EXIT HESI Set 2

A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? 3. Stop the infusion 5. Assess vital signs 1. Contact the healthcare provider 4. Document reaction to the drug 2. Initiate an adverse event report

1. Stop the infusion 2. Assess vital signs 3. Contact the healthcare provider 4. Document reaction to the drug 5. Initiate an adverse event report

A client is receiving a nitroglycerin infusion at 20 mcg/min. The pharmacy dispenses an IV solution of nitroglycerin 75 mg in 250 D5W. The nurse should program the infusion pump to deliver how many mL/hr?

4 mL/hr

The nurse is teaching a primigravida about preeclampsia. Which findings are indicators of preeclampsia and should be reported to the healthcare provider? A. Blurred vision B. Headache C. Lack of appetite D. Urinary frequency E. Chills and fever F. Swollen hands

A. Blurred vision B. Headache F. Swollen hands

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? A. Bring a heavy can close to body before lifting B. Locks knees while preparing food on the counter C. Widens stance while working near the sink D. Bends from the waist to pick trash off the floor E. Leans forward to pull a pan from a high shelf

A. Brings a heavy can close to body before lifting C. Widens stance while working near the sink

The nurse includes assessment for fat embolism syndrome (FES) in the plan of care for a client with a fractured femur. Which findings should the nurse include that are often the earliest indication of a FES? A. Confusion, restlessness B. Petechial rash C. Tachycardia, fever D. Pulmonary crackles

A. Confusion, restlessness

An adult woman who was recently diagnosed with type 2 DM is seen in the clinic for laboratory tests. The client's height is 5 feet 2 inches and weight is 165 pounds. Her recent laboratory findings are described above. In planning nutrition teaching for this client, what diet modifications should the nurse recommend? (Select all that apply). Labs: Creatinine 1.0 mg/dL BUN 16 mg/dl Diagnostics: Total cholesterol 250 mg/dl LDL 175 mg/dl HDL 35 mg/dl Triglyceride 250 mg/dl Flowsheets: Glucose 150 mg/dl A1c 9% A. Decrease processed carbohydrate in diet B. Eliminate alcohol intake except for special occasions. C. Increase sugar intake D. Increase dietary fiber such as whole grains

A. Decrease processed carbohydrate in diet B. Eliminate alcohol intake except for special occasions D. Increase dietary fiber such as whole grains

The nurse is preparing to send a client to the cardiac catheterization lab for elective cardioversion. Which intervention should the nurse implement before the client leaves the medical unit? A. Document that the client has remained NPO B. Confirm monitor reading in synchronous mode C. Notify the rapid response team of the transfer D. Secure cardioversion pads on the client's chest

A. Document that the client has remained NPO

Which instruction should the nurse provide a pregnant client who is reporting heartburn? A. Eat small meals throughout the day to avoid a full stomach. B. Take an antacid at bedtime and whenever symptoms worsen. C. Maintain a sitting position for two hours after eating. D. Limit fluids between meals to avoid overdistension of the stomach.

A. Eat small meals throughout the day to avoid a full stomach.

The nurse is caring for a client who is having a sickle cell crisis. What intervention should the nurse include in this client's plan of care? A. Ensure adequate IV and oral fluid intake B. Provide ice packs to major joint areas C. Space analgesics to prevent addiction to narcotics D. Re-enforce the importance of nutritional balance

A. Ensure adequate IV and oral fluid intake

Which type of leukocyte is involved with allergic responses and the destruction of parasitic worms? A. Eosinophils B. Neutrophils C. Lymphocytes D. Monocytes

A. Eosinophils

A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A. Explain that counseling will be provided to give her information about her cancer risk B. Offer assurance that there are a variety of effective treatments for breast cancer C. Gather additional information about the client's family history for all types of cancer D. Provide information about survival rates for women who have this g

A. Explain that counseling will be provided to give her information about her cancer risk

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first? A. Explore client's readiness to discuss the situation B. Discuss treatment options for abusive partners C. Report the finding to the police department D. Determine the frequency and type of client's abuse

A. Explore client's readiness to discuss the situation

When conducting diet teaching for a client who was diagnosed with hypertension, which foods should the nurse encourage the client to eat? A. Fruits without sauce B. Canned soup C. Fresh or frozen vegetables without sauce D. Cottage cheese E. Pickled olives

