HESI RN EXIT Q&A
A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? ( Arrange the actions in order of priority, with the highest priority first, and least priority last or at the bottom.)
1) Stop the infusion 2) Assess vital signs 3) Contact the healthcare provider 4) Document reaction to the drug 5) Initiate an adverse event report.
After placement of a left subclavian central venous catheter (CVC), the nurse receives report of the x-ray findings that indicate the CVC tip is in the client's superior vena cava. Which action should the nurse implement?
A) Initiate intravenous fluids as prescribed
During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client's list should the nurse encourage? (SATA)
A) Natural whole almonds D) Plain, air-popped popcorn
The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the healthcare provider?
A) Ortolani maneuver causing a click at the hip joint
A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?
A) Teach technique for scanning the environment
The nurse is caring for a client who reports experiencing pain. The client rates the pain as 2 out of 10 on the numeric 1 - 10 pain scale. Which prescription should the nurse administer?
Acetaminophen
A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly?
B) "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, but it goes away"
A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (SATA)
B) A full pitcher of water is on the bedside table D) The client is lying in a supine position in bed
A client's morning assessment includes bounding peripheral pulses, weight gain of 2 lbs, pitting ankle edema, and moist crackles bilaterally. Which intervention is MOST important for the nurse to include in the client's plan of care?
B) Administer prescribed diuretic.
Which conditions are most likely to respond to treatment with antihistamines? select all that apply.
B) Allergic rhinitis D) Contact dermatitis
The nurse is assigning care of a client with prostatitis to a practical nurse (PN). What instruction should the nurse provide the PN regarding care of this client?
B) Avoid urinary catheterization
The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured because the client has casts on both arms and is unable to be turned to the prone position for blood pressure measurement in the legs. Which action should the nurse implement?
B) Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed.
Following morning care, a client with a c-5 spinal cord injury who is sitting in a wheelchair becomes flushed and complains of a headache. Which interventions should the nurse implement first?
B) Relieve any kinks or obstruction in the client's foley tubing
Which class of drugs is the only source of a cure for septic shock?
C) Antiinfectives
A child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen?
C) Blood transfusions
Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?
C) Obtain a capillary glucose level
The nurse working in the psychiatric clinic has a phone messages from several clients. Which call should the nurse return first?
D) A family member of a client with dementia who has been missing for 5 hours.
What is the primary goal when planning nursing care for a client with degenerative joint disease (DJD)?
D) Achieve satisfactory pain control
A client is admitted with a severe asthma attack. For the last 3 hours the client has experienced increasing shortness of breath. Arterial blood gas results are: pH 7.22; PaCO2 55 mmHg; HCO3 25 mEq/L (25 mmol/L). Which intervention should the nurse implement?
D) Administer PRN dose of albuterol.
Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?
D) An adult who is one day postoperative for a laparoscopic cholecystectomy
Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client?
D) Orthopnea
A male client who was in a motor vehicle collision yesterday is receiving a unit of packed red blood cells. When half of the unit is infused, the client reports lower back pain, and the nurse observes a fine rash over his chest and back. Which intervention should the nurse implement?
D) Replace the transfusion with normal saline
The nurse is providing preoperative education for a Jewish client scheduled to receive a xenograft graft to promote burn healing. Which information should the nurse provide this client?
D) The xenograft is taken from nonhuman sources.
The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?
D) Vitamin supplements for high-risk pregnant women
An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is BEST for administering this prescription?
A) 1000, 1600, 2200, 0400.
The nurse is teaching the parents of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?
A) A diet of healthy fruits, such as bananas and kiwis, are best for the child
An adult male who fell 20 ft from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the ER prior to his transfer to the ICU. The nurse notes that the suction control chamber is bubbling at the -10 cm H20 mark, with fluctuation in the water seal, and over the past HR 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement?
A) Add sterile water to the suction control chamber
An older woman w/ a history of atrial fibrillation fell at home and fractured her left hip. She is currently taking warfarin 5 mg daily and has an INR value of 5.0. Upon admission, which prescription should the nurse expect to implement?
A) Administer Vitamin K injection
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 medication should the nurse bring to the healthcare provider's attention?
A) Allopurinol
An older client's daughter calls the home health nurse and reports that her mother has become forgetful and is very confused at night. The daughter states that her mother's behavior changed suddenly a few days ago and is now getting worse. Which actions should the nurse take? select all that apply.
A) Ask if the mother is experiencing any pain with urination. C) Instruct the daughter to check her mother's temperature. E) Determine if the mother has recently experienced a fall.
An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client's wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take?
A) Ask the wife to stop and assess the client's swallowing reflex
The nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and learns that the client has a current blood glucose level of 750 mg/dL. When assessing the client, what is the priority?
