HESI RN Exit Exam 2022

The nurse is wearing personal protective equipment (PPE) while caring for a client. When exiting the room, which PPE should be removed first? A. Gloves B. Mask C. Eyewear D. Gown

A. Gloves

Prior to obtaining a trapeze bar for a client with limited mobility, which client assessment is most important for the nurse to obtain? A. Upper body muscle strength B. Balance and posture C. Risk for disuse syndrome D. Pressure sore risk

A. Upper body muscle strength

A client who recently received a prescription for ramelteon to treat sleep deprivation reports experiencing several side effects since taking the drug. Which side effect should the nurse report to the healthcare provider? A. A change in the sleep-wake cycle B. Mild sedation C. Dizziness reported after initial dose D. Somnambulism

D. Somnambulism

A client who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the client, in which sequence should the nurse complete these actions? (descending order)

1. Observe breathing patterns 2. Assess blood pressure 3. Measure body temperature 4. Palpate for pedal edema

An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150mL of dark brown emesis. In what order should the nurse implement these interventions? (Highest to lowest priority)

1. Send emesis sample to the lab 2. Elevate the head of the bed 3. Complete focused assessment 4. Offer PRN pain medication

A heparin infusion is prescribed for a client who weighs 220 pounds. After administering a bolus dose of 80 units/kg, the nurse calculates the infusion rate for the heparin solution at 18 units/kg/hr. The available solution is Heparin Sodium 25,000 units in 5% Dextrose injection 250mL. The nurse should program the infusion pump to deliver how many mL/hour?

18

The healthcare provider prescribes a fluid challenge of 0.9% sodium chloride 1,000 mL to be infused intravenously over 4 hours. The IV administration set delivers 10gtt/mL. How many gtt/minute should the nurse regulate the infusion? (Round to the nearest whole number)

42 gtt/min

The nurse has complete the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective? A. A tuna fish sandwich with chips and ice cream B. A salad with three kinds of lettuce and fruit C. A peanut butter sandwich with soda and cookies D. Vegetable soup, crackers, and milk

A. A tuna fish sandwich with chips and ice cream

A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse? A. Abdominal pain decreases when lying supine B. Pain lasts an hour and leaves the abdomen tender C. Right upper quadrant pain refers to right scapula D. Drinks alcohol until intoxicated at least twice weekly.

A. Abdominal pain decreases when lying supine

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing actions should the nurse assign to the PN? (Select all that apply) A. Administer a dose of insulin per sliding scale for a client with Type 2 DM B. Start the second blood transfusion for a client 12 hours following a BKA C. Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty

A. Administer a dose of insulin per sliding scale for a client with Type 2 DM D. Perform daily surgical dressing change for a client who had an abdominal hysterectomy E. Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty

A client who gave birth 48 hours ago has decided to bottle feed the infant. During the assessment, the nurse observes that both breasts are swollen, warm, and tender on palpation. Which instruction should the nurse provide? A. Apply ice to the breasts for comfort B. Wear a loose-fitting bra during the day to prevent nipple irritation C. Run warm water over breasts D. Express small amounts of milk from the breasts to relieve pressure

A. Apply ice to the breasts for comfort

The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After administering surfactant, which assessment is most important for the nurse to monitor? A. Arterial blood gasses B. Breath sounds C. Oxygen saturation D. Respiratory rate

A. Arterial blood gasses

A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use? A. Ask the client to describe the pain B. Observe body language and movement C. Identify effective pain relief measures D. Provide a numeric pain scale

A. Ask the client to describe the pain

The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs (2kg) in 24 hours and an elevated central venous pressure for a client with full thickness burns. Which intervention should the nurse implement? A. Auscultate for irregular heart rate B. Review arterial blood gases results C. Measure ankle circumference D. Document abdominal girth

A. Auscultate for irregular heart rate

A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan, the nurse should teach the parents to report which sign of overdose? A. Bradycardia B. Tachypnea C. Hypertension D. Coughing

