movements frequency. d) Urinary output related to total fluid intake.

Cognitive acuity and level of orientation

107. At bedtime, an unlicensed assistive personnel (UAP) is positioning a client with obstructive sleep apnea syndrome (OSAS). The UAP elevates the head of the bed and encourages the client to turn n on the side. In supervising the UAP, what action should the nurse take? a) Reposition the client in supine position with the feet elevated on pillows b) After leaving the room, discuss correct positioning with the UAP c) Remind the UAP to pad the side rails to reduce risk for injury d) Confirm that the UAP has placed the call bell within reach of the client

Confirm that the UAP has placed the call bell within reach of the client

143. After applying a gait belt, the nurse assists a client with ambulation. While in the hallway , the client begins to fall. What action should the nurse implement? a. Advise the client to grab hold of the gait belt for support b. Ease the client to the floor while holding the gait belt securely c. Support the client in an upright position until the belt is removed d. Use the gait belt to slowly guide the client back to the room

Ease the client to the floor while holding the gait belt securely

112. A female client is admitted for diabetic crisis resulting from inadequate dietary practices. After stabilization, the nurse talks to the client about her prescribed diet. What client characteristic is most important for successful adherence to the diabetic diet? a) Frequently eats fruits and vegetables at meals and between meals b) Demonstrates a willingness to adhere to the diet consistently c) Has someone available who can prepare and oversee the diet d) Knows that insulin must be given 30 minutes before eating

Demonstrates a willingness to adhere to the diet consistently

137. The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? a. Fruity breath odor b. Polyphagia c. Diaphoresis d. Polydipsia

Diaphoresis

102. What action should the school nurse implement to provide secondary prevention for school-aged children? a) Observe a type 1 diabetic self administer a dose of insulin b) Collaborate with a science teacher to prepare a health lesson c) Prepare a presentation on how to prevent the spread of lice d) Initiate a hearing and vision screening program for first graders.

Initiate a hearing and vision screening program for first graders.

91. When obtaining subjective data from a client, what intervention should the nurse implement first? a) List client problems b) Validate objective data c) Establish rapport d) Clarify inferences

Establish Rapport

108. A newly hired male unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients? a) Review the UAP's skills checklist and experience with the person who hired him b) Ask the nurse experienced UAP on the team to partner with the newly hired UAP c) Assign the newly hired UAP to clients who require the least complex level of care d) Evaluate the newly hired UAP's level of competency by observing him deliver care.

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

114. The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide? a) Exercise at least three times weekly b) Monitor blood glucose levels daily c) Limit intake of foods high in saturated fat d) Learn to read all food product labels

Exercise at least three times weekly

116. Following a motor vehicle collision (MCV), a male adult in severe pain is brought to the emergency department via ambulance. His injured left leg is edematous, ecchymotic around the impact of injury on the thigh, and shorter than his right leg. Based on these findings, the client is at greatest risk for which complication? a) Arterial ischemia b) Tissue necrosis c) Fat embolism d) Nerve damage

Fat embolism

138. A 41 week gestation primigravida is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusions of oxytocin (Pitocin)? a. Biophysical profile results showing oligohydramnios b. Sterile vaginal exam revealing 3 cm dilation c. Regular contractions occurring every 10 minutes d. Fetal heart tones locate in upper right quadrant

Fetal heart tones locate in upper right quadrant

145. After experiencing several transient ischemic attacks (TIA), a client is transported to the emergency room by a family member. The client has slurred speech and is becoming combative. After providing oxygen and establishing IV access. Which interventions should the nurse implement? a. Notify the stroke team b. Apply soft limb restraints c. Initiate seizure precautions d. Obtain an electroencephalography (EEG)

Initiate seizure precautions

121. A female client is admitted with complaints of abdominal pain, loss of appetite, and a weight loss of 25 pounds in the last four months. During the admission assessment, the client tells the nurse that she has no interest in playing cards with her friends anymore and feels worthless most days. Which nursing problem should the nurse address first? a) Anxiety as evidenced by abdominal complaints secondary to depression b) Risk for self-directed violence as evidenced by feelings of hopelessness. c) Imbalanced nutrition as evidences by 25 pounds weight loss in four months d) Chronic low self-esteem as evidenced by feelings of worthlessness.

Imbalanced nutrition as evidences by 25 pounds weight loss in four months

130. The healthcare provider prescribes carboprost tromethamine (Hemabate) 250 mcg IM for a multigravida postpartum client who is experiencing heavy, bright red vaginal bleeding. Prior to administering this medication, which interventions should the RN implement? a) Obtain a second IV access. b) Decrease the room temperature. c) Give the prescribed antiemetic. d) Insert an indwelling catheter.

Insert an indwelling catheter.

142. An adult male who was admitted two days ago following a cerebrovascular accident (CVA) is confused and experiencing left-sided weakness. He has tried to get out of bed several times, but is unable to ambulate without assistance. Which intervention is most important for the nurse to implement? a. Ask a family member to sit with the client b. Apply bilateral soft wrist restraints c. Assign staff to check client q15 minutes d. Install a bed exit safety monitoring device

Install a bed exit safety monitoring device

133. Lactulose is prescribed for a client with hepatic encephalopathy. Which medication should the NURSE implement to evaluate the effectiveness? a) Observe the color of the client's bowel movements. b) Monitor the client's serum ammonia level. c) Assess the changes in abdominal ascites. d) Assess the client's BP frequently.

Monitor the client's serum ammonia level.

101. The first paddle has been placed on the chest of a client who needs defibrillation. Where should the nurse place the second paddle? (Mark the location where the second paddle should be placed on the image).