A. Fruits without sauce C. Fresh or frozen vegetables without sauce D. Cottage cheese

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? A. Gently close the eyes B. Remove resuscitation equipment from the room C. Take out dentures and place in a labeled cup D. Apply a body shroud E. Place a small pillow under the head

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

Which woman should the nurse consider at the highest risk for cervical cancer? A. History of unprotected sex with multiple partners B. Postmenopausal for 5 years with intermittent vaginal spotting C. Taking birth control pills after 40 years of age D. Multiparous delivery of infants more than 9 pounds

A. History of unprotected sex with multiple partners

A young woman with multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide? A. Immunizations can trigger a relapse of the disease, so get plenty of extra rest. B. These early signs of an infection may require medical treatment with antibiotics C. These are common side effects of the vaccines and will

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

The nurse is caring for a client admitted for evaluation of a descending aortic aneurysm. While outside the room documenting, the nurse hears the client screaming. The client tells the nurse that the pain is "sharp, like something inside is ripping and tearing." The client also reports dizziness. Which of the following is the likely cause? A. Impending rupture of the aneurysm B. The client is having a panic attack C. Clotting of the aneurysm D. The client is hallucinating from the opioids

A. Impending rupture of the aneurysm

What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump? A. Initiate the dosage lockout mechanism on the PCA pump B. Assess the client's ability to use a numeric pain scale C. Assess the abdomen for bowel sounds D. Instruct the client to use the medication before the pain becomes severe

A. Initiate the dosage lockout mechanism on the PCA pump

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendations should the nurse provide this client? A. Inspect skin for redness B. Avoid range of motion exercises C. Apply alcohol to the stump after bathing D. Use a residual limb shrinker E. Wash the stump with soap and water

A. Inspect skin for redness D. Use a residual limb shrinker E. Wash the stump with soap and water

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? A. Keep the nails trimmed short B. Apply baby lotion to the skin twice daily C. Bathe the child with bath oil D. Allow the child to wear only 100% cotton clothing

A. Keep the nails trimmed short

Which intervention is most important for the nurse to include in the plan of care for a client who is being mechanically ventilated and is receiving continuous enteral feedings? A. Maintain the head of the bed elevated at 45 degrees B. Check the feeding tube placement q8hours C. Assess the gastric residual volume q4hours D. Obtain a chest x-ray PRN for adventitious lung sounds

A. Maintain the head of the bed elevated at 45 degrees

The nurse identifies an electrolyte imbalance, crackles on auscultation and an elevated blood pressure in a client with progressive heart disease. Which intervention should the nurse include in the plan of care? A. Measure ankle circumference B. Record usual eating patterns C. Evaluate for muscle cramping D. Document abdominal girth

A. Measure ankle circumference

The charge nurse in an extended care facility in organizing unit activities for the day. Which action may be safely delegated to the practical nurse (PN)? A. Measure the client's body weight each morning B. Establish blood pressure parameters for client monitoring C. Evaluate a staff member providing wound care D. Evaluate client teaching through return demonstration

A. Measure the client's body weight each morning

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement? A. Move the client to a quiet place on the unti B. Encourage the client to use the punching bag C. Use firmness and direct the client to sit for awhile D. Suggest to the client that he take a walk

A. Move the client to a quiet place on the unit

A client with a history of schizophrenia is admitted with diabetic ketoacidosis (DKA). Which nursing interventions should the nurse implement during the admission process for this client? A. Obtain psychiatric and medical admission records B. Hold psychotropic medications until glucose is regulated C. Interview client about reason for admission to hospital D. Prepare the client for involuntary commitment admission E. Review the list of home medications and dosages

A. Obtain psychiatric and medical admissions records C. Interview client about reason for admission to hospital E. Review the list of home medications and dosages

The nurse is preparing to gavage feed a premature infant through an orogastric tube. During insertion of the tube, the infant's heart rate drops to 60 beats/minute. Which action should the nurse take? A. Postpone the feeding until the infant's vital signs are stable B. Continue the insertion since this is a typical response C. Insert the feeding tube into the infant's nasal passage D. Pause and monitor for a continued drop of the heart rate

A. Postpone the feeding until the infant's vital signs are stable

A female child is brought to the emergency department after awakening with a bark-like cough and stridor. upon arrival to the hospital, her respirations are labored, and she is drooling. What action should the nurse implement? A. Prepare for emergency tracheotomy B. Assess the child for dehydration C. Examine oropharyngeal area for foreign body D. Collect midstream urine specimen

A. Prepare for emergency tracheotomy

The laboratory findings for a client with chronic kidney disease (CKD) include elevated blood urea nitrogen (BUN) and serum creatinine levels. The client reports feeling fatigued and is unable to concentrate during the morning assessments. Based on these findings, which action should the nurse implement? A. Provide high protein snacks B. Administer PRN oxygen C. Schedule frequent rest periods D. Monitor glucose levels q4 hours.