A) Assess for signs of fluid volume deficit
A PT w/ leukemia who is receiving a myleosuppressive chemotherapy has a platelet count of 25,000/mm3. Which intervention is most important for the nurse to include in this PT's plan of care?
A) Assess urine and stool for occult blood
A client in the ICU is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. What action should the nurse take first?
A) Auscultate bilateral breath sounds
Which information is most important for the nurse to obtain when determining a PT's risk for obstructive sleep apnea syndrome?
A) BMI
The nurse is assigning rooms for 4 PTs, each newly diagnosed, and being admitted to the acute neuro unit for treatment. The PT w/ which condition should be assigned the only private room available?
A) Bacterial meningitis
The nurse is teaching a primigravida about preeclampsia. Which findings are indicators of preeclampsia and should be reported to the HCP? SATA
A) Blurred vision B) Headache F) Swollen hands
When assessing a multigravida on the first postpartum day, the nurse finds a moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths above the umbilicus. What action should the nurse implement first?
A) Check for a distended bladder
The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (SATA)
A) Chicken broth B) Apple juice
While caring for a PT'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 PT's lab values?
A) Culture for sensitive organisms
An UAP is assigned to provide personal care for a PT whose prescribed activity is bedrest w/ bedside commode use. The UAP reports to the nurse that the PT is so obese that the UAP feels unable to safely assist the PT in transferring from the bed to the bedside commode. How should the nurse respond?
A) Determine the PT's level of mobility and need for assistance
A client arrives on the surgical floor after major abdominal surgery. Which intervention should the nurse perform first?
A) Determine the client's vital signs
The nurse is assessing a PT who returns to the unit after a thoracentesis in the procedure room. Which finding should the nurse report to the HCP immediately?
A) Diminished breath sounds over the trocar insertion site
The nurse is preparing to send a PT to the cardiac catheterization lab for elective cardioversion. Which intervention should the nurse implement before the PT leaves the medical unit?
A) Document that the PT has remained NPO
Which instruction should the nurse provide a pregnant PT who is reporting heartburn?
A) Eat small meals throughout the day to avoid a full stomach
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.
An older adult client is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident. Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? (SATA)
A) Encourage family to participate in the client's care E) Measure neurological vital signs every 4 hours
A male client tells the nurse that he is concerned that he may have a stomach ulcer, because he is experiencing heartburn and a dull growing pain that is relieved when he eats. What is the best response by the nurse?
A) Encourage the client to obtain a complete physical exam, since these symptoms are consistent with an ulcer
Which type of leukocyte is involved w/ allergic responses and the destruction of parasitic worms?
A) Eosinophils
A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?
A) Evaluate the newly hired UAP's level of competency by observing the UAP deliver care
An adult male reports that he recently experience an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolo which maintains his blood pressure at 130/74 mmHg. Which risk factors should the nurse explore further with the client? (SATA)
A) Family health history C) History of hypertension
After an inservice about EHR security and safeguarding PT information, the nurse observes a colleague going home w/ printed copies of PT information in a uniform pocket. Which action should the nurse take?
A) File a detailed incident report w/ the specific hiring facility
An older client is admitted in respiratory distress secondary to heart failure (HF), coronary artery disease (CAD), hypertension (HTN), and atrial fibrillation. Which nursing problems should the nurse include in this client's plan of care? (SATA)
A) Fluid volume excess B) Decreased cardiac output C) Altered peripheral tissue perfusion E) Fatigue
A mother brings her child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?
A) Frequency that the child uses a rescue inhaler during the week
An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the PT's compliance with self care?
A) Have the Patient vocalize the instructions provided
A PT has w/ Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The PT's lab values include: NA 129 mEq/L, glucose 54 mg/dl and K 5.3. When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medication
A) Hydrocortisone
The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication?
A) Hypertension
A young woman w/ multiple sclerosis just received several immunizations in preparation for moving into a college dormitory. Two days later, she reports to the nurse that she is experiencing increasing fatigue and visual problems. What teaching should the nurse provide?
A) Immunizations can trigger a relapse of the disease, so get plenty of extra rest
The nurse is caring for a PT admitted for evaluation of a descending aortic aneurysm. While outside the room documenting, the nurse hears the PT screaming. The PT tells the nurse that the pain is "sharp, like something inside is ripping and tearing." The PT also reports dizziness. Which of the following is the likely cause?
A) Impending rupture of the aneurysm
A female who is undergoing chemotherapy tells the nurse that she plans to volunteer at the elementary school this winter. Which question is best for the nurse to ask this client?
A) Is it possible that you will be in direct contact with the children at the school?
When conducting diet teaching for a PT who is on a postoperative full liquid diet, which foods should the nurse encourage the PT to eat? SATA
A) Lentils B) Potato soup C) Tea
The charge nurse in an extended care facility is organizing unit activities for the day. Which action may be safely delegated to the practical nurse?