Near 5th intercostal space to the right of the nipple line

117. An older woman who lives alone in a two-story home is admitted after falling while shopping. X-rays reveal a fractured left hip. With no immediate family in the area, the client is concerned about her pets. Which interventions should the nurse implement? (Select all that apply.) a) Evaluate pain using a standard pain scale b) Assess ability to bear weight when standing c) Alert social worker of client's concerns d) Support left leg with two pillows e) Palpate and mark pedal pulses

Palpate and mark pedal pulses Alert social worker of client's concerns Evaluate pain using a standard pain scale

141. A client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this clients plan of care? a) restrict daily fluid intake by 1500 ml b) maintain accurate intake and output c) weigh client every morning d) administer prescribed diuretic

weigh client every morning

106. When caring for a client with deep partial-thickness burns to the posterior neck, which intervention should the nurse implement during the acute phase to prevent contractures at the site of injury? a) Place a towel roll under the client's neck or shoulder b) Passively raise arms above the head hourly while awake c) Actively turn head from side to side 90 degrees hourly d) Keep in supine position without the use of pillows

Place a towel roll under the client's neck or shoulder

122. A client's telemetry monitor indicates ventricular fibrillation (VF). What should the nurse do first? a) Administer epinephrine IV b) Give an IV bolus of amiodarone c) Provide immediate defibrillation d) Prepare for synchronized cardioversion

Provide immediate defibrillation

124. Five days after surgical fixation of a fractured femur, a client suddenly complains of chest pain and difficulty breathing. The nurse suspects that the client may have had a pulmonary embolus. What action should the nurse take first? a) Notify the healthcare provider b) Prepare a continuous heparin infusion per protocol c) Provide supplemental oxygen d) Bring the emergency crash cart to the bedside

Provide supplemental oxygen

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

Provide with only finger foods

103. A client who had a below-the-knee amputation is experiencing severe phantom limb pain (PLP) and asks the nurse if mirror therapy will make the pain stop. Which response by the nurse is likely to be most helpful? a) You can try mirror therapy, but do not expect complete elimination of the pain b) Research indicates that mirror therapy is effective in reducing phantom limb pain c) Where did you learn about the use of mirror therapy in treating phantom limb pain d) Trancutaneous electrical nerve stimulators (TENS) has been found to be more effective

Research indicates that mirror therapy is effective in reducing phantom limb pain

126. A client who had a right total knee replacement two days ago is progressed to a soft diet. Which food selections should the nurse recommend to this client? (Select all that apply) a) Ice cream with nuts a) Fried chicken and green salad b) Scrambled eggs and potatoes c) Steamed rice and cooked squash d) Pancakes with syrup e) Pasta with a cream sauce

Scrambled eggs and potatoes Steamed rice and cooked squash Pancakes with syrup

146. A male client returns to the mental health clinic for assistance with his anxiety reaction that is manifested by a rapid heartbeat, sweating, shaking, and nausea while driving over the bridge. What actions in the treatment plan should the nurse implement? a. Teach client to listen to music or audio books while driving b. Encourage client to have spouse drive in stressful places c. Tell client to drive over the bridge until fear is manageable d. Recommend that the client avoid driving over the bridge

Teach client to listen to music or audio books while driving

139. Which intervention should the nurse include in the preparation of a client who is scheduled for gastric bypass surgery? a. Encourage the family to participate in monitoring the client's dietary intake. b. Suggest avoiding shopping for food by designating someone to grocery shop. c. Teach the client how to prepare small meals that are low in fat and sugar. d. Advise the client's family to seek dietary counseling and exercise planning.

Teach the client how to prepare small meals that are low in fat and sugar.

111. The mother of a 2-day-old infant girl expresses concern about a "flea bite" type rash on her daughter's body. The nurse identifies a pink popular rash with vesicles superimposed over the thorax, back, buttocks, and abdomen. What explanation should the nurse offer? a) This rash is characteristic of a medication reaction b) This is a common newborn rash that will resolve after several days c) The rash is due to distended oil glands that will resolve in a few weeks d) The healthcare provider is being notified about the rash

This is a common newborn rash that will resolve after several days

132. A nurse is planning a class for a group of 18 adults recently diagnosed with the Type 2 DM. Included in the class content is blood glucose monitoring (BGM). Which teaching strategies are best for the NURSE to use with this group? a) Lecture followed by a question and answer session. b) Distribution of pamphlets on BGH with a follow up quiz c) Small group discussing with a packet of the BGM supplies d) Video presentation followed by a demonstration.

Video presentation followed by a demonstration.

115. A client who is schedule for an elective inguinal hernia repair today in day surgery is seem eating in the waiting area. What action should be taken by the nurse who is preparing to administer the preoperative medications? a) Review the surgical consent with the client b) Explain that vomiting can occur during surgery c) Remove the food from the client d) Withhold the preoperative medication

Withhold the preoperative medication

113. A mother calls the nurse to report at 0900 she administered a PO dose of digoxin (Lanoxin) to her 4-month-old infant, but at 0920 the baby vomited the medicine. What instruction should the nurse provide to this mother? a) Administer a half dose now b) Mix the next dose with food c) Give another dose d) Withhold this dose

Withhold this dose

40. An adolescent receives a prescription for an injection of sumatriptan (Imitrex) 4 mg subcutaneously for a migraine headache. Using a vial labeled, 6 mg/ 0.5 ml, how many ml should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest hundredth.)

0.33 mL

41. An infant who weighs 22 lbs. is to receive 15 mcg/kg of a medication. How many ml should the nurse administer if the medication is available in 1 mg/ 5 ml? Round to the nearest hundredth?

0.75

68. A client with a serum sodium level of 125 meq/mL should benefit most from the administration of which intravenous solution? a) 0.9 %sodium chloride solution (normal saline) b) 0.45% sodium chloride solution (half normal saline) c) 10% Dextrose in 0.45% sodium chloride d) 5% dextrose in 0.2% sodium chloride %

0.9 %sodium chloride solution (normal saline)

29. While the school nurse is teaching a group of 14-year-olds, one of the participants remarks, "You are too young to be our teacher! You're not much older than we are!" How should the nurse respond? a) "How old do you think I am?" b) "We need to stay focused on the topic." c) "I think I am qualified to teach this group." d) "Do you think you can teach it any better?"

"We need to stay focused on the topic."

77. While the nurse is taking a health history, the client announces, I don't have time for this. This is a waste of time. I need treatment" Which response is best for the nurse to provide? a) Ignore the angry outburst and continue with the history questions b) "You sound angry. Would you like to tell me about it?" c) Move closer and place a hand on his shoulder to demonstrate concern. d) "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

"You sound angry. Would you like to tell me about it?"