A. Provide high protein snacks

An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours. He found wandering into another client's room and is returned to his room by the unlicensed assistive personnel (UAP). Which actions should the nurse take? (Select all that apply). A. Review the client's most recent serum electrolyte values B. Assign the UAP to re-assess the client's risk for falls C. Report mental status changes to the healthcare provider D. Apply soft upper limb restraints. E. Assess the client's breath sounds and oxygen saturation

A. Review the client's most recent serum electrolyte values C. Report mental status change to the healthcare provider E. Assess the client's breath sounds and oxygen saturation

An older male client 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? A. Review the medication record to determine when the last analgesic was administered B. Reassure the client that the infection is resolved and the pain should soon disappear C. Teach the client about the importance of completing the full course of antiviral medication D.

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

A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care? A. Determine if the client is over-hydrating to feel satiated B. Maintain the client on an NPO status C. Encourage positive self accolades for dietary adherence D. Administer daily vitamin supplements

B. Maintain the client on an NPO status

A client with metabolic syndrome plans to begin an exercise program. Which instruction is most important for the nurse to provide this client? A. Wear long sleeves and a hat when exercising outdoors in direct sunlight B. Monitor blood pressure and heart rate as exercise activity is increased C. Weight bearing exercises are most effective in improving bone strength D. Use hand-held weights to strengthen muscles and build muscle mass

B. Monitor blood pressure and heart rate as exercise activity is increased

During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? A. Canned fruit in heavy syrup B. Natural whole almonds C. Plain, air-popped popcorn D. Lightly salted potato chips E. Cheddar cheese cubes

B. Natural whole almonds C. Plain, air-popped popcorn

After the risks and benefits of having a cardiac catheterization are reviewed by the healthcare provider, an older adult with unstable angina is scheduled for the procedure. When the nurse presents the consent form for signature, the client asks how the wires will keep a heart beating during the procedure. What action should the nurse take? A. Postpone the procedure until the client understands the risks and benefits B. Notify the healthcare provider of the client's lack of understanding C. Expl

B. Notify the healthcare provider of the client's lack of understanding

A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. While providing care the nurse finds the radiation implant in the bed. What action should the nurse take? A. Apply double gloves to retrieve the implant for disposal B. Place the implant in a lead container using long-handled forceps C. Reinsert the implant into the vagina D. Call the radiology department

B. Place the implant in a lead container using long-handled forceps

The nurse is providing care for a child who is brought to the emergency department a few days after a laceration to the leg from a barbed wire fence. The child has not received any tetanus immunizations and is manifesting early signs of muscular rigidity with spasms and jaw clenching or trismus. Which intervention should be the nurse's highest priority for this child? A. Suction oropharyngeal secretions B. Prepare for intubation with mechanical ventilation C. Minimize stimulation from sound, li

B. Prepare for intubation with mechanical ventilation

An older client is admitted to the hospital because of recurring transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first? A. Document neurologic changes B. Reduce environmental stimuli C. Administer prescribed neuroleptic D. Review medications for interactions

B. Reduce environmental stimuli

A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication? A. Monitor your blood pressure regularly B. Report unusual bruising or bleeding C. Elevate your feet if swelling occurs D. Check your pulse rate every day

B. Report unusual bruising or bleeding

The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse? A. Urine culture positive for MRSA B. Serum creatinine of 4.5 mg/dL C. Serum sodium of 145 mEq/L D. White blood cell count of 12,000mm3

B. Serum creatinine of 4.5mg/dL

A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? A. Bring a bedside commode to the client B. Stand on the client's right side as he walks C. Walk directly behind the client to prevent a fall D. Give the client a cane to hold in his right hand

B. Stand on the client's right side as he walks

The nurse is teaching a client newly diagnosed with systemic lupus erythematosus (SLE). Which information is accurate for the nurse to provide? A. The client can expect to progressively lose function in a fairly predictable sequence B. The disease is characterized by alternating periods of flare-ups and remissions C. Once an acute attack subsides, the client can expect to feel fine again D. Systemic lupus erythematosus (SLE) is a chronic, incurable, terminal illness

B. The disease is characterized by alternating periods of flare-ups and remissions

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide? A. "Does your child seem mentally slower than his peers also?" B. "Haven't you been feeding him according to recommended daily allowances for children?" C. "His smaller size is probably due to the heart disease."

