Hesi Foundations

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake

B. Broiled fish, green beans, and an apple

The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think my 4-month-old baby is choking!" What steps will the nurse take? (Select all that apply.) A. Compress the chest once between the nipples with two fingers. B. Note any obstruction or absence of breathing. C. Deliver five back slaps between the shoulder blades. D. Place the infant over the nurse's arm. E. Perform a blind finger sweep.

B. Note any obstruction or absence of breathing. C. Deliver five back slaps between the shoulder blades. D. Place the infant over the nurse's arm.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity

B. Right cephalic vein

After a needlestick occurs while removing the cap from a sterile needle, which action should the nurse take next? A. Complete an incident report. B. Select another sterile needle. C. Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately.

B. Select another sterile needle.

The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months

B. Taking anticoagulants for the past year

A client with frequent urinary tract infections (UTIs) asks the nurse to explain a friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A. "Orange juice has vitamin C that deters bacterial growth." B. "Apple juice is the most useful in acidifying the urine." C. "Cranberry juice stops pathogens' adherence to the bladder." D. "Grapefruit juice increases absorption of most antibiotics."

C. "Cranberry juice stops pathogens' adherence to the bladder."

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You"

C. "Decreasing Cholesterol Levels Through Diet"

One week after being told that she has terminal cancer with a life expectancy of 3 weeks, the client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family."

C. "Planning a party and thinking about all your friends sounds like fun

After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A. Ask the client to remain quiet so the procedure can be performed safely. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure.

C. Calmly reassure the client that the discomfort will be temporary.

The nurse worked with a client to alleviate pain with aroma and relaxation therapy. Twenty minutes after working with the client, the nurse returns to the room and finds the client's eyes are closed and breathing deeply. What is the best entry for the nurse to document this finding? A. Client sleeping B. Pain medication working C. Eyes closed, deeply breathing D. Effective use of alternative therapy

C. Eyes closed, deeply breathing

The nurse comes upon an automobile accident involving many cars. Which victim should the nurse see first? A. The victim who is not breathing and does not have a pulse B. The victim who is bleeding out of both the ears, and the nose and mouth, with a blank stare C. The victim who is heavily bleeding bright red blood from a thigh wound D. The victim who is crying, complaining of arm pain, and no other apparent injuries

C. The victim who is heavily bleeding bright red blood from a thigh wound

At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at 1845. The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at 1915 and notes there is less than 50 mL left in the IV bag. What is the nurse's next action? A. Contact the healthcare provider on call. B. Call in the off going nurse and request an explanation. C. Tell the client that 950 mL of fluid just accidentally infused. D. Auscultate the client's lungs.

D. Auscultate the client's lungs.

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings.

D. Compare the current reading with the client's previously documented blood pressure readings.

Which action is most important for the nurse to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway.

D. Encourage frequent ambulation in the hallway.

The health care provider diagnoses metastatic cancer and recommends a gastrostomy for an elderly client in stable condition. The client's adult child is concerned and states to the nurse, "I don't think my parent 'can handle' the cancer diagnosis." What information will guide the nurse's response? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the adult child has the right to waive informed consent for the parent. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.

The nurse is making an initial daily assessment at 0715 and notes 550 mL of LR running at 75 mL an hour. At what time, in military time, will the nurse hang the next bag of IV fluid? _____

1435 Rationale: 60 min × 0.33333 = 19.99 min = 20 min 7 hr 20 min + 0715 = 1435

How many mL will the nurse document on the client's intake and output record from the items listed? _____ mL1200 mL water 4 ounce container of gelatin 8 ounces of orange juice 355 mL can of soda 1 cup of soup

2155 mL

The postoperative client states to the nurse, "When I had surgery last year I got constipated. It was miserable. What can I do to avoid constipation after this surgery this time?" (Select all that apply.) A. "Drink approximately 3000 mL of non-caffeinated fluid per day." B. "I will make sure that you get out of bed an walk for 10 minutes, six times per day." C. "I will administer your pain medication even if you do not have any pain." D. "I will ask your healthcare provider for a prescription of docusate." E. "When you are on a regular diet, make sure you order plenty of fruits and vegetables." F. "When you are resting in bed, make sure you are flat on your back."

A. "Drink approximately 3000 mL of non-caffeinated fluid per day." B. "I will make sure that you get out of bed an walk for 10 minutes, six times per day." D. "I will ask your healthcare provider for a prescription of docusate." E. "When you are on a regular diet, make sure you order plenty of fruits and vegetables."