32. The nurse is (caring?) a client with nasogastric (NG) tube. Which task (can the nurse delegate to the unlicensed assistive personnel (UAP)??) e) (Secure?) the NG tube if it (slides?)out of the client's nasal passage f) (Replace?) the NG tube as prescribed by the healthcare provider g) Disconnect the NG tube suction so the client can ambulate in the hallway h) Reconnect the NG suction when the suction when the client returns from ambulating

(Secure?) the NG tube if it (slides?)out of the client's nasal passage

59. The nurse is verifying a blood transfusion for a client whose blood type is A positive. Which blood type is incompatible for this client? a. O, Rh negative b. AB, RH positive c. A, Rh negative d. O, Rh positive

AB, RH positive

18. An adult female client with chronic kidney disease (CKD) is becoming increasingly restless and is hyperventilating. Urine output is 25 ml/hr and urine pH is 4.5. On admission, her arterial blood gases (ABGs) are: pH 7.20, PaCO2 37 mEq/L, and HCO3 14 mEq/L. Which action should the nurse implement? a) Administer IV solution with sodium bicarbonate b) Flush AV fistula with 0.9 Sodium chloride c) Give laxatives or an enema as client requests d) Maintain the client NPO (nothing by mouth)

Administer IV solution with sodium bicarbonate

61. Based on the principles of asepsis, the nurse should consider which circumstance to be sterile? e) A wrapped, unopened sterile 4x4 gauze pad placed on a damp table f) An open sterile Foley catheter kit set up on a table at the nurse's waist level g) A one-inch border around the edges of a sterile field set up in the operating room h) A sterile syringe is placed on sterile area as the burse reaches over the sterile field

An open sterile Foley catheter kit set up on a table at the nurse's waist level

90. While completing assessment of a peripheral IV with a vasopressors infusing, the nurse recognizes that the extremity is swollen, painful, and pale. What actions should the nurse implement? (select all that apply.) a) Apply cold compressed to the infiltration site b) Inject a subcutaneous antidote per protocol c) Elevate the affected extremity on several pillows d) Stop the IV infusion pump before discontinuing the infusion e) Aspirate remaining vasopressors form IV catheter before withdrawal

Apply cold compressed to the infiltration site Elevate the affected extremity on several pillows

89. The nurse determines that an elderly client with pneumonia has a nursing diagnosis of, "Altered nutrition, less than body requirements." What instruction should the nurse give the UAP assisting with the care of this client? a) Listen to the client's breath sounds and after meals b) Assist the client in selecting high protein foods on the menu c) Offer to assist the client with meal preparation and feeding d) Thicken the client's liquids if aspiration seems likely

Assist the client in selecting high protein foods on the menu

57. The nurse assesses a child in a 90-90 skeletal traction. Where should the nurse assess for signs of compartment syndrome? (Click the correct location).

At the cast

82. A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first? a) Review the heart rhythm on cardiac monitors b) Check urinary catheter for obstruction c) Auscultated bilateral breath sounds d) Give PRN dose of lorazepam (Ativan)

Auscultated bilateral breath sounds

84. Hand washing is the most important intervention aimed at reducing the spread of infection in the hospitalized population. What mechanism describes the effect that hand washing has upon the chain of infection? a) Destroys non-human reservoir b) Blocks a portal of entry c) Reduces victim's susceptibility d) Blocks pathogen transmission

Blocks pathogen transmission

75. The nurse enters the room of a disoriented female client to supervise the care being provided by an unlicensed assistive personnel (UAP). The UAP has left the room to obtain linens, leaving the client supine and lying on wet sheets, with side rails down and the bed in the high position. Which action should the nurse implement first? a) Explain risks of the client's unsafe situation to the UAP b) The client should be re-oriented to her surroundings c) Both upper side rails of the bed should be raised d) Place the client in lateral position off the wet linens

Both upper side rails of the bed should be raised

38. When assessing a multigravada the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first? a) Massage the uterus to decrease atony b) Review the hemoglobin to determine hemorrhage c) Increase intravenous infusion d) Check for a distended bladder

Check for a distended bladder

11. The nurse assesses a male client following surgery for a gunshot wound to the abdomen and determines that his dressing is saturated with blood and petechiae are on his extremities. His current blood pressure is 80/40, and his heart rate is 130 beats/minute. Which laboratory finding confirms the presence of disseminated intravascular coagulopathy (DIC)? a) Low prothrombin time b) Elevated fibrinogen c) Positive d-Dimer d) Normal hemoglobin

Elevated fibrinogen

43. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? a. Hypernatremia b. Excessive thirst c. Elevated heart rate d. Poor skin turgor

Elevated heart rate

46. A clinical trial is recommended for a 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? a) Explain to the family that they must accept their Mother's decision b) Explore the client's decision to refuse treatment and offer support c) Discuss success of clinical trials and ask the client to consider participating for one month. d) Ask the client with her children present if she fully understands the decisions she has made.

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

92. In caring for a client with Cushing syndrome, which serum laboratory value is most important for the nurse to monitor? a) Lactate b) Glucose c) Hemoglobin d) Creatinine

Glucose

56. The nurse is developing the plan of care for a hospitalized child with von Willebrand's disease. What priority nursing intervention should be included in this child's plan of care? A. Eliminate contact with cold drafts B. Reduce contact with other children C. Reduce exposure to infection D. Guard against bleeding injuries

Guard against bleeding injuries

48. The unit secretary in the emergency department reports to the charge nurse that a woman is outside at the entry to the hospital in a wheelchair with a broken liquor bottle and is cutting herself. What action should the nurse take? a) Have two nurses assess the woman for a psychiatric referral b) Have a security guard accompany the nurse to assess the woman c) Since the woman is outside the hospital, no nursing action is required. d) Have a male attendant take the woman to the observation unit.