A) Measure the PT's body weight each morning
A male client with a history of mitral valve prolapse is admitted because of fever and dyspnea on exertion, and is diagnosed with acute infective endocarditis. During the admission assessment, the nurse observes multiple areas of petechiae on the client's skin. Which interventions should the nurse include in the client's plan of care? (SATA)
A) Monitor cardiac rhythm via telemetry. B) Report changes in pre-existing murmurs. E) Initiate contact transmission precautions.
The nurse caring for a child w/ mononucleosis can expect the child to exhibit which symptoms?
A) Positive Epstein-Barr, and malaise
While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab value?
A) Potassium
A female child is brought to the emergency department after awakening with a bark-like cough and stridor. Upon arrival to the hospital, her respirations are labored, and she is drooling. What action should the nurse implement?
A) Prepare for emergency tracheotomy
A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vital signs are temperature 99.6 F, heart rate 98 beats/minute, respirations 18 breaths/minute, blood pressure 140/82 mmHg and oxygen saturation 88%. Which action should the nurse implement?
A) Prepare for endotracheal intubation
The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is BEST for the nurse to implement?
A) Provide dolls and equipment to re-enact feelings associated with painful procedures
A nurse determines that more than 25% of the students at a middle school are overweight. The nurse presents the information at a parent-teacher meeting. What action is most important for the nurse to include in the meeting?
A) Provide information on ways to increase activity for the family
A low risk primigravida at 28 weeks gestation arrives for her regular antepartal clinic visit. Which assessment finding should the nurse consider within normal limits for this client?
A) Pulse increase of 10 beats/minute
The home health nurse is scheduling visits for clients with diabetes who need blood glucose measurements, one postoperative client who needs wound care, and two new clients who need admission assessments and care plans established. Staffing includes one nurse (RN) and two licensed practical nurses (PN). Which is the best home visit assignment?
A) RN completes the two admission assessments. One PN completes the blood glucose measurements, and one PN completes the postoperative visit
A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which interventions should the nurse implement? (SATA)
A) Report serum albumin and globulin levels D) Note signs of swelling and edema E) Monitor abdominal girth
A PT w/ cirrhosis of the liver is admitted w/ complications r/t end stage liver disease. Which interventions should the nurse implement? SATA
A) Report serum albumin and globulin lvls C) Note signs of swelling and edema D) Monitor abnormal girth
An older male PT who was successfully treated for shingles with an antiviral medication reports that he is now experiencing pain on his trunk where the lesions were located. Which action should the nurse take?
A) Review the medication record to determine when the analgesic was administered
The nurse is caring for a client with a history of neuropathy who reports increasing numbness and tingling in the lower extremities. Which problem should the nurse determine is the priority for promoting foot care at this time?
A) Risk for infection.
An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gain. Which assessment is most important for the nurse to report to the healthcare provider?
A) Serum lithium level of 1.6 mEq/L or mmo/L
Which snack selection indicates to the nurse that a school-aged boy w/ gastroesophageal reflux understands his dietary restrictions?
A) Sugar cookies
An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. which response is best for the nurse to provide?
A) Tell the client to discuss the medication side effects with the healthcare provider
The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse (SATA)
A) Thirst and frequent requests for bathroom breaks B) Shaking that changes the child's handwriting legibility E) Sunburn with blisters on the face, arms, and hands
What statement by a PT who is 24 hrs post-subtotal thyroidectomy requires an immediate investigation by the nurse?
A) When I get out of bed quickly, I feel a little dizzy
Following a house fire, an adult male is admitted to the ER w/ partial and full thickness burns. He used a blanket to cover his head and face, but his skin is burned on the dorsal surfaces of both arms and hands and his anterior legs. Using the Rule of Nines to assess the extent of the PT's burns, what percentage of burned body surface area should the nurse document?
B) 27%
The nurse who is working on a surgical unit receives change of shift report for a group of clients for the upcoming shift. A client with which condition requires immediate attention by the nurse?
B) Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills
The nurse is preparing a hepatitis teaching program. Which individual has the greatest need for teaching about prophylactic Hep B immunizations?
B) An office worker who requires hemodialysis for CKD
An older client is having photocoagulation for macular degeneration. Which intervention should the nurse implement during the post-procedure care in the outpatient surgical unit?
B) Apply bilateral eye patched while sleeping
An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?
B) Assess the surroundings for noise and distractions
When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is BEST for the nurse to implement?
B) Assure the parents that a terminal diagnosis was inevitable.
The nurse observes a client prepare a meal in the kitchen of rehabilitation facility prior to discharge. Which behaviors indicate the client understands how to maintain balance safely? (SATA)
B) Bends from the waist to pick trash off the floor D) Brings a heavy can close to the body before lifting
The mother of a child with cerebral palsy (CP) ask the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?
B) Brain damage with CP is not progressive but does have a variable course.
A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assess the client's vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement?