The client reports to the clinic nurse, "I sleep for about 2 hours and then I have to get up to use the bathroom. I repeat that pattern about three to four times per night." What questions will the nurse include in this client's assessment? (Select all that apply.) A. "How much fluid do you drink after 8:00 in the evening?" B. "Does your spouse wake up with you, and use the bathroom after you?" C. "What time of day do you take your water pill?" D. "Do you drink any alcoholic beverages in the evening?" E. "When did this pattern of urination start?" F. "Do you have any itching or burning when you urinate?"

A. "How much fluid do you drink after 8:00 in the evening?" C. "What time of day do you take your water pill?" D. "Do you drink any alcoholic beverages in the evening?" E. "When did this pattern of urination start?" F. "Do you have any itching or burning when you urinate?"

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult."

A. "How will this affect your present sexual activity?"

The nurse is at a teen event. Which teen's statement would cause the nurse to input some safety tips? (Select all that apply.) A. "My boyfriend and I fool around on occasion, but he never comes when he is inside me." B. "I hang around with my friends after the games, like football and baseball." C. "I work until 10:00 pm at a local fast-food restaurant." D. "I never use my seatbelt while I am driving. I hate the way it feels." E. "We often go and play beach volleyball when it is nice out."

A. "My boyfriend and I fool around on occasion, but he never comes when he is inside me." D. "I never use my seatbelt while I am driving. I hate the way it feels."

The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and 8:00 pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan on drawing the test? A. 7:00 am B. 9:00 am C. 12:00 noon D. 2:00 pm

A. 7:00 am

The nurse is preparing to administer 0.32 mL of medication subcutaneously. What supplies will the nurse need to deliver the medication? (Select all that apply.) A. A 1 mL syringe B. A 3 mL syringe C. Alcohol prep pads D. Sterile gloves E. A 24-gauge ¾″ needle F. A 20-gauge 1″ needle

A. A 1 mL syringe C. Alcohol prep pads E. A 24-gauge ¾″ needle

The nurse is orienting a new graduate to the reporting regulations often seen in the emergency department. Which clients will the nurse need to report to the nurse manager/supervisor to alert the proper authorities? (Select all that apply.) A. A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the back in various stages of healing. B. An 88-year-old who states, "My child lives 5 minutes away no longer stops to visit. My days are long and lonely." C. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was shot in the shoulder." D. An 18-year-old who states, "Once I turned 18 my parents demanded I leave their home. I was no longer welcomed there." E. A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked that family. It is just that way."

A. A 7-year-old who states, "I get beat up by my parents all the time." The child has bruising on the back in various stages of healing. C. A 40-year-old who states, "I was in an argument with my sibling and the next thing I knew I was shot in the shoulder." E. A 30-year-old who states, "The brawl was worth the stab wound I got. My family has never liked that family. It is just that way."

The nurse is preparing an IV solution containing 10 mEq of potassium in 100 mL of normal saline. Which findings would concern the nurse? (Select all that apply.) A. A red and swollen peripheral IV site B. An order to infuse the solution at 50 mL/hr C. Starting the infusion without an infusion device D. Inverting the potassium solution every 30 minutes while infusing E. The solution is a lemon-yellow color

A. A red and swollen peripheral IV site C. Starting the infusion without an infusion device E. The solution is a lemon-yellow color

The postoperative client is placed on a clear liquid diet. Which selections will the nurse select for the client? (Select all that apply.) A. Apple juice B. Popsicles C. Vanilla pudding D. Tomato soup E. Gelatin F. Black coffee

A. Apple juice B. Popsicles E. Gelatin F. Black coffee

A client is laughing at a television program when the evening nurse enters the room. The client states, "My foot is hurting. I would like a pain pill." How should the nurse respond? A. Ask the client to rate the pain using a 1 to 10 scale. B. Encourage the client to wait until bedtime for the pill. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct the client in the use of deep breathing exercises for pain control.

A. Ask the client to rate the pain using a 1 to 10 scale

The nurse is preparing to administer a bolus tube feeding. What steps must the nurse include prior to administering the feeding? (Select all that apply.) A. Aspirate the stomach contents. B. Assess bowel sounds. C. Position the client in semi-Fowler's position. D. Irrigate the lumen after the contents are replaced. E. Warm the feeding to room temperature. F. Assess the pH of the stomach contents.