A. Bradycardia

A young adult visits the client reporting symptoms associated with gastritis. Which information in the client's history is most important for the nurse to address in the teaching plan? A. Consumes 10 or more drinks of alcohol every weekend B. Snacks on foods with very high salt content on a daily basis C. Exercises vigorously every evening right before going to bed D. Recently became a vegetarian and eats a lot of high fiber foods

A. Consumes 10 or more drinks of alcohol every weekend

An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. Which effect is the nurse likely to note as a result of this increase in glaucoma surgeries? A. Decreased prevalence of glaucoma in the population B. Increased incidence of glaucoma in the population C. Decreased morbidity in the elderly population D. Increased mortality in the elderly population

A. Decreased prevalence of glaucoma in the population

Prolonged exposure to high concentrations of supplemental oxygen over several days can cause which pathophysiological effect? A. Disrupted surfactant production B. Metabolic acidosis C. Aphasia and memory loss D. Deep sleep or coma

A. Disrupted surfactant production

A young male client is admitted to rehabilitation following a right above-knee amputation (AKA) for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his "right foot is aching". The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement? A. Encourage discussion of feelings about the loss of his limb B. Administer a prescription for gabapentin, a neuroleptic agent C. Tech the client how to wrap the stump with an elastic bandage D. Offer to assist the client to a quieter location so he can relax

A. Encourage discussion of feelings about the loss of his limb

The home care nurse visits a client who has cancer. The client reports having a good appetite but experiencing nausea when smelling food cooking. Which action should the nurse implement? A. Encourage family members to cook meals outdoors and bring the cooked food inside B. Assess the client's mucous membranes and report the findings to the healthcare provider C. Advise the client to replace cooked foods with a variety of different nutritional supplements D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting

A. Encourage family members to cook meals outdoors and bring the cooked food inside

A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take? A. Encourage the client to use cooler water and apply calamine lotion after soaking B. Obtain a PRN prescription for an analgesic that the client can use for symptom relief C. Suggest that the client take brief showers and apply oil-based lotion after showering D. Explain that the symptoms are caused by liver damage and cannot be relieved

A. Encourage the client to use cooler water and apply calamine lotion after soaking

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. Determine the frequency and type of client's abuse C. Report the finding to the police department D. Discuss treatment options for abusive partners

A. Explore client's readiness to discuss the situation

The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which information in the client's admission assessment is relevant to the nurse's plan for taking the blood pressure reading? (Select all the apply) A. Frequent syncope B. Occasional nocturia C. Flat affect D. Blurred vision E. Frequent drooling

A. Frequent syncope C. Flat affect D. Blurred vision

The nurse assess a client being treated for Herpes zoster (shingles). Which assessments should the nurse include when evaluating the effectiveness of the the treatment? (Select all that apply) A. Functional ability B. Skin integrity C. Pain scale D. Bowel sounds E. heart sounds

A. Functional ability B. Skin integrity

When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency? A. History of intermittent claudication B. A positive Brodie-Trendelenburg test C. Ankle ulceration and edema D. A serum cholesterol level of 250mg/dl (6.47mmol/L)

A. History of intermittent claudication

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. Instructions about how much fluid the child should drink daily. B. Signs of addiction to opioid pain medications C. Information about non-pharmaceutical pain relief measures D. Referral for social services for the child and family

A. Instructions about how much fluid the child should drink daily

The nurse is caring for a seated client who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? (Select all that apply) A. Loosen restrictive clothing B. Insert a bite block C. Ease the client to the floor D. Note the duration of the seizure E. Restrain the client

A. Loosen restrictive clothing C. Ease the client to the floor D. Note the duration of the seizure

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care? A. observe color of urine B. Measure body temperature C. Assess skin turgor D. Check for pedal edema

A. Observe color of urine

While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement? A. Obtain sputum sample B. Document degree of edema C. Initiate hourly urine output measurement D. Administer intravenous diuretics

A. Obtain sputum sample

The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) A. Report any client complaint of pain or discomfort B. Evaluate the client for sleep disturbances C. Assess the client for weakness and fatigue D. Weigh the client and report any weight gain E. Note and report the client's food and liquid intake during meals and snacks