B) Check neurovascular status of the distal digits.
When caring for a PT w/ full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention? SATA
B) Complaint of increased pain and pressure C) Change in the quality of the peripheral pulses D) Loss of sensation to the left lower extremity
A client's telemetry monitor indicates ventricular fibrillation (VF). Which action should the nurse implement immediately?
B) Defibrillate with one shock
A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on hands, face, and on the front of the child's clothes. After ensuring the airway is patent, what action should the nurse implement first?
B) Determine type of chemical exposure
A new nurse preparing to irrigate an intravenous catheter is attaching a 24-gauge needle. Which action should the charge nurse implement?
B) Direct the nurse to change IV tubing
The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include?
B) Divide the medication into 2 injections with volumes under 1 mL
A PT arrives for an annual physical exam and complains of having calf pain. The PT's health history reveals peripheral arterial disease. Which question should the nurse ask the PT about expected findings r/t chronic arterial symptoms?
B) Does the calf pain occur when walking short distances?
A 12 y/o PT who had an appendectomy 2 days ago is receiving 0.9% normal saline at 50 mL/hr. The PT's urine specific gravity is 1.035. What action should the nurse implement?
B) Encourage popsicles and fluids of choice
A PT is admitted to the ICU w/ syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?
B) Evaluate swallow
The nurse asks the parent to stay during the examination of a male toddler's genital area. Which intervention should the nurse implement?
B) Examine the genitalia as the last part of the total exam
The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the start of the procedure?
B) Experiences facial swelling after eating crab
An adult male was diagnosed with stage IV lung cancer 3 weeks ago. His wife approaches the nurse and asks how will she know that her husband's death is imminent because their 2 children want to be there when he dies. Which is the best response by the nurse?
B) Explain that the PT will start to lose consciousness and the body systems will slow down
A client with generalized anxiety disorder does not want to communicate with friends, smokes 2-3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?
B) Focus on small achievable tasks, not taxing problems
The nurse is assessing a male client with a history of Addison's disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that the he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The healthcare provider diagnoses acute adrenal insufficiency. Which medication will most likely be prescribed?
B) Hydrocortisone 100 mg IV every 6 hours until systolic BP reaches 110 mmHg
A female client who has a borderline personality disorder is being discharged today. When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that "My favorite nurse is on duty now." Which response is BEST for the nurse to provide to this client's dichotomous tendency?
B) I am happy that you are getting better and will be able to go home.
A client in menopause reports being lactose intolerant. She exercises 3 times a week, drinks wine 1 to 3 times a month, and drinks a cup of coffee daily. which instruction should the nurse provide to the client to reduce her risk of developing osteoporosis?
B) Increase calcium intake
A PT is receiving IV heparin and oral warfarin after a pulmonary embolism. The nurse determines the PT's activated partial prothromboplastin time (aPTT) value is two times the control value; the prothrombin time (PT) level is the same as the control, and the international normalized ratio (INR) is 1. Which protocol prescription should the nurse implement?
B) Increase the warfarin dose
A male client with a fracture of the left femur has skeletal traction in place while waiting for surgery. The client is restless and tells the nurse that he needs to urgently urinate. What intervention should the nurse implement?
B) Insert an indwelling urinary catheter
A client with cirrhosis of the liver is having numerous, liquid, incontinent stools, and continues to be confused. In reviewing the client's laboratory studies, the nurse identifies an elevated serum ammonia level. Based on this finding, which prescription is MOST important for this client to receive?
B) Lactulose
A client with syndrome of inappropriate antidiuretic hormone secretion (SIADH) is admitted with hyponatremia. Which intervention is most important for the nurse to include in the plan of care to protect the client from injury?
B) Limit oral water intake
A PT w/ a history of using illicit drug intravenously is admitted w/ Kaposi's sarcoma. Which intervention should the nurse include in this PT's admission plan of care?
B) Monitor for secondary infections
The nurse is preparing a teaching plan for an older female client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?
B) Names 3 home safety hazards to be resolved immediately.
An older adult male who is in his early 70's is admitted to the ER because of a COPD exacerbation. The PT is struggling to breath and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the PT, asks the nurse to stop the procedure and provides the nurse a copy of the PT's living will. What action should the nurse take?
B) Notify the healthcare provider of the PT's wishes
A client with cellulitis of the right great toe has been taking an antibiotic for 7 days. Which assessment should the nurse complete to determine the effectiveness of the medication?
B) Observe for signs of inflammation on and surrounding the toe.
A client with a history of upper respiratory symptoms is admitted with chest tightness, a productive cough, and difficulty breathing. The clients arterial blood gases indicate respiratory acidosis. An increase in which lab test result supports this finding?
B) PaCO2
The nurse is providing teaching to a client who has been recently diagnosed with gestation diabetes mellitus. Which complication poses the GREATEST risk to the fetus is euglycemia is not maintained?