Have a security guard accompany the nurse to assess the woman

28. In assessing a client at 34-weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up? a) Heart rate of 92 beats per minute b) Systolic murmur c) Hematocrit of 28% d) Elevated parathyroid hormone level

Hematocrit of 28%

100. An adult male is admitted to the psychiatric into from the emergency department because he is in the manic stage of bipolar disorder. He has lost 10 pounds in the last two weeks and has not bathed in a week because he has been "trying to start a new business" and is "too busy to eat." He is alert and oriented to time, Place, and person, but not situation. Which nursing problem has the greatest priority? a) Disturbed sleep pattern b) Hygiene self-care deficit c) Self neglect d) Imbalanced nutrition

Imbalanced nutrition

23. The nurse is caring for a client with hypovolemic shock who is receiving two units of packed red blood cells (RBCs) through a large bore peripheral IV. What action promotes maintenance of the client's cardiopulmonary stability during the blood transfusion? a) Increase the oxygen flow via nasal cannula if dyspnea is present. b) Place in a Trendelenburg position to increase cerebral blood flow c) Monitor capillary glucose measurements hourly during transfusion. d) Encourage increased intake of oral fluid to improve skin turgor.

Increase the oxygen flow via nasal cannula if dyspnea is present.

30. When implementing a disaster intervention plan, which intervention should the nurse implement first? a) Initiate the discharge of stable clients from hospital units b) Identify a command center where activities are coordinated c) Assess community safety needs impacted by the disaster d) Instruct all essential off-duty personnel to report to the facility

Initiate the discharge of stable clients from hospital units

88. An Unna boot is applied to the foot and lower leg of a client with a venous stasis ulcer. What instruction should the nurse provide the client? a) Wear boot whenever you are out of bed b) Keep the foot elevated as much as possible c) Loosen the bandage wrap slightly each day d) Remove the boot to wash the site once a day

Keep the foot elevated as much as possible

96. A male client who was discharged 3 days after an exploratory laparoscopic biopsy is admitted to the hospital with a warm, tender, reddened, and swollen left lower leg.The nurse is preparing to initiate herparin therapy. What additional intervention should the nurse include in this client's plan of care? a) Maintain the client on bed rest b) Encourage a diet high in iron and ascorbic acid c) Encourage the client to dangle his legs frequently d) Administer the client's routine daily aspirin

Maintain client on bed rest

85. The nurse is preparing a client for discharge from the hospital following a liver transplant. Which instruction is most important for the nurse to include in this client's discharge teaching plan? a) Monitor for an elevated temperature b) Measure the abdominal girth daily c) Report the onset of sclera jaundice d) Keep a record of daily urinary output

Monitor for an elevated temperature

9. A male client with renal cell carcinoma is returned to the unit following a radical nephrectomy. The nurse notes that his vital signs and urine output are within normal range, his bandage is dry, and the drain from the incision site is producing a small amount of serasanguinous drainage. Which intervention should the nurse implement? a) Place a pressure bandage at the drainage site b) Document assessment findings in the electronic medical record c) Monitor urinary catheter output for a decrease below 30 ml/hr d) Notify surgeon of color and amount of wound drainage.

Notify surgeon of color and amount of wound drainage

76. While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value? a) Hemoglobin b) Potassium c) Protein d) Calcium

Potassium

67. A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. What intervention should the nurse implement? a) Apply soft bilateral wrist restraints b) Leave the lights on in the room at night c) Redress the abdominal incision d) Replace the IV site with a smaller gauge

Redress the abdominal incision

71. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? a) Reduce risks factors for infection b) Administer high flow oxygen during sleep c) Limit fluid intake to reduce secretions d) Use diaphragmatic breathing to achieve better exhalation

Reduce risks factors for infection

87. The nurse is caring for a 2-year-old male with nephritic syndrome who is receiving corticosteroid therapy. The toddler is edematous and fatigued. What nursing action is most important for the nurse to implement? a) Measure the abdominal girth twice daily b) Monitor intake and output c) Restrict sodium in the diet d) Observe for signs of Cushing's syndrome

Restrict sodium in the diet

60. The nurse is auscultating a client's heart sounds. Which description should the nurse document this sound? http://youtu.be/1B6dUwDJ3uo http://youtu.be/g8x4NM3PuuM a. Murmur b. Pericardial friction rub c. S1 s2 s3 d. S1 s2

S1 s2 s3

39. The nurse makes a supervisory home visit to observe an unlicensed assistive personnel (UAP) who is providing personal care for a client with Alzheimer's disease. The nurse observes that whenever the client gets upset, the UAP changes the subject. What action should the nurse take in response to this observation? a) Tell the UAP to offer more choices during the personal care to prevent anxiety b) Meet with the UAP later to role model more assertive communication techniques c) Assume care of the client to ensure that effective communication is maintained. d) Affirm that the UAP is using and effective strategy to reduce the client's anxiety.

Tell the UAP to offer more choices during the personal care to prevent anxiety

5. The charge nurse of the Intensive Care Unit is making assignments for the permanent staff and one RN who was floated from a medical unit. The client with which condition is the best to assign to the float nurse? a) Diabetic ketoacidosis and titrated IV insulin infusion b) Emphysema extubated 3 hours ago receiving heated mist c) Subdural hematoma with an intracranial monitoring device d) Acute coronary syndrome treated with vasopressors

a) Diabetic ketoacidosis and titrated IV insulin infusion

35. A client in septic shock has a double lumen central venous catheter with one liter of 0.9Normal Saline solution at 100 mL/hour through one lumen and Total Parenteral Nutrition (TPN) infusing at 50 mL/ hour through one port. The nurse prepares a newly prescribed IV antibiotic that should take 45 minutes to infuse. What intervention should the nurse implement? a) Use as secondary port of the Normal Saline solution to administer the antibiotic b) Add the antibiotic to the Normal Saline solution and continue both infusions c) Add the antibiotic to the TPN solution, and continue the normal saline solution d) Stop the TPN infusion for the time needed to administer the prescribed antibiotic. %

Use as secondary port of the Normal Saline solution to administer the antibiotic

24. A client with renal lithiasis is receiving morphine sulfate every four hours for pain and renal colic. Which assessment finding should prompt the nurse to administer a PRN dose of naloxone (Narcan)? a) Complaints of increasing flank pain b) Statements about visual hallucinations c) Respiratory rate of 12 breaths/minute d) Unresponsive to verbal or tactile stimuli