A. Report any client complaint of pain or discomfort D. Weigh the client and report any weight gain E. Note and report the client's food and liquid intake during meals and snacks

A toddler presenting with a history of intermittent skin rashes, hives, abdominal pain, and vomiting that occurs after ingesting of milk products arrives to the clinic accompanied by the parents. Which type of testing should the nurse provide education to the toddler's family about? A. Serum immunoglobulin E (IgE) B. Intradermal test C. Atopy patch test D. Placebo-controlled food challenge

A. Serum immunoglobulin E (IgE)

A new nurse 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. Instruct the nurse to remove the needle C. Direct the nurse to change the IV tubing D. Prompt the nurse to apply povidone to the site

A. Suggest the nurse use a 20-gauge needle

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. Teach coughing and deep breathing exercises B. Assess the client's oral cavity for ulcerations C. Request thick nectar liquids for the client D. Monitor the client when using a straw for liquids

A. Teach coughing and deep breathing exercises

The nurse is caring for a 24-month-old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two-word phrases. Which assessment should the nurse administer? A. The modified checklist for autism in toddlers (M-CHAT) B. Psychology Systems Questionnaire (PHQ-2) C. Behavioral Style Questionnaire (BSQ) D. The Ages and Stages Questionnaire (ASQ)

A. The Modified Checklist for Autism in Toddlers (M-CHAT)

The nurse is developing an educational program for older clients who are being discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics? (Select all that apply) A. Uses common words with few syllables B. Printed using a 12-point type font C. Uses pictures to help illustrate complex ideas D. Contains a list with definitions of unfamiliar terms E. Written at a twelfth-grade reading level

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

A combination multi-drug cocktail is being considered for an asymptomatic HIV-infected client with a CD4 cell count of 500. Which nursing assessment of the client is most crucial in determining whether therapy should be initiated? A. Willing to comply with complex drug schedules B. Maintains an adequate social support system C. Qualifies for a prescription assistance program D. States various side effects of retroviral agents

A. Willing to comply with complex drug schedules

A client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds (0.91 kg), pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client's plan of care? A. Maintain accurate intake and output B. Administer prescribed diuretic C. Weigh client every morning D. Restrict daily fluid intake to 1500mL

B. Administer prescribed diuretic

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity? A. Core strengthening B. Aerobic exercise C. Weight-bearing exercise D. Muscle stretching and toning

B. Aerobic exercise

A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention? A. Esinapril B. Allopurinol C. Furosemide D. Aspirin, low dose

B. Allopurinol

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication? A. Auscultate for bowel sounds in all quadrants B. Ask the client about gastrointestinal pain C. Monitor the client's serum electrolyte levels D. Measure the client's fluid intake and output

B. Ask the client about gastrointestinal pain

A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to the child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take? A. Develop a water safety teaching plan for the family B. Ask the older brother how he felt during the incident C. Tell the older brother that he seems depressed D. Commend the older brother for his heroic actions

B. Ask the older brother how he felt during the incident

A nurse receives report on a client who is four hours post-total abdominal hysterectomy. The previous nurse reports that it was necessary to change the client's perineal pad hourly and that it is again saturated. The previous nurse also reports that the client's urinary output has decreased. Which action should the nurse implement first? A. Evaluate the skin turgor B. Assess for weakness or dizziness C. Change the perineal pad D. Measure the urinary output

B. Assess for weakness or dizziness

Which self care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus? A. Self-injection techniques B. Blood glucose monitoring C. Diabetic diet meal planning D. A realistic exercise plan

B. Blood glucose monitoring

The nurse is providing discharge teaching to the parents of a 13 month old child who underwent repair for an atrial septal defect. The healthcare provider prescribes aspirin and an antibiotic for the first 6 months postoperatively to prevent infective endocarditis (IE). What information is most important for the nurse discuss with the parents about the child's recovery and prevention of IE? A. Refer the mother to the healthcare provider to discuss infective endocarditis B. Brush the child's teeth every day and ensure the child receives regular dental followup C. Give the child acetaminophen for pain or fever and visit the surgeon for follow-up D. Monitor the child for regular bowel movements and urine output that exceeds intake