B) Preterm birth
The nurse is feeding a client who was admitted this morning with syncope and generalized weakness. The client has a history of aspiration and begins coughing while attempting to drink through a straw. Which action should the nurse implement?
B) Provide nectar thickened liquids
Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?
B) Report any painful urination, blood in urine, or fever
A client with atrial fibrillation receives a new prescription for dabigatran etexilate. Which instruction is important for the nurse to emphasize when teaching the client about this medication?
B) Report unusual bruising or bleeding
The nurse notes that an older client has a moist cough that increases in severity during and after meals. Based on this finding, which action should the nurse take?
B) Request a consultant to confirm dysphagia.
A client has had several episodes of clear, watery diarrhea that started yesterday. What action should the nurse implement?
B) Review the client's current list of medications
A client is admitted with a diagnosis of urolithiasis. Which finding is most important for the nurse to report to the healthcare provider?
B) Serum potassium level is elevated
Which lab results should the nurse closely monitor in a PT who has end-stage renal disease?
B) Serum potassium, calcium, and phosphorus
When assessing a 6-month-old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant?
B) Sitting upright
A male PT w/ right-sided weakness calls for assistance w/ ambulating to the bathroom. What action should the nurse implement?
B) Stand on the PT's right side as he walks
The nursing staff on a medical unit includes a registered nurse, a practical nurse, and an unlicensed assistive personnel. Which task should the charge nurse assign to the RN?
B) Supervise a newly hired graduate nurse during an admission assessment
After receiving report on an inpatient acute care unit, which client should the nurse assess first?
B) The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity
The nurse is teaching a PT newly diagnosed w/ systemic lupus erythematosus (SLE). Which information is accurate for the nurse to provide?
B) The disease is characterized by alternating periods of flare-ups and remissions
A client who is admitted to the ICU with a right chest tube attached to a THORA-SEAL chest drainage unit becomes increasing anxious and complains of difficulty breathing. The nurse determines the client is tachypneic with absent breath sounds in the client's right lung fields. Which additional finding indicates that the client has developed a tension pneumothorax?
B) Tracheal deviation toward the left lung
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? (SATA)
B) Use a residual limb shrinker C) Wash the stump with soap and water D) Inspect skin for redness
While caring for a toddler receiving O2 via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?
B) Use a water soluble lubricant on affected oral and nasal mucosa
The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?
B) Vitamin supplements for high-risk pregnant women
The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?
B) Weight-bearing exercise
During discharge teaching, a male client recently diagnosed with malignant hypertension tells the nurse that he really enjoys downhill skiing and asks if he can continue with this sport. Which is the best response by the nurse?
C) "Cold weather may constrict your blood vessels raising your blood pressure"
What might the nurse suggest to a client with fibrocystic breasts in an attempt to relieve her symptoms
C) "Eliminate caffeine from your diet"
A client with delusions tells the nurse, "You aren't doing your job. Go get those people over there and shoot them before they get me." Which statement is the nurse's best response?
C) "You seem quite frightened right now."
The psychiatric nurse is caring for PTs on an adolescent unit. Which PT requires the nurse's immediate attention?
C) An 18 year old with antisocial behavior who is being yelled at by other Patients
At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, "I just know I can't handle all the pain." Which is the PRIORITY nursing problem for this client?
C) Anxiety
An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran a marathon one year ago, his spouse states that the client no longer runs, but sits and watches television most of the day. Which intervention is most important for the nurse to include in this client's plan of care for today?
C) Assist client in identifying goals for the day
A 15-year-old male client was recently diagnosed with the type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement?
C) Assist him in identifying popular fast foods that are within his meal plan for diabetes
The nurse is caring for a PT who is admitted to the ER after a motor vehicle accident. The PT begins to experience a decreased LOC and the pupils do not respond equally to light. Which vital signs changes indicate the PT is manifesting Cushing's triad?
C) BP of 180/80, bounding HR of 50, respirations of 30 w/ apneic episodes
A PT who received hemodialysis yesterday is experiencing a BP of 200/100 mmHg, HR 110 bpm, and RR 36 breaths/min. The PT manifesting SOB, bilateral 2+ pedal edema, and an O2 sat of 89%. Which action should the nurse take first?
C) Begin supplemental O2
The mother of a 12-month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a lost of appetite. Which instruction should the nurse provide?
C) CPT should be performed more frequently, but at least an hour before meals
When caring for a client with full-thickness burns to both lower extremities, which assessment findings warrant immediate intervention by the nurse? (SATA)
C) Change in the quality of the peripheral pulses D) Loss of sensation to the left lower extremity E) Complaint of increased pain and pressure
A nurse is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms requires the most immediate intervention by the nurse?
C) Chest discomfort one hour after consuming a large- spicy meal
A PT is admitted w/ the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use in planning the PT's care?