C. "His smaller size is probably due to the heart disease"

A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? A. A bedside commode is positioned near the bed B. A saline lock is present in the right forearm C. A full pitcher of water is on the bedside table D. A low sodium diet tray was brought to the room E. The client is lying in a supine position in bed

C. A full pitcher of water is on the bedside table E. The client is lying in a supine position in bed

The nurse is assessing a client's breath sounds. Which medication from the client's prescriptions will have the most positive effect on this respiratory finding? Sound: wheezing A. Chloroquine B. Enalapril C. Albuterol D. Losartan

C. Albuterol

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the priority nursing problem for this client? A. Pain (acute) B. Knowledge deficit C. Anxiety D. Anticipatory grieving

C. Anxiety

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill". What question should the nurse ask the client next? A. When did these voices begin? B. Have you taken any hallucinogens? C. Are you planning to obey the voices? D. Do you believe the voices are real?

C. Are you planning to obey the voices?

The nurse is caring for a client who is admitted to the emergency center after a motor vehicle collision. The client begins to experience a decreased level of consciousness and the pupils do not respond equally to light. Which vital signs changes indicate the client is manifesting Cushing's triad? A. Blood pressure of 80/40 mmHg, weak heart rate of 40 beats/minute, Cheyne-Stokes respirations of 10 breaths/minute B. Blood pressure 180/120 mmHg, weak heart rate of 92 beats/minute, Kussmaul respirations, respiratory rate of 18. C. Blood pressure of 180/80 mmHg, bounding heart rate of 50 beats/minute, respirations of 30 breaths/minute with apneic episodes D. blood pressure of 120/80 mmHg, heart rate 102, respiratory rate 26

C. Blood pressure of 180/80 mmHg, bounding heart rate of 50 beats/minute, respirations of 30 breaths/minute with apneic episodes

A 62-year-old male client tells the nurse that he has a high-density lipoprotein (HDL) level of 85 mg/dl. Which action should the nurse take? A. Encourage the client to reduce consumption of fatty foods B. Ask the client about hereditary cardiac risk factors C. Confirm that this value is helpful in reducing cardiac risk D. Explain that the client may need medication therapy

C. Confirm that this value is helping in reducing cardiac risk

The parents of a 6 year old child 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. Explain that their child is too young to understand the risks associated with swimming C. Encourage the parents to allow the child to continue attending swimming lessons with supervision D. Suggest

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

The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take? A. Instruct the PN that this technique promotes infection in elderly females B. Recommend a complete bath to cleanse the perineal area more fully C. Evaluate the effectiveness of this measure to stimulate client voiding D. Suggest contacting the healthcare provider for a prescri

C. Evaluate the effectiveness of this measure to stimulate client voiding

The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure? A. Drank a glass of water in the past 2 hours B. Verbalizes a fear of being in a confined space C. Experiences facial swelling after eating crab D. Reports left chest wall pain prior to admission

C. Experiences facial swelling after eating crab

While providing a health history, a female client tells the clinic nurse that she frequently thinks about hurting herself. Which question is most important for the nurse to ask? A. Do you often have feelings of sadness? B. Are you having problems concentrating? C. Have you thought about taking your life? D. What problems are you facing right now?