B. Brush the child's teeth every day and ensure the child receives regular dental followup

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse? A. Notify the nurse when the transfusion has finished, so further client assessment can be done B. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately D. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion

B. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete

The nurse is evaluating the chest drainage system of a client with a chest tube inserted to treat a left hemothorax. Which finding requires intervention by the nurse? A. Rise and fall of water level with respiration B. Continuous bubbling in the water-seal chamber C. Total fluid level in water-seal chamber unchanged D. An average collection of 50 mL/hr drainage

B. Continuous bubbling in the water-seal chamber

While caring for a client's postoperative dressing, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values? A. Serum albumin B. Culture for sensitive organisms C. Serum blood glucose level D. Creatinine level

B. Culture for sensitive organisms

An S3 heart sound is auscultated in a client in her third trimester of pregnancy. What intervention should the nurse take? A. Prepare the client for an echocardiogram B. Document in the client's record C. Notify the healthcare provider D. Limit the client's fluids

B. Document in the client's record

An adult client is admitted to the emergency department after falling from the ladder. While waiting to have a computed tomography (CT) scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the client asks for something stronger. Which intervention should the nurse implement? A. Review client's history for use of illicit drugs B. Explain the reason for using only non-narcotics C. Assess client's pupils for their reaction to light D. Request that the CT scan be done immediately

B. Explain the reason for using only non-narcotics

A client with type 2 diabetes mellitus arrives to the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation? A. Potassium 3.5 mEq/L B. Fingertips feel numb C. Sodium 135 mEq/L D. Cervical spine stiffness

B. Fingertips feel numb

A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide? A. Consume a high protein diet B. Increase physical activity C. Take vitamin supplements D. Obtain a prostate-specific antigen blood level test

B. Increase physical activity

An unlicensed assistive personnel (UAP) is assigned to ambulate a client with influenza who has droplet precautions implemented. The UAP requests a change in assignment, stating the reason of having not been fitted yet for a N95 respirator mask. Which action should the nurse take? A. send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client. B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client C. Before changing assignments, determine which staff members have fitted particulate filter masks D. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before providing personal care

B. Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client

Which intervention should the nurse include in the plan of care for a child with tetanus? A. Encourage coughing and deep breathing B. Minimize the amount of stimuli in the room C. Reposition from side to side every hour D. Open window shades to provide natural light

B. Minimize the amount of stimuli in the room

The nurse is reviewing the diagnostic tests prescribed for a client with a positive skin test. Which subjective findings reported by the client supports the diagnosis of tuberculosis? A. Barking cough and vomiting B. Mucopurulent cough and night sweats C. Dry cough and chest tightness D. Chronic cough and fatty stools

B. Mucopurulent cough and night sweats

A client with bacterial meningitis is receiving phenytoin. Which assessment finding indicates to the nurse that the client is experiencing a therapeutic response?

B. Normal electroencephalogram after drug administration

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching? A. Find outlets for more social interaction B. Practice using muscle relaxation techniques C. Center attention on positive upbeat music D. Think about reasons the episodes occur

B. Practice using muscle relaxation techniques

When assessing an IV site that is used for fluid replacement and medication administration, the client complains of tenderness when the arm is touched above the site. Which additional assessment finding warrants immediate intervention by the nurse? A. Client uses the arm cautiously B. Red streak tracking the vein C. A sluggish blood return D. Spot of dried blood at insertion site

B. Red streaks tracking the vein

An older client with a long history of coronary artery disease (CAD), hypertension (HTN), and heart failure (HF) arrives in the Emergency Department (ED) in respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expected in the client with acute HF? A. Increased cardiac contractility B. Reduced preload C. Relaxed vascular tone D. Decreased afterload

B. Reduced preload

When providing client care the nurse identifies a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision-making process in response to the problem and clinical question is evidence-based. When gathering evidence, which consideration is most important? A. Past experience with similar problems B. Relevance to the situation C. Related personal values D. Frequency that the problem occurs