C) Confusion
A PT is admitted w/ acute pancreatitis. The PT admits to drinking a pint of bourbon daily. The nurse medicates the PT for pain and monitors vital signs every 2 HRs. Which finding should the nurse report immediately to the healthcare provider?
C) Confusion and tremors
The nurse is caring for a PT who is entering the 2nd stage of labor. Which action should the nurse implement first?
C) Convery to the PT that birth is imminent
A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?
C) Current diagnosis of hepatitis B
The nurse should expect a client diagnosed with regional enteritis (Crohn's disease) to exhibit what initial symptoms?
C) Diarrhea, abdominal pain, and weight loss
The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?
C) Dilated pupils, tachycardia, elevated blood pressure, elation
The nurse observes a PN pouring warm water over the perineal area of a female PT who has frequent urinary incontinence while the PT is positioned on a bed pan. Which action should the nurse take?
C) Evaluate the effectiveness of this measure to stimulate PT voiding
The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobaimain two days ago. He tells the nurse that he is worried that she may be getting Alzheimer's disease. What action should the nurse take?
C) Explain that memory loss and confusion are common with Vitamin B12 deficiency
In caring for a Patient with Cushing's syndrome, which serum lab value is most important for the nurse to monitor?
C) Glucose
A toddler is brought to the emergency department after ingesting several tablets of acetaminophen from a bottle that the toddler found in the mother's purse. The healthcare provider prescribes acetylcysteine solution for oral administration. Which action should the nurse implement if the child vomits?
C) If does is vomited within 1 hour of administration, repeat that oral dose
After several months of chronic fatigue, morning stiffness, and joint pain, a young adult is diagnosed w/ rheumatoid arthritis, and the HCP prescribes prednisone. Which education should the nurse provide the PT w/ regard to taking prednisone?
C) If sequential doses are missed, notify the HCP
A client is experiencing withdrawal from the benzodiazepine alprazolam is demonstrating severe agitation and tremors. What is the BEST initial nursing action?
C) Initiate seizure precautions
A client with chronic renal insufficiency is preparing for the discharge from the hospital. Which information is most important for the nurse to include in this client's discharge teaching?
C) Instructions regarding a restricted protein diet
An older client arrives to the emergency department (ED) with reports of severe nausea and vomiting large amounts of liquid brown emesis at home. The client's vital signs are temperature 95.4F, heart rate 112 beats/minute, respirations 14 breaths/minute, and blood pressure 74/37 mmHg. Which intervention is most important for the nurse to implement?
C) Keep head of bed raised 45 degrees
The nurse is assessing a 4-year-old with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?
C) Keep the nails trimmed short
The nurse is caring for a seated PT who is experiencing a tonic-clonic seizure. Which actions should the nurse implement? SATA
C) Loosen restrictive clothing D) Note the duration of the seizure E) Ease the PT to the floor
A client with acute renal failure (ARF) is admitted for uncontrolled type 1 diabetes mellitus and hyperkalemia. The nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in this client's plan of care?
C) Monitor the client's cardiac activity via telemetry
A client with deep vein thrombosis in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?
C) Observe for bleeding side effects related to heparin therapy
An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal "increase daily intake of fluids". What nursing intervention is most useful in assisting the resident to meet this goal?
C) Offer glass of fluid every hour while awake
The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every 2 hours. What additional action should the nurse instruct the UAP to take each time the client is turned?
C) Offer the client oral fluids
The nurse is evaluating a tertiary prevention program for PTs w/ cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective?
C) PTs who incurred disease complications promptly received rehab
A client is admitted to the hospital after experiencing a stroke or cerebral vascular accident. The nurse should request a referral for a speech therapy if the client exhibits which finding?
C) Persistent coughing while drinking
After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which interventions should the nurse take to prepare the body before the family enters the room? (SATA)
C) Place a small pillow under the head. D) Remove resuscitation equipment from the room. E) Gently close the eyes
The nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome (SIDS). Which information is most important to provide parents of newborns and infants?
C) Position the infant in a supine position while sleeping
The nurse observes an UAP applying an alcohol-based hand rub while leaving a PT's room after taking vital signs. What action should the nurse take?
C) Remind the UAP to continue rubbing the hands together until they are dry
Which laboratory values are critical for the nurse to monitor for a client who is experiencing thyrotoxic crisis?
C) Renal and liver function tests
Following a total knee replacement, a PT is discharged from the hospital w/ a prescription for warfarin. In reviewing discharge teaching, the PT tells the nurse that he will avoid eating foods high in potassium, such as bananas and melon. How should the nurse respond?
C) Review teaching about the effects of food rich in Vitamin K
A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?
C) Send a stool sample to the lab for a guaiac test
A male PT on the psych unit is making sexual advance towards a female nurse. Which action should this nurse implement first?