A. Aspirate the stomach contents. B. Assess bowel sounds. E. Warm the feeding to room temperature. F. Assess the pH of the stomach contents.

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. What is the priority nursing action for this client? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Request that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate.

A. Assist the client to walk to the bathroom and do not leave the client alone.

For the client with a sodium level of 128 mEq/L, which meal selections should the nurse suggest to the client? (Select all that apply.) A. Bacon, egg, and cheese biscuit B. Chinese chicken and vegetables, with rice and soy sauce C. Strawberry, spinach salad with yogurt-based blue cheese dressing D. Chicken salad stuffed fresh tomato with a side of celery sticks E. Grilled tilapia with a fresh green side salad F. Grilled hot dog on a bun with ketchup and mustard

A. Bacon, egg, and cheese biscuit B. Chinese chicken and vegetables, with rice and soy F. Grilled hot dog on a bun with ketchup and mustard The client is hyponatremic and additional salt is needed in the diet. Fresh fruits and vegetables are low in sodium. Bacon, soy, and hot dogs with ketchup and mustard are high in sodium.

The nurse is providing care to a client who had major abdominal surgery. Upon return from the recovery room, the client's vital signs were at the pre-operative baseline. The client was sleepy, but arousable, and the skin was warm and dry to the touch. At the 1 hour post admission assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and the skin is cool and clammy to the touch. What are the priority nursing actions? (Select all that apply.) A. Call the health care provider. B. Elevate the head of the bed. C. Observe for restlessness/confusion. D. Administer oxygen by re-breather mask. E. Observe the abdominal bandage.

A. Call the health care provider. C. Observe for restlessness/confusion. D. Administer oxygen by re-breather mask. E. Observe the abdominal bandage.

In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels.

A. Check the bath water temperature.

The nurse is working with one LPN and two aides on a 20 bed unit. Which are the appropriate tasks to delegate to the appropriate person? (Select all that apply.) A. Feeding an elderly and confused client to the aide B. Toileting the client for the first time after surgery to the LPN C. Placing the bathroom supplies in the room of the new admission to the LPN D. Reinforcing the discharge teaching instructions to the LPN E. Administering a po pain medication to the LPN F. Performing the routine dressing change 5 days after surgery to the LPN

A. Feeding an elderly and confused client to the aide. D. Reinforcing the discharge teaching instructions to the LPN E. Administering a po pain medication to the LPN F. Performing the routine dressing change 5 days after surgery to the LPN

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level

A. Low serum albumin level

The nurse is providing care to clients at a day treatment center. One of the clients who is usually talkative and eats well is now confused and did not eat lunch. The nurse learns these are new findings as of today. What are the next nursing actions? (Select all that apply.) A. Obtain a clean catch urine sample. B. Take the client's vital signs. C. Assess for the initiation of any new medications. D. Obtain an oxygen saturation. E. Call the client's children to report the confusion. F. Call the facility's bus service to return the client home.

A. Obtain a clean catch urine sample. B. Take the client's vital signs. C. Assess for the initiation of any new medications. D. Obtain an oxygen saturation.

The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which action should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift.

A. Perform range-of-motion exercises to prevent contractures.

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which nursing actions are correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Explain that placement of the tube is painless. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx.

A. Place the client in a high Fowler position. D. Instruct the client to swallow after the tube has passed the pharynx.

Which steps should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back.

A. Place the client in a side-lying position. B. Pull the auricle upward and outward. The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of respiratory compromise for this client. What will the nurse include in this client's plan of care? (Select all that apply.) A. Raise the head of the bed to no less than a 45 degrees angle. B. Have the client use an incentive spirometer 10 times every hour while awake. C. Limit total fluid intake to no more than 1000 mL/day. D. Have the client sit on the side of the bed instead of getting up and walking. E. Ask the client to take deep breaths and cough five times every hour while awake.

A. Raise the head of the bed to no less than a 45 degrees angle. B. Have the client use an incentive spirometer 10 times every hour while awake. E. Ask the client to take deep breaths and cough five times every hour while awake.

The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the nurse consider when administering PN? (Select all that apply.) A. Remove the PN from the refrigerator 30 minutes before infusing. B. Have a second nurse double check the PN before connecting the solution. C. Have a second IV line in place for administering IV medications. D. Assure the infusion time for the PN does not exceed 24 hours. E. Tell the client a feeling of being full should occur with PN. F. Return amber and cloudy solutions of PN to the pharmacy.