B. Relevance to the situation

A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6h are prescribed. What actions should the nurse include in this client's plan of care? (Select all that apply) A. Do not contaminate the insulin aspart so that it is available for IV use B. Review with the client proper foot care and prevention of injury C. Teach subcutaneous injection technique, site rotation, and insulin management D. Coordinate carbohydrate controlled meals at consistent times and intervals. E. Mix bedtime dose of insulin glargine with insulin aspart sliding scale dose F. Fingerstick glucose assessments every 6h with meals

B. Review with client proper foot care and prevention of injury C. Teach subcutaneous injection technique, site rotation, and insulin management D. Coordinate carbohydrate controlled meals at consistent times and intervals F. Fingerstick glucose assessments every 6h with meals

The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)? A. Tachycardia and tachypnea B. Sluggish and unequal pupillary responses C. Increased head circumference and bulging fontanels D. Blood pressure fluctuations and syncope

B. Sluggish and unequal pupillary responses

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? (Select all that apply) A. Avoid range of motion exercises B. Use a residual limb shrinker C. Apply alcohol to the stump after bathing D. Inspect skin for redness E. Wash the stump with soap and water

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

The nurse is caring for a client who has chronic obstructive pulmonary disease (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. Administering narcotics for pain relief D. Increasing the client's fluid intake

C. Administering narcotics for pain relief

A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still is taking hours to fall asleep at night. Which action should the nurse implement? A. Advise the client that lifestyle changes often take several weeks to be effective B. Encourage the client to exercise everyday to eliminate bedtime wakefulness C. Ask the client for a description of the exercise schedule that is being followed D. Determine the amount of weight the client has lost since increasing activity

C. Ask the client for a description of the exercise schedule that is being followed

In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client become lethargic. Which assessment data should the nurse obtain next? A. Temperature B. Breath sounds C. Blood glucose D. White blood cell count

C. Blood glucose

The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective? A. Only 30% of clients did not attend self-management education sessions. B. More than 50% of at-risk clients were diagnosed early in their disease process C. Clients who developed disease complications promptly received rehabilitation D. Average client scores improved on specific risk factor knowledge tests

C. Clients who developed disease complications promptly received rehabilitation

The nurse is providing care for a client with schizophrenia who receives haloperidol decanoate 75mg IM every 4 weeks. The client begins developing a puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement? A. Monitor lying, sitting, and standing blood pressures B. Provide coaching in relaxation techniques C. Complete abnormal involuntary movement scale (AIMS) D. Discontinue all medications immediately

C. Complete abnormal involuntary movement scale (AIMS)

While the nurse is assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take? A. Inform the client that falls occur more often in the hospital than at home B. Record a minimal risk for falls, documenting the client's statement C. Continue to obtain client data needed to complete the fall risk survey D. Place the client on a high fall risk protocol because of advanced age

C. Continue to obtain client data needed to complete the fall risk survey

Prior to surgery, written consent must be obtained. Which is the nurse's legal responsibility with regard to obtaining written consent? A. Explain the surgical procedure to the client and ask the client to sign the consent form B. Ask the client or a family member to sign the surgical consent form C. Determine that the surgical consent form has been signed and is included in the client's record. D. Validate the client's understanding of the surgical procedure to be conducted

C. Determine that the surgical consent form has been signed and is included in the client's record

A client in the emergency center demonstrates rapid speech, flight of ideas, and reports sleeping only three hours during the past 48 hours. Based on these findings, it is most important for the nurse to review the laboratory value for which medication? A. Lorazepam B. Fluoxetine C. Divalproex D. Olanzapine

C. Divalproex

A client in the third trimester of pregnancy reports that she fells some "lumpy places" in her breasts and that her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in two weeks. What action should the nurse take? A. Tell the client to begin nipple stimulation to prepare for breast feeding. B. Reschedule the client's prenatal appointment for the following day C. Explain that this normal secretion can be assessed at the next visit D. Recommend that the client start wearing a supportive brassiere