C) Tell the PT in a matter-of-fact manner to stop the sexual advances
A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?
C) This hernia is a normal variation that resolves without treatment
An older client returns to the clinic and receives refills on several medications. The client shares concerns with the nurse about having to take so many medications and asks if one pill could be substituted for many of the others. Which instruction should the nurse implement to address the client's concerns?
C) Use a medication reminder system to prevent forgetting to take the right medications at the right time
Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer?
C) Use a sponge to debride the affected area
While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?
D) Administer a nebulizer treatment
A client with peptic ulcer disease receives a prescription for intermittent suction via a Salem Sump nasogastric tube (NGT). After inserting the NGT and obtaining coffee-ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit, the client complains of nausea. Which action should the nurse implement first?
D) Administer a prescribed antiemetic agent
The charge nurse of a critical care unit is informed at the beginning of the shift that less that less than the optimal number of registered nurses will be working that shift. In planning assignments, which client should receive the most care hours by a RN?
D) An 82 year oid Patient with Alzheimer's disease and a newly-fractured femur who has a foley catheter and soft wrist restraints applied
After years of struggling with weight management, a middle-age man is evaluated for gastroplasty. He has experienced difficulty with managing his diabetes mellitus and hypertension, but he is approved for surgery. Which intervention is most important for the nurse to include in this client's plan of care?
D) Apply sequential compression stockings
The nurse enters a client's room to administer oral medications and finds an unlicensed assistive personnel providing personal care to the client, whose condition has obviously deteriorated. The client is lying in a supine position and is weak, pale, and diaphoretic. What is the priority nursing action?
D) Ask the UAP to position the client so the oral medication can be administered.
The nurse is caring for a PT w/ chronic obstructive pulmonary disease (COPD) who uses O2 at 2 L/min per nasal cannula continuously. The nurse observes that the PT is having increased SOB w/ respirations at 23 breaths/minute. Which action should the nurse implement first?
D) Assess the delivery mechanism of the O2 tank, tubing, and cannula
A male PT who fell of a roof has right and left femur fractures and crushing injuries to both ankles. He is supine w/ bilateral skin traction applied to the lower extremities while awaiting surgery within the next 4 hrs. When asked to evaluate his pain on a scale of 1-10, he screams 20. For the last 4 hrs, he has received morphine 2 mg IV hourly. His vital signs are HR 130 bpm, RR 32 breaths/min, BP180/90. Which intervention is most important for the nurse to implement?
D) Assess the extremities for signs of compartment syndrome Q2 hours
A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?
D) Assessment of a bruit on the left forearm
An unconscious client is admitted to the intensive care unit and is placed on a ventilator. The ventilator alarms continuously and the client's oxygen saturation is 62%. Which action should the nurse take first?
D) Begin manual ventilation immediately
The nurse is caring for a client who has been diagnosed with malnutrition. Which finding supports the medical diagnosis?
D) Body mass index (BMI) of 17
An adult PT is admitted to the psychiatric unit because of a daily, complex handwashing ritual that takes 2 hours or longer to complete. The PT worries about staying clean and refuses to sit on any of the chairs in the day area. This PT's handwashing is an example of which clinical behavior?
D) Compulsion
The nurse is caring for a client is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first?
D) Continue to monitor intake and output with the next exchange
After initiating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take NEXT?
D) Continue with the blood pressure assessment
The nurse is caring for a client entering the second stage of labor. Which action should the nurse implement first?
D) Convey to the client that birth is imminent
The practical nurse is preparing a client for a lumbar puncture. The nurse observes the PN turning the client on the side with the legs straight and the head of the bed in semi-Fowler's position. Which action should the nurse implement?
D) Demonstrate to the PN how to position the client more effectively for the procedure
The nurse knows that several complications can occur with the administration of blood. Which finding is an indication of an air emboli?
D) Difficulty breathing
An adult PT is admitted to the ER after falling from a ladder. While waiting to have a CT scan, the PT requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the PT asks for something stronger. Which intervention should the nurse implement?
D) Explain the reason for using non-narcotics
A clinical trial is recommended for a female PT w/ metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. The PT's son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond?
D) Explore the PT's decision to refuse treatment and offer support
A 41 week gestation primigravida woman is admitted to labor and delivery for induction of labor. Which finding should the nurse report to the healthcare provider before initiating the infusion of Oxytocin?
D) Fetal heart tone located in upper right quadrant
The healthcare provider prescribes methylergonovine maleate for a postpartum PT w/ uterine atony. What finding should indicate to the nurse to withhold the next dose of the medication?
D) HTN
In assessing a client at 34-weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28%, a heart rate of 92 beats per minute, and a systolic murmur. Which finding requires follow-up?
D) Hematocrit of 28%
A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?
