Nursing Fundamentals HESI Prep
A client has an anaphylactic reaction after receiving intravenous penicillin. What does the nurse conclude is the cause of this reaction? A) An acquired atopic sensitization occurred. B) There was passive immunity to the penicillin allergen. C) Antibodies to penicillin developed after a previous exposure. D) Potent antibodies were produced when the infusion was instituted
Correct Answer: C
The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. A) Orientation B) Capillary refill C) Pupillary response D) Respiratory rate E) Pulse and skin temperature F) Movement and sensation
Correct Answer: B,E,F
A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? A) A defibrillator B) An IV infusion pump C) A tracheostomy tray D) An electrocardiogram (ECG) monitor
Correct Answer: C
After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals.
Correct Answer: A
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A) Be sure to have a complete physical examination before beginning your planned exercise program. B) Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C) Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D) Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
Correct Answer: A
A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? A) Limits had to be set to control the child's crying. B) The child had a right to remain in the room with the other children. C) The child had to be removed because the other children needed to be considered. D) Segregation of the child for more than half an hour was too long a period of time
Correct Answer: B
The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A) Immediately after exhalation. B) During the inhalation. C) At the end of three inhalations. D) Immediately after inhalation.
Correct Answer: B
A nurse cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? A) Abrasion B) Fracture C) Crush injury D) Incisional laceration
Correct Answer: C
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A) 80 B) 8 C) 21 D) 25
Correct Answer: C
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia? A) Crohn's B) Cushing's C) End-stage renal D) Gastroesophageal reflux
Correct Answer: C
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse expect the dietary plan to include? A) Low in fat B) High in iron C) High in fluids D) Low in residue
Correct Answer: C
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? A) Stage I B) Stage C) Stage III D) Unstageable
Correct Answer: D
The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: A) Promote equalization of osmotic pressures. B) Prevent hypoxia associated with diaphoresis. C) Promote integrity of intracerebral neurons. D) Reduce brain metabolism and limit hypoxia.
Correct Answer: D
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. A) Tetany B) Seizures C) Diarrhea D) Weakness E) Dysrhythmias
Correct Answer: C,D,E
A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL
1.5
Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? A) 0.5 tablet. B) 1 tablet. C) 1.5 tablets. D) 2 tablets.
Correct Answer: B
After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals.
Correct Answer: A
Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? A) Encouraging daily physical exercise B) Performing yearly physical examinations C) Providing hypertension screening programs D) Teaching a person with diabetes how to prevent complications
Correct Answer: A
Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A) Chocolate pudding. B) Graham crackers. C) Sugar free gelatin. D) Apple slices.
Correct Answer: A
A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A) Sexual activity patterns. B) Nutritional history. C) Leisure activities. D) Financial stressors.
Correct Answer: B
An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is A) Prone. B) Fowler's. C) Sims'. D) Supine.
Correct Answer: B
In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly A) is to be expected, and progresses with age. B) often follows relocation to new surroundings. C) is a result of irreversible brain pathology. D) can be prevented with adequate sleep.
Correct Answer: B
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A) Arms. B) Upper torso. C) Head. D) Feet.
Correct Answer: B
A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? A) Apathy B) Euphoria C) Detachment D) Emotionalism
Correct Answer: C
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A) Adequate venous blood flow to the lower extremities. B) Estimated amount of body fat by an underarm skinfold. C) Degree of flexion and extension of the client's knee joint. D) Change in the circumference of the joint in centimeters.
Correct Answer: C
Which action is most important for the nurse to implement when donning sterile gloves? A) Maintain thumb at a ninety degree angle. B) Hold hands with fingers down while gloving. C) Keep gloved hands above the elbows. D) Put the glove on the dominant hand first.
Correct Answer: C
A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important? A) Sodium B) Calcium C) Chloride D) Potassium
Correct Answer: D
An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? A) 30 B) 60 C) 120 D) 180
Correct Answer: D
The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot.
Correct Answer: D
A nurse is teaching a patient recovering from diabetic ketoacidosis (DKA) about management of "sick days." The patient asks the nurse why it is important to monitor the urine for ketones. Which of the following statements is the nurse's best response?