Unresponsive to verbal or tactile stimuli

12. After a routine physical examination, the healthcare admits a woman with a history of Systemic Lupus Erythematous (SLE) to the hospital because she has 3+ pitting ankle edema and blood in her urine. Which assessment finding warrants immediate intervention by the nurse? a) Blood pressure 170/98 b) Joint and muscle aches c) Urine output 300 ml/hr d) Dark, rust-colored urine

Urine output 300 ml/hr

14. While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement? a) Ask the mother what she usually uses on the child's lips and nose b) Apply a petroleum jelly (Vaseline) to the child's nose and lips c) Use a topical lidocaine (Zylocaine viscous) analgesic for cracked lips d) Use a water soluble lubricant on affected oral and nasal mucosa

Use a water soluble lubricant on affected oral and nasal mucosa

69. When planning care for a female client recently diagnosed with anorexia nervosa, which intervention is most important for the nurse to include in the plan of care? a) Weight the client daily at the same time using the same scale b) Encourage the client to talk about her sources of anxiety c) Document daily nutritional intake and record daily output d) Monitor the client's complete blood count at least weekly

Weight the client daily at the same time using the same scale

7. The nurse weighs a 6-month-old infant during a well baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? a) What food does your baby usually eat in a normal day? b) What was the baby's weight at the last well-baby clinic visit? c) The baby is below the normal percentile for weight gain d) Your baby is gaining weight right on schedule

What food does your baby usually eat in a normal day?

65. When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority? a) Initiate IV fluid replacement b) Evaluate intake and output ratio c) Administer antiemetics as needed d) Withhold food and fluid intake

Withhold food and fluid intake

31. A middle-aged woman, diagnosed with Graves' disease, asks the nurse about this condition. Which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply.) a) Graves disease, an autoimmune condition, affects thyroid stimulating hormone receptors. b) T3 and T4 hormone levels are increased c) Large protruding eyeballs are a sign of hyperthyroid function d) Weight gain is a common complaint in hyperthyroidism e) Early treatment includes levothyroxine (Synthroid).

a) Graves disease, an autoimmune condition, affects thyroid stimulating hormone receptors. b) T3 and T4 hormone levels are increased c) Large protruding eyeballs are a sign of hyperthyroid function

21. The healthcare provider prescribes an IV solution of Heparin Sodium 25,000 Units in 5% Dextrose Injection 500 ml for a client with unstable angina who weighs 60 kg. After administering the loading dose, the nurse initiates the infusion at 12 units/kg/hour per protocol. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only. If rounding is required, round to the whole number.)

14 mL/hr

34. A client with bacterial meningitis is receiving phenytoin (Dilantin) Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response to the phenytoin? a) Decrease in intracranial pressure and cerebral edema b) Increased time of ambulation between periods of rest c) Normal electroencephalogram after drug administration d) Absence of seizure activity for the duration of treatment

Absence of seizure activity for the duration of treatment

37. When five family members arrive at the hospital, they all begin asking the nurse questions regarding the prognosis of their critically ill mother. What intervention should the nurse implement first? a) Include the family in client's care b) Request the chaplain's presence c) Ask the family to identify a specific spokesperson d) Page the healthcare provider to speak with family.

Ask the family to identify a specific spokesperson

79. When administering brompheniramine maleate (Demetane Extentab) the nurse is told by the male client that he cannot swallow tablets." Which intervention should the nurse implement? a) Ask the pharmacist to send medication in liquid form b) Crush tablet and mix with small amount of pudding c) Document that the client cannot take the prescription d) Document the client's refusal to take medication

Ask the pharmacist to send medication in liquid form

47. During a clinic visit, a male client with heart failure (HF) reports that he has gained 4 pounds in the last 3 days. Which action should the nurse implement? e) Recommend controlled portions at mealtimes f) Encourage a reduced intake of table salt g) Auscultate all lung fields for fine crackles h) Assess for bilateral pitting pedal edema

Assess for bilateral pitting pedal edema

25. The nurse is assessing the emotional status of a client with Parkinson's disease. Which client finding is most helpful in planning goals to meet the client's emotional needs? a) Stares straight ahead without blinking b) Face does not convey any emotion c) Uses a monotone when speaking d) Cries frequently during the interview

Cries frequently during the interview

42. A 3 year old boy is brought to the emergency room after the mother found the child in the back yard holding a piece of toy in his hand and in respiratory distress. The child is dusky with a loud, inspiratory stridor and weak attempts to cough. Which actions should the nurse implement? a. Request a stat chest x ray and prepare medications for an asthmatic episode. b. Obtain a pulse oximetry reading an arterial blood gases. c. Determine if the child ingested a toxic substance and if vomiting occurred d. Auscultate all pulmonary lung fields and attempt a Heimlich maneuver

Auscultate all pulmonary lung fields and attempt a Heimlich maneuver

16. Which instruction is most important for the nurse to include in the discharge teaching plan of a client who had a prostatectomy three days ago? a) Ambulate and exercise as tolerated b) Read written follow up instructions c) Avoid lifting 20 pounds for 6 weeks d) Increase fluid intake to one quart daily

Avoid lifting 20 pounds for 6 weeks

8. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? a) Finger stick blood glucose 120 mg/dL post exchange b) Arteriovenous (AV) graft surgical site pulsations. c) Anorexia and poor intake of adequate dietary protein d) Cloudy dialysate output and rebound abdominal pain

Cloudy dialysate output and rebound abdominal pain

94. A young boy who is in a chronic vegetative state and living at home is readmitted to the hospital with pneumonia and pressure ulcers. The mother insists that she is capable of caring for her son and that she is going to take him home when he is discharged. Which action should the nurse implement next? a) Consult the ethics committee to determine how to proceed b) Determine the mother's basic skill level in providing care c) Report the incident to the local Child Protective Services d) Find a home health agency that specializes in brain injuries

Determine the mother's basic skill level in providing care

54. The parents of a 6 year old recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond? a. Provide a list of alternative activities that are less likely to cause the child to experience fatigue b. Suggest that the child be encouraged to participate in a team sport to encourage socialization c. Encourage the parents to allow the child to continue attending swimming lessons with supervision d. Explain that their child is too young to understand the risks associated with swimming

Encourage the parents to allow the child to continue attending swimming lessons with supervision

19. The nurse is evaluating the health teaching of a female client with condyloma acuminate. Which statement by the client indicates that teaching has been effective? a) Early treatment is very effective b) I will clean my hot tub better c) These warts are caused by a fungus d) I need to have regular pap smears

I need to have regular pap smears

97. The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL. When assessing the client, what is the priority? a) Measure the level of acute pain b) Observe wound drainage characteristics c) Assess for signs of fluid volume deficit d) Determine when the client last ate

Observe wound drainage characteristics

45. The nurse observes that a client receiving haloperidol (Haldol) is demonstrating uncontrollable facial movements. Which action is most important for the nurse to implement? a. Obtain a consult for speech therapy to assess for dysphagia b. Hold the next dose of Haldol until the health care provider is notified c. Perform a comprehensive neurologic assessment d. Provide a quiet calm environment with minimal distractions during mealtimes.