C. Have you thought about taking your life?

The nurse is assisting the healthcare provider with a wound debridement at the bedside of a client who is mildly confused. The client is draped and a sterile field is created. Which nursing intervention should the nurse implement for client safety? A. Assess for discomfort when procedure is completed B. Verify that the client has given informed consent C. Instruct the client to keep hands under the sterile field D. Pour cleansing solution onto the sterile cloth field

C. Instruct the client to keep hands under the sterile field

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement? A. Tell the client to stop the inappropriate behavior B. Complete an unusual occurrence report C. Leave the room and close the door quietly D. Ignore the behavior and hang the IV antibiotic

C. Leave the room and close the door quietly

A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? A. Initiate seizure precautions B. Assess neurological status every 8 hours C. Limit oral water intake D. Administer a hypertonic IV fluids as prescribed

C. Limit oral water intake

The nurse is assessing a first day postpartum client. Which finding is most indicative of a postpartum infection? A. Blood pressure of 122/74 mmHg B. White blood count of 19,000mm3 C. Moderate amount of foul-smelling lochia D. Oral temperature of 100.2F

C. Moderate amount of foul-smelling lochia

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values? A. Platelet count B. Serum sodium level C. Neutrophil count D. Hematocrit

C. Neutrophil count

One day after abdominal surgery, a client with obesity reports pain and heaviness in the right calf. Which action should the nurse implement? A. Encourage ambulation in the room B. Palpate the femoral pulse C. Observe for unilateral swelling D. Apply a warm compress to the area

C. Observe for unilateral swelling

The nurse enters a client's room and observes the unlicensed assistive personnel (UAP) making an occupied bed as seen in the picture. Which action should the nurse take first? A. Instruct the UAP to raise the bed level B. Provide gloves for the UAP to apply C. Offer to help reposition the client D. Place the side rails in an up position

C. Offer to help reposition the client

While changing a client's postoperative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take? A. Start progressive mobilization B. Request a nutrition consult C. Request a wound culture and sensitivity D. Force oral fluids

C. Request a wound culture and sensitivity

Following a total knee replacement, a client is discharged from the hospital with a prescription for warfarin. In reviewing discharge teaching, the client tells the nurse that he will avoid eating foods high in potassium, such as bananas and melon. How should the nurse respond? A. Discuss necessary fluid restrictions as well as food restrictions B. Explain that no dietary restrictions are needed with warfarin C. Review teaching about the effects of foods rich in Vitamin K D. Provide a written li

C. Review teaching about the effects of foods rich in Vitamin K

Following a house fire, an adult male is admitted to the emergency department with partial and full thickness burns. He used a blanket to cover his head and face, but his skin is burned on the dorsal surfaces of both arms and hands, and his anterior legs. Using the Rule of Nines to assess the extent of the client's burns, what percentage of burned body surface area should the nurse document? A. 50% B. 27% C. 9% D. 36%

B. 27%

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement? A. Assist the client to lie back in bed B. Administer a nebulizer treatment C. Call for an Ambu resuscitation bag D. Increase oxygen t

B. Administer a nebulizer treatment

The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic hepatitis B immunizations? A. A child daycare worker who has a history of type 2 diabetes mellitus B. An office worker who requires hemodialysis for chronic kidney disease (CKD) C. A restaurant chef who was diagnosed one year ago with hepatitis A D. A sales person who travels internationally and eats food in foreign countries.

B. An office worker who requires hemodialysis for chronic kidney disease (CKD)

A male client suffering from depression has been taking an antidepressant medication for two days. He tells the nurse that he is smiling more and feeling better. Which response is best for the nurse to provide? A. Feeling hopeful is a good sign that your depression is improving. B. Antidepressants usually begin to improve your mood after 2 to 4 weeks. C. Antidepressants can cause mild mood swings within several days D. Antidepressants can stabilize your mood within several days.

B. Antidepressants usually begin to improve your mood after 2 to 4 weeks.

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents? A. Diapering will be provided since hospitalization is stressful to preschoolers B. Children usually resume their toileting behaviors when they leave the hospital C. A potty chair should be brought from home so he can maintain hi

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

During a clinic visit, a client with a kidney transplant asks, "What will happen if chronic rejection develops?" Which response is best for the nurse to provide? A. A different combination of immunosuppressant medications will be implemented B. Dialysis would need to be resumed if chronic rejection becomes a reality C. Dialysis may be necessary until the chronic rejection can be reversed D. The immunosuppressant medication will be increased until the rejection subsides

B. Dialysis would need to be resumed if chronic rejection becomes a reality

A new nurse is preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement? A. Suggest the nurse use a 20-gauge needle B. Direct the nurse to change the IV tubing C. Instruct the nurse to remove the needle D. Prompt the nurse to apply povidone to the site

B. Direct the nurse to change the IV tubing

An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. the nurse notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the nurse to implement? A. Ask family members to remain with the client in the evenings from 1700 to 2100pm B. Ensure that the client is assigned to the room close to the nurses' station C. Postpone administration of nighttime medications until after 2300pm D. Adm