A. Remove the PN from the refrigerator 30 minutes before infusing. D. Assure the infusion time for the PN does not exceed 24 hours. F. Return amber and cloudy solutions of PN to the pharmacy.

The spouse is at the bedside of the client who just died. The hospice nurse states to the spouse, "I know your children want to come over and say goodbye before we call the funeral home. Just let me know when you are ready for me to prepare the body." What steps will the nurse include in the postmortem care? (Select all that apply.) A. Remove the existing Foley catheter. B. Wash the genitalia only. C. Close the client's eyes. D. Remove soiled padding under the client. E. Place a dressing over the abdominal scar.

A. Remove the existing Foley catheter. C. Close the client's eyes. D. Remove soiled padding under the client.

The nurse evaluates the insertion site of an IV catheter and suspects the IV is infiltrated. Which findings support the evaluation? (Select all that apply.) A. The area around the insertion site is swollen. B. There is bruising 1 inch below the insertion site. C. The insertion site is cool to the touch. D. The client complains of a burning pain at the site. E. Redness is noted in the area of the insertion site. F. Blood is noted in the IV tubing when the IV bag is lowered.

A. The area around the insertion site is swollen. C. The insertion site is cool to the touch. D. The client complains of a burning pain at the site. E. Redness is noted in the area of the insertion site.

The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is 128 mEq/L. The nurse should be alert for which findings? (Select all that apply.) A. Weakness in the hands and feet B. +1 reflexes to the patella C. Headache D. Muscle twitching E. Nausea F. Facial redness

A. Weakness in the hands and feet B. +1 reflexes to the patella C. Headache E. Nausea

A 65-year-old client who attends an adult daycare program and is wheelchair mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. "Take a vitamin supplement tablet once a day." B. "Change positions in the chair frequently" C. "Increase daily intake of water or other oral fluids." D. "Purchase a newer model wheelchair."

B. "Change positions in the chair frequently"

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale."

B. "Compress the inhaler while slowly breathing in through your mouth."

The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate will the nurse document? A. 14 B. 16 C. 17 D. 28

B. 16 The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Options A, C, and D are inaccurate recordings

The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When viewing the consent form, the nurse notes the surgeon's signature, but not the client's signature. What steps must the nurse take? (Select all that apply.) A. Call the surgeon. B. Ask the client, "Did your surgeon explain the procedure to you?" C. Have the client's spouse sign the form. D. Ask the client, "Do you have any questions?" E. Witness the signature. F. Obtain the consent.

B. Ask the client, "Did your surgeon explain the procedure to you?" D. Ask the client, "Do you have any questions?" E. Witness the signature.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse take next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.

B. Assess the client's neurologic status.

The client 12 hours after a laparotomy reports to the nurse a pain rating of 7 to 10. The nurse reviews the medication orders and it is another hour before the client can have another dose of pain medication. What actions can the nurse take to assist the client? (Select all that apply.) A. Administer the IV pain medication an hour early. B. Assist the client into side-lying, curled position. C. Obtain a warm pack to apply to the site of the incision. D. Suggest to the client taking 10 deep breaths, in through the nose and out through the mouth. E. Help the client with sustained concentration of a personally pleasant topic.

B. Assist the client into side-lying, curled position. C. Obtain a warm pack to apply to the site of the incision. D. Suggest to the client taking 10 deep breaths, in through the nose and out through the mouth. E. Help the client with sustained concentration of a personally pleasant topic.

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A. Apply a warm compress proximal to the site. B. Check for kinks in the tubing and raise the IV pole. C. Adjust the tape that stabilizes the needle. D. Flush with normal saline and recount the drop rate.

B. Check for kinks in the tubing and raise the IV pole.

A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality.

B. Explain the relationship to the charge nurse and ask for reassignment.

The nurse is evaluating measures implemented for the non-responsive client. Which findings indicate the effectiveness of the care delivered? (Select all that apply.) A. Footboard at the end of the bed B. Heals without redness bilaterally C. Skin intact on the back D. Sheepskin booties in place E. Elbow joint fully flexes and extends. F. Ankle joint rotates 360 degrees freely.

B. Heals without redness bilaterally C. Skin intact on the back E. Elbow joint fully flexes and extends. F. Ankle joint rotates 360 degrees freely.