Perform a comprehensive neurologic assessment

62. While performing a skin inspection for a female adult client, the nurse observes a rash that is well circumscribed, has silvery scales and plaques, and is located on the elbows and knees. These assessment findings are likely to indicate which condition? a) Tinea corporis b) Herpes zoster c) Psoriasis d) Drug reaction

Psoriasis

27. An adolescent client on a drug treatment unit becomes angry and pulls the refrigerator from the wall and then throws the microwave. After the client fails to respond to redirection, the healthcare provider prescribes restraints. Which assessment should the nurse include in the client's record while the client is in restraints? a) Pupils equal, round and reactive. b) Responsive to painful stimuli c) Speech patterns and processes d) Range -of- motion and circulation

Range -of- motion and circulation

51. A female client newly diagnosed with breast cancer is scheduled for a mastectomy next week. During the preoperative assessment, she complains that her husband has become withdrawn and complains about her irritability and frequent crying. How should the nurse respond? a) Encourage the spouse to be more supportive at this difficult time b) Refer the couple to a counselor to help them with coping strategies c) Inquire if the couple has met a minister to discuss their feelings d) Explain that a positive attitude helps reduce postoperative complications

Refer the couple to a counselor to help them with coping strategies

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

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

70. AN adolescent boy who is attending summer camp becomes ill. His immunizations record indicated that he did not receive the HA vaccine (HAV). After receiving the confirmed diagnosis of Hepatitis A (HA), in which priority should the camp nurse take action? (Arrange in sequence from highest to lowest priority). a) Review all campers record for history of HA vaccine immunization b) Monitor all campers without HAV for signs of illness c) Notify all parents of each camper's possible exposure d) Review health department protocols for reporting incidents of HA

a) Review all campers record for history of HA vaccine immunization b) Monitor all campers without HAV for signs of illness c) Notify all parents of each camper's possible exposure d) Review health department protocols for reporting incidents of HA

93. Skeletal traction is applied to the affected leg of a client with compound fracture to the tibia and fibula. Which intervention is most important for the nurse to include in the client's plan of care? a) Teach divisional activities while in traction b) Reinforce the need for bed rest exercises c) Encourage family to participate in care d) Assess and provide routine pin care

assess and provide routine pin care

6. A client admitted to the emergency center had inspiratory and expiratory wheezing, nasal flaring, and thick, tenacious sputum secretions observed during the physical examination. Based on these assessment findings, what classification of pharmacologic agents should the nurse anticipate administering? a) Beta blockers b) Bronchodilators c) Corticosteroids d) Beta-adrenergics

b) Bronchodilators

78. The nurse prepares to insert an oral airway by first measuring for the correct sized airway. Which picture shows the correct approach to airway size measurement?

corner of mouth to ear

3. The nurse is interviewing a client with schizophrenia. Which client behavior requires immediate intervention? a) Lip smacking and frequent eye blinking b) Shuffling gait and stooped posture c) Rocks back and forth in the chair d) Muscle spasms of the back and neck

d) Muscle spasms of the back and neck

95. The healthcare provider prescribes methylergonvine maleate (Methergine) for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the mediation? a) Difficulty locating the uterine fundus b) Hypertension c) Saturation of more than one pad per hour d) Excessive lochia

hypertension

53. Which nursing problem is best for the nurse to use when planning care for a client with early Parkinson's disease? a. Impaired physical mobility b. Ineffective airway clearance c. Altered cardiac output d. Altered nutrition: less than body requirements

Altered nutrition: less than body requirement

33. A client with a recent colostomy expresses concern about the ability to control flatus. Which intervention is most important for the nurse to include in the client's plan of care? a) Adhere to a bland diet whenever planning to eat out b) Decrease fluid intake at meal times c) Avoid foods that caused gas before the colostomy d) Eliminate foods high in cellulose

Eliminate foods high in cellulose

86. A young woman with multiple sclerosis just received several immunizations in preparation for moving in to a dormitory. Two days later, she reports to the nurse that she is experiencing fatigue and visual problems. What teaching should the nurse provide? a) These are common side effects of the vaccines and will resolve in a few days b) Immunizations can trigger a relapse of the disease, so get plenty of extra rest c) Plans to move into the dormitory need to be postponed for at least a semester d) These early signs of an infection may require medical treatment with antibiotics

Immunizations can trigger a relapse of the disease, so get plenty of extra rest

13. In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete? a) Evaluate the client's ability to use an incentive spirometer b) Monitor the amount of drainage from the client's incision c) Observe both lower extremities for redness and swelling d) Palpate all peripheral pulse points for volume and strength

Monitor the amount of drainage from the client's incision

52. The nurse caring for a client with dysphagia is attempting to insert a nasogastric tube but the client will not swallow and is not gagging. What action should the nurse implement to facilitate the NGT passage into the esophagus? a. Flex the client's head with chin to the chest and insert b. Offer the client sips of water or ice and coax to swallow c. Elevate the bed 90 degrees and hyperextend the head d. Push the NGT beyond the oropharynx gently yet swiftly

Offer the client sips of water or ice and coax to swallow

44. After a coronary artery bypass graft, a client is discharged home with a referral for care and cardiac rehabilitation. Which assessment should the nurse obtain for this client's tertiary prevention? a. Historical changes in lifestyle and compliance with medical recommendations. b. Status of the client's incisions an indications of postoperative complications c. Symptoms of exacerbation or progression of the underlying cardiac disease d. The client's tolerance to exercise progression and psychosocial adaptation

Status of the client's incisions an indications of postoperative complications

1. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room? a) Ensure that the restraints are snug against the client's wrists. b) Move the ties so the restraints are secured to the side rails. c) Ensure that the knot can be quickly released. d) Tie the knot with a double turn or square knot.

c) Ensure that the knot can be quickly released.