Ketones accumulate in the blood and urine when fat breaks down. Ketones signal a deficiency of insulin that will cause the body to start to break down stored fat for energy.
The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. A) Whole grains B) Cooked fruit and vegetables C) Nuts and seeds D) Lean red meats E) Milk and eggs
Correct Answer: A,B,E
A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A) Give an around-the-clock schedule for administration of analgesics. B) Administer analgesic medication as needed when the pain is severe. C) Provide medication to keep the client sedated and unaware of stimuli. D) Offer a medication-free period so that the client can do daily activities.
Correct Answer: A
A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? A) Commend the client for selecting a high biologic value protein. B) Remind the client that protein in the diet should be avoided. C) Suggest that the client also select orange juice, to promote absorption. D) Encourage the client to attend classes on dietary management of CRF.
Correct Answer: A
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A) Assist the ambulating client back to the bed. B) Encourage the client to ambulate to resolve pneumonia. C) Obtain a prescription for portable oxygen while ambulating. D) Move the oximetry probe from the finger to the earlobe.
Correct Answer: A
A nurse is caring for an older adult who is taking acetaminophen (Tylenol) for the relief of chronic pain. Which substance is most important for the nurse to determine if the client is taking because it intensifies the most serious adverse effect of acetaminophen? A) Alcohol B) Caffeine C) Saw palmetto D) St. John's wort
Correct Answer: A
A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the nurse? A) "We have no record of that client on our unit. Thank you for calling." B) "The new privacy laws prevent me from providing any client information over the phone." C) "The client has requested that no information be given out. You'll need to call the client directly." D) "It is against the hospital's policy to provide you with any information regarding any of our clients."
Correct Answer: A
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A) It is important that you continue your medication while learning to meditate. B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily. C) Obtain your healthcare provider's permission before starting meditation. D) Complementary therapy and western medicine can be effective for you.
Correct Answer: A
An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
Correct Answer: A
During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A) Listen and show interest as the client expresses these feelings. B) Reinforce that this behavior means they were not true friends. C) Ask the healthcare provider for a psychiatric consult. D) Continue with the assessment and tell the client not to worry.
Correct Answer: A
Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A) 11,000 units. B) 13,000 units. C) 15,000 units. D) 17,000 units.
Correct Answer: A
The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? A) 0.5 ml. B) 1 ml. C) 1.5 ml. D) 2 ml.
Correct Answer: A
The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A) Avoid any types of sprays, powders, and perfumes. B) Wearing a mask while cleaning will not help to avoid allergens. C) Purchase any type of clothing, but be sure it is washed before wearing it. D) Pollen count is related to hay fever, not to allergens.
Correct Answer: A
The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A) Genetic and familial health disorders. B) Chronic health problems. C) Reason for seeking health care. D) Undetected disorders.
Correct Answer: A
The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A) Observe the appearance of the skin under the ice pack. B) Instruct the client regarding the need for the covering. C) Reapply the covering after filling with fresh ice. D) Ask the client how long the ice was applied to the skin.
Correct Answer: A
The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A) Client. B) Healthcare provider. C) A family member. D) Previous medical records
Correct Answer: A
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A) The client voluntarily signed the form. B) The client fully understands the procedure. C) The client agrees with the procedure to be done. D) The client authorizes continued treatment.
Correct Answer: A
Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? A) Give the infant to the client and instruct her regarding the infant's care. B) Explain to the client that she can leave, but her infant must remain in the hospital. C) Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. D) Tell the client that hospital policy prevents the staff from releasing the infant until ready for discharge
Correct Answer: A
What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? A) If the client is allowed to give consent B) The client cannot make informed decisions about health care. C) If the client is permitted to give voluntary consent when parents are not available D) The client probably will be unable to choose between alternatives when asked to consent
Correct Answer: A
What type of interview is most appropriate when a nurse admits a client to a clinic? A) Directive B) Exploratory C) Problem solving D) Information giving
Correct Answer: A
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A) Loosen the right wrist restraint. B) Apply a pulse oximeter to the right hand. C) Compare hand color bilaterally. D) Palpate the right radial pulse.