The client states to the nurse, "This medication makes my mouth so dry." What are the nurse's suggestions to quench the client's thirst? (Select all that apply.) A. Drink 2, 8 ounce glasses of lemon-lime soda every day. B. Infuse your water with fresh citrus fruits to quench your thirst. C. Freeze strawberries and water together in popsicle mold. D. Add ginger ale to your daily glass of juice every day. E. Keep a few pieces of hard candy with you to suck on.

B. Infuse your water with fresh citrus fruits to quench your thirst. C. Freeze strawberries and water together in popsicle mold. E. Keep a few pieces of hard candy with you to suck on.

The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts were made prior to obtaining the sample with the tourniquet in place for nearly 5 minutes. Which laboratory finding would the nurse suspect is inaccurate related to the prolonged tourniquet placement? A. Na 148 mEq/L B. K 5.3 mEq/L C. Cl 102 mEq/L D. Ca 9.3 mg/dL

B. K 5.3 mEq/L Prolonged tourniquet placement can cause accumulation of potassium, skewing the result upward. The sodium level is also high, but that is not related to the blood draw. The chloride and calcium levels are normal.

Which fluid will the nurse select to administer with the prescribed blood transfusion? A. 5% Dextrose and water B. Normal saline C. Lactated Ringers solution D. 5% Dextrose and lactated ringers

B. Normal saline

The nurse is preparing the room for a client after a laparotomy with a 5 inch midline abdominal incision. The nurse plans on teaching the client how to splint the wound when coughing or deep breathing. What extra item will the nurse place in the client's room? A. Pillow case B. Pillow C. Sheet D. Blue absorbent pad

B. Pillow

The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the nurse bring to the attention of the healthcare provider? A. Temperature: 97.5°F/36.4°C B. Pulse: 80 beats/min C. Respirations: 26 breaths/min D. Blood pressure: 90/53 mm Hg

B. Pulse: 80 beats/min

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly.

B. Put bed rails up on the side of bed opposite from the nurse.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

B. Remind the client to walk carefully down the stairs until reaching a lower floor.

The nurse teaches the use of a gait belt to a caregiver whose spouse has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to use the belt? A. Standing on the spouse's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on the spouse's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind the spouse, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of the spouse, the caregiver guides the client forward by gently pulling on the gait belt.

B. Standing on the spouse's weak side, the caregiver provides security by holding the gait belt from the back.

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse to intervene with the UAP's approach? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.

The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity.

B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What action has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns

B. Use of careful handwashing technique

The clinic nurse is conducting an assessment of a 2-year-old. The nurse asks the mother, "What is your child playing with now?" Which response indicates to the nurse that further teaching is needed? (Select all that apply.) A. "We color together using jumbo crayons." B. "Finger paints in the kitchen are a favorite pastime." C. "A marble run race track is set up in the playroom." D. "When outside, the wagon filled with soccer balls is the preferred toy." E. "We got a golf set because my other children play golf."

C. "A marble run race track is set up in the playroom." E. "We got a golf set because my other children play golf."

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client safely administered the injections. What is the nurse's best response? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home."

C. "When I watched you give yourself the injection, you did it correctly."

A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A. Americans with Disabilities Act of 1990 B. ANA Code of Ethics with Interpretative Statements C. ANA's Scope and Standards of Nursing Practice D. Patient's Bill of Rights of 1990

C. ANA's Scope and Standards of Nursing Practice

A client in a long-term care facility reports to the nurse, "I have not had a bowel movement in 2 days." What is the nurse's first action? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

C. Assess the client's medical record to determine the client's normal bowel pattern.

The nurse who is preparing to give a 14-year-old client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents.

C. Do not give the medication and document the reason.

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C. Dorsiflex and plantarflex the feet 10 times each hour. D. Drink approximately 4 ounces of water every hour.

C. Dorsiflex and plantarflex the feet 10 times each hour.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.

C. Leave the catheter in place and reattempt with another catheter.

When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A. Remind the child to clean his genital area. B. Defer perineal care because of the child's age. C. Retract the foreskin gently to cleanse the penis. D. Ask the parents why the child is not circumcised.

C. Retract the foreskin gently to cleanse the penis

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which statement reflects the likely outcome for the nurse? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions are protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.

C. There will be no judgment against the nurse, whose actions are protected under the Good Samaritan Act.

In the middle of running a resuscitation for a cardiac arrest the LPN states to the nurse, "What can I do for your other patients?" The nurse says to the LPN, "Go ahead and start that blood on the client in 434B. It is primed and ready to go. You have seen me do it a million times. You can do it." What is the LPN's best response? A. "No way am I starting the blood on that client!" B. "I am going to tell the manager you asked me to start blood." C. "Sure, no problem. I can do that. I have done it before." D. "I can take over compressions so you can start the blood."