17. Sublingual nitroglycerin is administered to a male client with instable angina who complains of crushing chest pain. Five minutes later the client becomes nauseated and his blood pressure drops to 60/40. Which intervention should the nurse implement? a) Give a PRN antiemetic medication b) Infuse a rapid IV normal saline bolus c) Begin external chest compressions d) Administer second dose of nitroglycerin

infuse a rapid IV normal saline bolus

81. The nurse is caring for several clients on a telemetry unit. Which client should the nurse assess first? The client who is demonstrating a) A paced rhythm with 100 capture after pacemaker replacement b) Normal sinus rhythm and complaining of chest pain c) Atrial fibrillation with congestive heart failure and complaining of fatigue d) Sinus tachycardia 3 days after a myocardial infarction

Atrial fibrillation with congestive heart failure and complaining of fatigue

63. The nurse instructs a client in use of an incentive spirometer. The client performs a return demonstration as seen in the video. What action should the nurse take in response to the return demonstration? http://youtu.be/LNWGOBybQ4Q a) Auscultated the client's lungs for adventitious sounds b) Encourage the client to practice until successful c) Emphasize the need to inhale slowly into the spirometer d) Remind the client to cough after using the spirometer

Emphasize the need to inhale slowly into the spirometer

4. A female client with rheumatoid arthritis (RA) comes to the clinic complaining of joint pain and swelling. The client has been taking prednisone (Deltasone) and ibuprofen (Motrin Extra Strength) every day. To assist the client with self-management of her pain, which information should the nurse obtain? a) Presence of bruising, weakness, or fatigue b) Therapeutic exercise included in daily routine. c) Average amount of protein eaten daily d) Existence of gastrointestinal discomfort

b) Therapeutic exercise included in daily routine.

49. When should intimate partner violence (IPV) screening occur? a) Once the clinician confirms a history of abuse b) Only when a client [resents with an unexplained injury c) As soon as the clinician suspects a problem d) As a routine part of each health care encounter

As a routine part of each health care encounter

74. A 4-year-old who fell off a tricycle is admitted to the hospital for observation. Which action should the nurse implement to facilitate the child's cooperation during the admission assessment? a) Allow the child to play with an empty syringe without the needle b) Explain the function of each organ during the steps of the assessment c) Have the parent hold the child's arms during the head to toe assessment d) Ask the child to blow out the pen light and turn it off to stimulate success.

Ask the child to blow out the pen light and turn it off to stimulate success.

55. An infant who is admitted to the newborn nursery has facial features that are commonly observed in newborns with Down syndrome. Which additional finding should the nurse identify? a. Flat occipital bone b. High pitch shrill cry c. Cranial suture fusion d. Hypoplasia of maxillae

a. Flat occipital bone

72. A woman who is gravida 2, para 1 has been in labor for 10 hours, without an epidural or intravenous pain medication, and is now experiencing intensifying contractions that are occurring every 2 minutes. Assessment by the nurse determines that the client's cervix is 100 percent effaced and dilated 8 cm. The client is requesting intravenous nalbuphine hydrochloride (Nubain). Which action should the nurse implement? a) Administer nalbuphine hydrochloride b) Prepare client for epidural medication c) Hold medication until 9 cm dilation d) Reinforce relaxation techniques

Reinforce relaxation techniques

36. When evaluating the discharge teaching for a male client who is taking diclofenac (Zipsor), the nurse knows the teaching was effective if the client states that he will stop taking the drug and notify the healthcare provider if which symptom occurs? a) Indigestion b) Skin rash c) Nervousness d) Insomnia

Skin rash

2. When gathering for a group therapy session at 1400 hours, a female client complains to the nurse that a smoking break has not been allowed all day. The nurse responds that 15 minute breaks were called over the unit intercom after breakfast and after lunch. The nurse is using what communication technique in responding to the client? a) Doubt b) Observation c) Confrontation d) Reflection

d) Reflection

80. The legs of a client who is receiving hospice care have become mottled in appearance. When the nurse observes the unlicensed assistive personnel (UAP) place a heating pad on the mottled areas, what action should the nurse take? a) Elevate the client's feet on a pillow and monitor the client's pedal pulses frequently b) Remove the heating pad and place a soft blanket over the client's legs and feet c) Instruct the UAP to reposition the heating pads to the side of the legs and feet d) Advise the UAP to observe the client's skin while heating pads are in place.

Instruct the UAP to reposition the heating pads to the side of the legs and feet

10. A client with chronic obstructive lung disease, who is receiving oxygen at 1.5 liters/minute by nasal cannula, is currently short of breath. What action should the nurse take? a) Ask the client to take short, rapid breaths b) Instruct the client in pursed lip breathing c) Increase oxygen to three liters/minute d) Have the client breathe into a paper bag

Instruct the client in pursed lip breathing

58. A male client, newly diagnose with type 2 diabetes mellitus (DM2), awakens in the morning with a temperature of 101.6 F. He calls the clinic and reports he took his morning dose of metformin (Glucophage) after obtaining a morning fasting blood glucose of 325 mg. Which action instruction should the nurse provide to the client? a. Increase the daily dose of metformin (Glucophage). b. Watch closely for clinical manifestations of hypoglycemia c. Begin a routine sliding scale for lispro (Humalog) insulin d. Monitor blood glucose levels more frequently

Monitor blood glucose levels more frequently

66. During a return demonstration of teaching provided by the nurse, the daughter of a client administers her mother's eye drops by resting her dominant hand on her mother's forehead and dropping the medication into the conjuctival sac. What action should the nurse take in response to this demonstration? a) Advise the daughter to keep her hand farther from her mother's eye b) Remind the client to gently close her eyes after the eye drops are instilled c) Offer to demonstrate the eye drop procedure to the daughter one more time d) Instruct the mother to gently rub the affected eye to distribute the drops

Offer to demonstrate the eye drop procedure to the daughter one more time

26. It is most important for the nurse to assess which client first? a) Six hours after a pelvic fracture a client reports severe pain in the pelvic region. b) A client with deep vein thrombosis who is receiving a continuous heparin infusion. c) One day following a hip fracture, a client exhibits signs of fat embolism syndrome. d) A postoperative client scheduled to receive an IV antibiotic that has an inflamed IV site.