D) Hemoglobin
A male client with stomach cancer returns to the unit following a total gastrectomy. He has a NG tube to suction and is receiving lactated ringer's solution at 75 mL/hr IV. One hr after admission to the unit, the nurse notes 300 mL of blood in the suction canister, the client's HR is 155 bpm, and his blood pressure is 78/48 mmHg in addition to reporting the findings to the surgeon, which action should the nurse implement first?
D) Increase the infusion rate of Lactated Ringer's solution
A 46-year-old male client who had a myocardial infarction 24-hours ago comes to the nurses station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?
D) Ineffective coping related to denial
The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider IMMEDIATELY?
D) Intensifying headache
When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus, the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?
D) Leave the client's room and return later in the day
A new mother on the postpartum unit runs out of the room screaming that her newborn infant's crib is empty and the baby is missing. What action should the nurse take first?
D) Match ID bands of all infants and mothers on the unit
When caring for a PT w/ a TBI who had a craniotomy for ICP, the nurse assesses the PT using the GCS every 2 hrs. For the past 8 hrs the PT's GCS score has been 14. What does the GCS finding indicate about this client?
D) Neurologically stable w/o indications of an increased ICP
A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration. The medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 mins after the admission assessment, should the nurse report immediately to the emergency department healthcare provider?
D) No wheezing upon auscultation of the chest
An older adult male who is in his early 70's is admitted to the emergency department because of a COPD exacerbation. The client is struggling to breath and the healthcare team is preparing for endotracheal intubation. The spouse's wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provides a copy of the client's living will. Which action should the nurse take?
D) Notify the healthcare provider of the client's wishes
A client is admitted with possible urosepsis. Which intervention should the nurse perform as soon as possible?
D) Obtain a urine specimen for a prescribed culture and sensitivity test
Which client's vital signs indicating increased intercranial pressure should the nurse report to the healthcare provider?
D) P 55, BP 160/70; P 50, BP 194/70 mmHg; irregular respirations
To prevent medication errors by an older PT who is sometimes confused, which intervention by the home health nurse is likely to be most effective?
D) Provide education both verbally and in written format
A client with end-stage renal disease (ESRD) is refusing all treatment and requests that no life-saving measures be implemented. The healthcare provider refuses to write do-not-resuscitate instructions. Which action should the nurse take?
D) Provide the healthcare provider with a copy of the client's bill of rights
A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the IV line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement?
D) Redress the abdominal incision
A client with renal lithiasis is receiving morphine sulfate every 4 hours for pain and renal colic. Which assessment finding should prompt the nurse to administer a PRN dose of naloxone?
D) Respiratory rate of 12 breaths/minute
A multiparous client who delivered her infant 3 hours ago asks the nurse if she can take a warm sitz bath because it helped reduce perineal pain after her last delivery. What action should the nurse implement?
D) Review the use of sitz bath equipment with the client.
The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the client understands the prescribed diet?
D) Roast turkey, canned vegetables
The nurse is preparing to administer an IV dose of ciprofloxacin to a client with a urinary tract infection. Which client data requires the most immediate intervention by the nurse?
D) Serum creatinine of 4.5 mg/dL
A client with diabetes insipidus has an average urinary output of 500 mL of dilute urine every hour for the last 4 hours. Which laboratory test is most important for the nurse to monitor?
D) Serum sodium
The nurse is assigned to care for a PT diagnosed w/ psoriasis. Which behavior by the nurse addresses this PT's psychosocial need for acceptance?
D) Shaking the PT's hand during an introduction
An older PT is admitted w/ fluid volume deficit and dehydration. Which assessment finding is the best indicator of hydration that the nurse should report to the healthcare provider?
D) Skin tenting occurs when the PT's forearm is pinched
A client who is pregnant seems confused and presents with the onset of headache, polyuria, and blurry vision. Which action should the nurse implement?
D) Take serial blood pressure readings
An older male was recently admitted to the rehab unit w/ unilateral neglect syndrome as the result of a cerebrovascular accident. Which action should the nurse include in the plan of care?
D) Teach the Patient to turn his head from side to side for visual scanning
The wife of a newly-diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide?
D) Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism.
The nurse is developing a plan of care for a PT who reports tingling of the feet and who is newly diagnosed w/ peripheral vascular disease. Which outcome should the nurse include in the plan of care for this PT?
D) The PT's skin on the lower legs will be intact at the next clinic visit
The nurse is caring for 4 PTs: PT A, who has emphysema and whose O2 saturation is 94%; PT B, w/ a postoperative hemoglobin of 8.2 mg/dL; PT C, newly admitted w/ a potassium level of 3.8 mEq/L; and PT D, scheduled for an appendectomy who has a WBC count of 14,000 mm3. What intervention should the nurse implement?
D) Verify that PT B has two units of packed cells available
A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond?
a. Explain that counseling will be provided to give her information about her cancer risk.