B. Ensure that the client is assigned to a room close to the nurses' station

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include? A. Swaddle the infant in a blanket for sleeping B. Ensure that the infant's crib mattress is firm C. Place the infant in a prone position whenever possible D. Prop the infant with a pillow when in a side-lying position

B. Ensure that the infant's crib mattress is firm

When developing a teaching plan for a client with newly diagnosed type 1 diabetes, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs? A. Resume normal physical activity B. Give a dose of regular insulin as prescribed C. Measure urine output over the next 24 hours D. Drink electrolyte fluid replacements

B. Give a dose of regular insulin as prescribed

The practical nurse (PN) reports that a client who has a fingerstick glucose of 35 mg/dL is alert and diaphoretic. What action should the charge nurse take? A. Assess client for polyuria and polyphagia B. Give the client a glass of orange juice C. Notify the healthcare provider D. Collect a blood sample for hemoglobin A1c

B. Give the client a glass of orange juice

A client is receiving IV heparin and oral warfarin after a pulmonary embolism (PE). The nurse determines the client's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as teh control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement? A. Withhold the heparin and continue the same dose of warfarin B. Increase the warfarin dose C. Decrease the heparin dose D. Incr

B. Increase the warfarin dose

The nurse is assessing a 3-month-old infant who had a pylorotomy yesterday. This child should be medicated for pain based on which findings? A. Peripheral pallor of the skin B. Increased pulse rate C. Clenched fists D. Restlessness E. Increased temperature F. Increased respiratory rate

B. Increased pulse rate C. Clenched fists D. Restlessness F. Increased respiratory rate

The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? A. Administer PRN oral analgesics to a client with a history of chronic pain B. Transport a client who is receiving IV fluids to the radiology department C. Supervise a newly hired graduate nurse during an admission assessment D. Complete ongoing focused assessments of a client with wrist restraints

C. Supervise a newly hired graduate nurse during an admission assessment

During shift report, the charge nurse receives notice of several problems. Which problem should the nurse address first? A. The census report has not been completed B. A client's wife has asked to speak with the charge nurse C. One staff member has not reported to work D. A bucket of water was spilled in the hallway

D. A bucket of water was spilled in the hallway

A nurse working on an Endocrine Unit should see which client first? A. An older client with Addison's disease whose current blood sugar level is 62 mg/dL B. An adult with a blood sugar of 284 mg/dL and a urine output of 350 mL in the last hour C. An adolescent male with type 1 diabetes who is arguing about his insulin dose D. A client taking corticosteroids who has become disoriented in the last two hours

D. A client taking corticosteroids who has become disoriented in the last two hours

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask and requiring staff to observe airborne, as well as standard precautions? A. A female adolescent admitted with multiple genital herpes simplex II lesions B. An older client with scabies who is admitted from an extended care facility C. Twin siblings admitted with scarlet fever that is complicated with pneumonia D. A client with a positive Mantoux and sputum cultures results positive for AFB

D. A client with a positive Mantoux and sputum cultures results positive for AFB

A client with bacterial meningitis is receiving phenytoin. 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

D. Absence of seizure activity for the duration of the treatment

The nurse is caring for client who has COPD and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a client with COPD? A. Monitoring telemetry and cardiac rhythm B. Assisting client to cough and deep breath C. Increasing the client's fluid intake D. Administering narcotics for pain relief

D. Administering narcotics for pain relief

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. What action should the nurse implement first? A. Provide a printed health care assessment form B. Ask the family member to answer the questions C. Defer the health history until the client is less anxious D. Assess the surroundings for noise and distractions

D. Assess the surroundings for noise and distractions

An adult client is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes two hours or longer to complete. The client worries about staying clean and refuses to sit on any of the chairs in the day area. This client's handwashing is an example of which clinical behavior? A. Phobia B. Addiction C. Obsession D. Compulsion

D. Compulsion

Which conditions are most likely to respond to treatment with antihistamines? A. Bronchitis B. Myocarditis C. Otitis media D. Contact dermatitis E. Allergic rhinitis

D. Contact dermatitis E. Allergic rhinitis

In monitoring tissue perfusion in a client following an above the knee amputation (AKA), which action should the nurse include in the plan of care? A. Assess skin elasticity of the stump B. Observe for swelling around the stump C. Note amount and color of wound drainage D. Evaluate closest proximal pulse