One day following a hip fracture, a client exhibits signs of fat embolism syndrome.

83. A mother who is HIV positive asks the nurse about her infant's positive ELISA test. What information should the nurse provide to the mother? The infant has a) Converted to HIV positive status b) Received HIV maternal antibody transmission c) Developed CMV (cytomegalovirus) d) Been infected with congenital syphilis

Received HIV maternal antibody transmission

22. An older male client who was successfully treated for Herpes zoster (shingles) with an antiviral medication reports that he is now experiencing pain on his trunk where the lesions were located. Which action should the nurse take? e) Contact the healthcare provider about the need to resume the client's antiviral medication. f) Teach the client about the importance of completing the full course of antiviral medication. g) Reassure the client that the infection is resolved and the pain should soon disappear. h) Review the medication record to determine when the last analgesic was administered.

Review the medication record to determine when the last analgesic was administered.

20. The nurse administers an oral antiviral to a client with shingles. Which finding is most important for the nurse report to the health care provider? a) Decreased white blood cell count b) Pruritus and muscle aches c) Elevated liver function tests d) Vomiting and diarrhea

Elevated liver function tests

99. The nurse is using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning and preparing the client, rank the actions in the sequence they should be implemented, (place the first action at the top with the last action at the bottom.) a) Don sterile gloves and prepare the sterile field b) Open the sterile catheter kit close to the client's perineum c) Cleanse the urinary meatus using the solution, swabs, and forceps provided d) Place distal end of the catheter in sterile specimen cup and insert catheter in meatus

Open the sterile catheter kit close to the client's perineum Don sterile gloves and prepare the sterile field Cleanse the urinary meatus using the solution, swabs, and forceps provided Place distal end of the catheter in sterile specimen cup and insert catheter in meatus

64. The charge nurse observes the practical nurse (PN) apply sterile gloves in preparation for performing a sterile dressing change. Which action by the PN requires correction by the charge nurse? http://youtu.be/g-h0ht4Y0uo http://youtu.be/idHRbgcHTfk a) Opening the package b) Picking up the second glove c) Picking up the first glove d) Positioning of the table

Opening the package

15. A client develops urticaria on the trunk and neck shortly after a secondary infusion of pipercillin (Zosyn) is initiated. In what order should the nurse implement these interventions? (Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.) a) Stop the infusion b) Assess vital signs c) Contact the healthcare provider d) Document reaction to the drug e) Initiate an adverse event report

a) Stop the infusion b) Assess vital signs c) Contact the healthcare provider d) Document reaction to the drug e) Initiate an adverse event report

118. A client with polycystic kidney disease (PKD) receiving antibiotics for an infected cyst is experiencing severe pain. What action should the nurse implement? a) Hold the next dose of antibiotic until contacting the healthcare provider b) Teach the client how to use a dry heating pad over the painful area c) Encourage the client to practice pelvic floor exercises every hour d) Assist the client to splint the site by applying an abdominal binder

Teach the client how to use a dry heating pad over the painful area

73. While admitting a female client with uncontrolled atrial fibrillation, the nurse teaches the client about the benefits and risks of taking the prescribed anticoagulant, warfarin sodium (Coumadin).What information should the nurse ensure that the client understands? (Select all that apply). a) Limit intake of foods that interact with medication b) INR levels are required after antibiotic therapy is completed c) Take an extra dose whenever palpitations are felt d) Herbal and over-the-counter medications can effect bleeding e) Report bleeding gums and increased bruising immediately

Limit intake of foods that interact with medication INR levels are required after antibiotic therapy is completed Herbal and over-the-counter medications can effect bleeding Report bleeding gums and increased bruising immediately

104. An older female client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sounds. She has a history of smoking 2 packs of cigarettes/daily for 50 years and is currently restless and confused. Vital signs are: Temperature 96 F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure (MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dL, platelets 60,000, and white blood cell count (WBC) 3,000/mm3. Based on these findings, this client is at greatest risk for which pathophysiological condition? a) Acquired immunodeficiency syndrome (AIDS) b) Multiple organ dysfunction syndrome (MODS) c) Chronic obstructive pulmonary disease (COPD) d) Disseminated intravascular coagulation (DIC)

Multiple organ dysfunction syndrome (MODS)

131. In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, The nurse assesses that the client in lethargic with a blood pressure of 90/60, pulse rate of 118 beats per minute, and respiratory rate of 8 breaths per minutes. What assessment should the nurse perform next? a) Note the appearance and patency of the client's peripheral IV site. b) Palpate the volume of the client's right radial pulse c) Auscultate the client's breath sounds bilaterally. d) Observe the amount and dose of morphine in the PCA pump syringe.

Observe the amount and dose of morphine in the PCA pump syringe.

135. The NURSE assesses a male client following surgery for a gunshot to the abdomen and determines that his dressing is saturated with blood and petechiae are on his extremities. His current BP is 80/40, and his heart rate is 130 beats/minute. Which lab finding confirms the presence of DIC? a) Low PT. b) Elevated fibrinogen. c) Positive d-Dimer. d) Normal hemoglobin.

Positive d-Dimer. Positive d dimer (also think PT PTT and decreased fibrinogen)

129. A male client is receiving ferrous sulfate, docusate sodium (Colace) and morphine sulfate. He reports that his last bowel movement was three days ago. In using the SBAR format to communicate with the healthcare provider, what recommendation should the nurse make? a) Discontinue the prescription for morphine sulfate b) An increase in the dosage of the ferrous sulfate. c) The addition of a laxative to the current regimen. d) Replace the docusate sodium with a laxative.

The addition of a laxative to the current regimen.