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

An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis? A. Ate an extra peanut butter sandwich before gym class B. incorrectly administered too much insulin C. Had a cold and ear infection for the past two days D. Skipped eating lunch

C. Had a cold and ear infection for the past two days

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. Plans to move into the dormitory need to be postponed for at least a semester B. These are common side effects of the vaccines and will resolve in a few days C. Immunizations can trigger a relapse of the disease, so get plenty of extra rest D. these early signs of an infection may require medical treatment with antibiotics

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

An older client is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall at home. The client's daughter, who has power of attorney, has brought the client's prescriptions. Which information should the nurse provide first when reporting to the healthcare provider using SBAR communication? A. currently prescribed medications B. Client's healthcare power of attorney C. Increasing confusion of the client D. Fall at home as reason for admission

C. Increasing confusion of the client

A client who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous questions about the procedure. In preparing the client for the procedure, which intervention has the highest priority? A. Allow client to gargle with warm salt water B. Administer a sedative to alleviate anxiety C. Instruct client to write down the questions D. Deny client's request for a midnight snack

C. Instruct client to write down the questions

The father of a 4-year-old has been battling metastatic lung cancer for the past 2 years. After discussing the remaining options with his healthcare provider, the client requests that all treatment stop and that no heroic measures be taken to save his life. When the client is transferred to the palliative care unit, which action is most important for the nurse working on the palliative care unit to take in facilitating continuity of care? A. Reassure the client that his child will be allowed to visit B. Provide the client written information about end-of-life care C. Obtain a detailed report from the nurse transferring the client D. Mark the chart with client's request for no heroic measures

C. Obtain a detailed report from the nurse transferring the client

The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding? A. Elevate the legs to assess for color changes B. Provide a heating pad for PRN use C. Offer cold packs when the pain occurs D. Suggest dangling the legs when pain occurs

C. Offer cold packs when the pain occurs

The nurse has received funding to design a health promotion project for African-American women who are at risk for developing breast cancer. Which resource is most important in designing this program? A. A listing of African-American women who live in the community B. Morbidity data for breast cancer in women of all races C. Participation of community leaders in planning the program D. Technical assistance to produce a video on breast self-examination

C. Participation of community leaders in planning the program

A client is receiving enoxaparin 30mg subcutaneously twice a day. In assessing for adverse effects of the medication, which serum laboratory value is most important for the nurse to monitor? A. Glucose B. Calcium C. Platelet count D. White blood cell count

C. Platelet count

After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment findings should the nurse report to the healthcare provider? (Select all that apply) A. Location of the initial IV site B. Red blood cell count (RBC) C. Swollen lymph nodes in the groin D. White blood cell count (WBC) E. Core body temperature

C. Swollen lymph nodes in the groin D. White blood cell count (WBC) E. Core body temperature

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement? A. The impending signs of death should be documented B. The client's status should be conveyed to the chaplain C. The client's need for pain medication should be determined D. The nurse manager should be updated on the client's status

C. The client's need for pain medication should be determined

A client with hyperthyroidism is admitted to the postoperative unit after a subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse? A. T3- uptake at 50% B. Glucose 150 mg/dL C. Total calcium 5.0 mg/dL D. Thyroxine 12 mcg/dL

C. Total calcium 5.0 mg/dL

On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain? A. Which family member has the client's suicide note B. What drugs the client used for the suicide attempt C. When the client last took drugs for bipolar disorder D. Whether the client over attempted suicide in the past

C. When the client last took drugs for bipolar disorder

After reviewing the Braden Scale findings of residents at a long-term facility, the charge nurse should to tell the unlicensed assistive personnel (UAP) to prioritize skin care for which client? A. A poorly nourished client who requires liquid supplements B. An older adult who is unable to communicate elimination needs C. A woman with osteoporosis who is unable to bear weight D. A older man whose sheets are damp each time he is turned

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

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention? A. A 14yo client with anorexia nervosa who is refusing to eat the evening snack B. A 16yo client diagnosed with major depression who refuses to participate in group C. A 17yo client diagnosed with bipolar disorder who is pacing around the lobby D. An 18yo client with antisocial behavior who is being yelled at by other clients