D. Evaluate closest proximal pulse

A clinical trial is recommended for a female client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. the client's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond? A. Explain to the family that they must accept their mother's decision B. Discuss success of clinical trials and ask the client to consider participating for one month C. Ask the

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

A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin? A. Regular contractions occurring every 10 minutes B. Sterile vaginal exam revealing 3cm dilation C. Biophysical profile results showing oligohydramnios D. Fetal heart tones located in upper right quadrants

D. Fetal heart tones located in upper right quadrants

A client with a C-6 spinal cord injury is in rehabilitation. In the middle of the night the client reports a severe, pounding headache, and has observable piloerection or "goose bumps". The nurse should assess for which trigger? A. Loud hallway noise B. Frequent cough C. Fever D. Full bladder

D. Full bladder

After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the X-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement? A. Notify the healthcare provider of the need to reposition the catheter B. Remove the catheter and apply direct pressure for 5 minutes C. Secure the catheter using aseptic techniques D. Initiate intravenous fluids as prescribed

D. Initiate intravenous fluids as prescribed

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge? A. Signs of addiction to opioid pain medication B. Information about non-pharmaceutical pain relief measures C. Referral for social services for the child and family D. Instructions about how much fluid the child should drink

D. Instructions about how much fluid the child should drink

A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first? A. Determine if the newborn is in the nursery B. Activate the lockdown procedure C. Ask the mother if any visitors were expected to arrive D. Match ID bands of all infants and mothers on the unit

D. Match ID bands of all infants and mothers on the unit

An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal? A. Bring the client to the team meeting to discuss the treatment plan B. Explain the purpose of each medication the client is currently taking C. Ask the client to wr. D. Play a board game with the client and begin talking about stressors.

D. Play a board game with the client and begin talking about stressors

The nurse should be most concerned about risk for injury (falls) after administering which medication? A. Pantoprazole B. Famotidine C. Clarithromycin D. Promethazine

D. Promethazine

An older adult client with chronic emphysema is admitted to the emergency room from home with acute onset of weakness, palpitations, and vomiting. Which information is most important for the nurse to obtain during the initial interview? A. History of smoking over the past 6 months B. Sleep patterns during the previous few weeks C. Activity level prior to onset of symptoms D. Recent compliance with prescribed medications

D. Recent compliance with prescribed medications

The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement? A. Assess the client's oral cavity for ulcerations B. Monitor the client when using a straw for liquids C. Teach coughing and deep breathing exercises D. Request thick nectar liquids for the client

D. Request thick nectar liquids for the client

The nurse is assigned to care for a client diagnosed with psoriasis. Which behavior by the nurse addresses this client's psychosocial need for acceptance? A. Encouraging the client to join a support group B. Wearing gloves when interviewing the client C. Allowing the client to ventilate feelings D. Shaking the client's hand during an introduction

D. Shaking the client's hand during an introduction

The nurse is developing a plan of care for a client who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client? A. The client will express acceptance of their newly diagnosed health status. B. The nurse will encourage the client to walk thirty minutes every day C. The client's blood pressure readings will be less than 160/90 mmHg D. The client's skin on the lower legs will be intact at t

D. The client's skin on the lower legs will be intact at the next clinic visit

After removing a client's dressing that is saturated with sanguineous drainage, where should the nurse place the dressing?

red bin

An adolescent receives a prescription for an injection of S-matriptan succinate 4mg subcutaneously for a migraine headache. Using a vial labeled, 6mg/0.5mL, how many mL should the nurse administer?

0.33 mL

A school-aged child who weighs 42 pounds receives a post-tonsillectomy prescription for promethazine 0.5 mg/kg IM to prevent postoperative nausea. The medication is available in 25 mg/mL ampules. How many mL should the nurse administer?

0.4 mL

The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order?

1. Obtain blood glucose level 2. Verify the insulin prescription 3. Draw insulin into insulin syringe 4. Clean the selected site

Which snack selection indicates to the nurse that a school-age boy with gastroesophageal reflux understands his dietary restrictions? A. Sugar cookies B. Pizza C. Chocolate milkshake D. Tacos

A. Sugar cookies

The nurse assesses a child in 90-90 skeletal traction. Where should the nurse assess for signs of compartment syndrome?

Click spot right on toes on injured foot