D. "I can take over compressions so you can start the blood."

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 8:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before."

D. "This is a new pill I have never taken before."

The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports, "I am still unable to sleep, despite following the same routine every night." Which action should the nurse take next? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine he is currently following.

D. Ask the client to describe the routine he is currently following.

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the health care provider to renew the prescription for the medication.

D. Contact the health care provider to renew the prescription for the medication.

The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing action? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea.

D. Determine if pain is causing the client's tachypnea.

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle.

D. Discard the saline solution and obtain a new unopened bottle.

The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time.

D. Discuss the client another time.

After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

D. Encourage the client to call the clinic nurse or health care provider if any questions arise.

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor.

D. Gently lower the client to the floor.

The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted.

D. Observe the client change the dressing unassisted.

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which nursing action is best for this client? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client.

D. Review the schedule of outdoor breaks with the client.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium

D. Sodium

The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has the highest priority? A. Assist the client with daily cleansing. B. Tell the client that incontinence happens with aging. C. Offer 200 mL of fluid every 2 hours while awake. D. Take the client's temperature every 4 hours.

D. Take the client's temperature every 4 hours.

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse take first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying.

D. Talk to the client and attempt to find out why the client is crying.

The nurse is providing care to a client receiving high doses of chemotherapy. Which situation will cause the nurse to intervene for this client? A. Co-workers walk into the room with a 2′ × 3′ get well card. B. A neighbor stops by with a box of chocolate candy. C. A clergy member places a book of prayers at the client's bedside. D. The florist delivers an arrangement of fresh flowers.

D. The florist delivers an arrangement of fresh flowers.

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device.

D. Turn off the intermittent suction device.

The goal is for the client to take in 1500 calories/day administered through by a feeding tube. The concentration of the feeding is 1.5 calories/mL. How many mL per hour will the nurse need to set the infusion pump to deliver the feeding over 18 hours? _____ Enter a whole number.

56

In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? A. Daily black, sticky stool B. Daily dark brown stool C. Firm brown stool every other day D. Soft light brown stool twice a day

A. Daily black, sticky stool

The nurse is using the Glasgow Coma Scale to perform a neurological assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider.

A. Document that the client responds to painful stimulus.

The nurse is preparing to administer a new medication through an existing IV line containing a vasopressor. What action must the nurse take first? A. Flush the line with normal saline at the same rate as the vasopressor. B. Administer the medication at the prescribed IV rate. C. Start a second IV line to administer the new medication. D. Call the health care provider to change the order for the new medication to po.

A. Flush the line with normal saline at the same rate as the vasopressor.

The nurse is concerned the client will develop a nosocomial infection. Which nursing action is best for the nurse to take when providing care for an incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers.

A. Maintain standard precautions.

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit

A. Mode of transmission

A 75-year-old client states to the nurse, "I am just not hungry anymore." The client has lost 10 pounds/4.53 kg in the past 4 months. Which snacks will the nurse recommend to the client? (Select all that apply.) A. Nuts B. Milkshakes C. Chocolate candy bar D. Peanut butter and crackers E. Glass of whole fat milk

A. Nuts B. Milkshakes D. Peanut butter and crackers E. Glass of whole fat milk

The nurse is providing care to a client immediately after a total right mastectomy. What steps will the nurse include when positioning the client? (Select all that apply.) A. Raise the head of the bed 30 to 45 degrees. B. Roll the client to her right side and place a pillow behind her back. C. Elevate her right arm under two pillows. D. Require the client to stay in bed for 72 hours post procedure. E. Place a sandbag on the incision.

A. Raise the head of the bed 30 to 45 degrees. C. Elevate her right arm under two pillows.

The postoperative nurse is reviewing the use of an incentive spirometer. Which instructions will the nurse include in the client's teaching plan? (Select all that apply.) A. Sit in an upright position. B. Cough deeply three times. C. Hold breath for 5 seconds after inhaling on the spirometer. D. Place mouth securely around the mouthpiece of the spirometer. E. Remove mouth from mouthpiece and exhale through the nose.

A. Sit in an upright position. C. Hold breath for 5 seconds after inhaling on the spirometer. D. Place mouth securely around the mouthpiece of the spirometer.

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to take for this client? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate.

A. Stay with the client while the client is standing.