D. An 18yo client with antisocial behavior who is being yelled at by other clients

A client presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal discharge. Which action should the nurse take first? A. Start an intravenous infusion B. Administer oxygen via facemask C. Perform a vaginal exam D. Begin continuous fetal monitoring

D. Begin continuous fetal monitoring

Then nurse identifies several nursing problems for client who is immobile and who has been experiencing fecal incontinence and diarrhea for several days. The client's spouse is the primary caregiver. In planning care, which problem has the highest priority? A. Impaired bed mobility B. Caregiver role strain C. Fluid volume deficit D. Bowel incontinence

D. Bowel incontinence

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. A retraining program will need to be initiated when the child returns home. B. Diapering will be provided since hospitalization is stressful to preschoolers C. A potty chair should be brought from home so he can maintain his toileting skills D. Children usually resume their toileting behaviors when they leave the hospital

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

An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information? A. The client probably has an organic brain disease and will likely have Alzheimer's disease within a few years B. The family needs a social worker to talk to them about how to handle their father when he becomes annoying C. The daughter is under stress and should be encouraged to think about happier times D. If the client was compulsive about food when he was younger, the aging process can magnify this

D. If the client was compulsive about food when he was younger, the aging process can magnify this

A client at 12 weeks gestation is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Which action is most important for the nurse to implement? A. Obtain the client's 24-hour dietary recall B. Document mucosal membrane status C. Schedule a consult with a nutritionist D. Initiate prescribed intravenous fluids

D. Initiate prescribed intravenous fluids

The healthcare provider prescribes a sepsis protocol for a client with multi-organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care? A. Assess warmth of extremities B. Keep head of bed raised 45 degrees C. Monitor blood glucose level D. Maintain strict intake and output

D. Maintain strict intake and output

The nurse instructs a client in use of a incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration? A. Auscultate the client's lungs for adventitious sounds B. Encourage the client to practice until successful C. Emphasize the need to inhale slowly into the spirometer D. Remind the client to cough after using the spirometer

D. Remind the client to cough after using the spirometer

A client with urge incontinence was treated with onabotuilinumtoxinA injections and is now experiencing urinary retention. Which action should the nurse include in the client's plan of care? A. Provide a bedside commode for immediate use in the client's room B. Teach the client techniques for performing intermittent catheterization C. Explain the need to limit intake of oral fluids to reduce client discomfort D. Remind the client to practice pelvic floor (Kegel) exercises regularly

D. Remind the client to practice pelvic floor (Kegel) exercises regularly

A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance? A. Respiratory acidosis B. Metabolic alkalosis C. Metabolic acidosis D. Respiratory alkalosis

D. Respiratory alkalosis

When assessing a recently delivered, multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding? A. The second stage of labor lasted 10 minutes B. She received butorphanol 2mg IVP during labor C. She is over 35 years of age D. She is a gravida 6, para 5

D. She is a gravida 6, para 5

A client is scheduled for a spiral computed tomography (CT) scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse? A. CT scan that was performed 6 months earlier B. Metal hip prosthesis was placed 20 years ago C. Report of client's sobriety for the last 5 years D. Takes metformin for type 2 diabetes mellitus

D. Takes metformin for type 2 diabetes mellitus

A client fell in the bathroom when left unattended by the unlicensed assistive personnel (UAP). Which information should the nurse include in the client's health record? A. The UAP left the client to assist another client B. The last time client was assisted to the bathroom C. The unit was understaffed when the client fell D. The client fell sustaining a fracture to the left hip

D. The client fell sustaining a fracture to the left hip

After receiving report on an inpatient acute care unit, which client should the nurse assess first? A. The client with an obstruction of the large intestine who is experiencing abdominal distention B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity

D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity

A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position? A. Supine B. supine; feet elevated higher than head C. supine; head elevated higher than feet D. Fowlers

Fowlers

To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location on the image with a red dot).

I placed the red dot on the base of the neck on the right side