Correct Answer: A
While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A) Acknowledge that she is supporting the arm correctly. B) Encourage her to keep the joint covered to maintain warmth. C) Reinforce the need to grip directly under the joint for better support. D) Instruct her to grip directly over the joint for better motion.
Correct Answer: A
What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply. A) Count the client's respirations. B) Document the intensity of the client's pain. C) Withhold the medication if the client reports pruritus. D) Verify the number of doses in the locked cabinet before administering the prescribed dose.
Correct Answer: A,B,D
A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. A) Pain history, including location, intensity, and quality of pain B) Client's purposeful body movement in arranging the papers on the bedside table C) Pain pattern, including precipitating and alleviating factors D) Vital signs such as increased blood pressure and heart rate E) The client's family statement about increases in pain with ambulation
Correct Answer: A,C
A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. A) Ask the client what is the client's acceptable level of pain. B) Eliminate all activities that precipitate the pain. C) Administer the pain medications regularly around the clock. D) Use a different pain scale each time to promote patient education. E) Assess the client's pain every 15 minutes
Correct Answer: A,C
The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. A) Allergy to the medication B) Itching in the ear canal C) Drainage from the ear canal D) Tympanic membrane rupture E) Partial hearing loss in the affected ear
Correct Answer: A,C,D
A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. A) Clean the eyelid and eyelashes. B) Place the dropper against the eyelid. C) Apply clean gloves before beginning of procedure. D) Instill the solution directly onto cornea. E) Press on the nasolacrimal duct after instilling the solution.
Correct Answer: A,C,E
A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. A) "What is diabetes?" B) "What will my friends think?" C) "How do I give myself an injection?" D) "Can you tell me how the glucose monitor works?" E) "How do I get the insulin from the vial into the syringe?
Correct Answer: A,D
The nurse manager is planning to assign an unlicensed assistive personnel (UAP) to care for clients. What care can be delegated on a medical-surgical unit to a UAP? Select all that apply. A) Performing a bed bath for a client on bed rest B) Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3) C) Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered D) Assisting a client who has patient-controlled analgesia (PCA) to the bathroom E) Assessing the wound integrity of a client recovering from an abdominal laparotomy
Correct Answer: A,D
An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply. A) Assessment of skin turgor B) Documentation of vital signs C) Assessment of intake and output D) Administration of antiemetic drugs E) Replacement of fluid and electrolytes
Correct Answer: A,D,E
A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A) In 8 weeks you will be able to bend at the waist to reach items on the floor. B) Place a pillow between your knees while lying in bed to prevent hip dislocation. C) It is safe to use a walker to get out of bed, but you need assistance when walking. D) Take pain medication 30 minutes after your physical therapy sessions.
Correct Answer: B
A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? A) Administer the medication more rapidly using the same IV site. B) Initiate an alternate site for the IV infusion of the medication. C) Notify the healthcare provider before administering the next dose. D) Give the client a PRN dose of aspirin while the medication infuses.
Correct Answer: B
A client is receiving an intravenous (IV) infusion of 5% dextrose in water. The client loses weight and develops a negative nitrogen balance. The nurse concludes that what likely contributed to this client's weight loss? A) Excessive carbohydrate intake B) Lack of protein supplementation C) Insufficient intake of water-soluble vitamins D) Increased concentration of electrolytes in cells
Correct Answer: B
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? A) 13 ml/hour. B) 63 ml/hour. C) 80 ml/hour. D) 125 ml/hour.
Correct Answer: B
A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? A) Famotidine (Pepcid) B) Methyldopa (Aldomet) C) Ferrous sulfate (Feosol) D) Levothyroxine (Synthroid)
Correct Answer: B
A client who had abdominal surgery is receiving patient-controlled analgesia (PCA) intravenously to manage pain. The pump is programmed to deliver a basal dose and bolus doses that can be accessed by the client with a lock-out time frame of 10 minutes. The nurse assesses use of the pump during the last hour and identifies that the client attempted to self-administer the analgesic 10 times. Further assessment reveals that the client is experiencing pain still. What should the nurse do first? A) Monitor the client's pain level for another hour. B) Determine the integrity of the intravenous delivery system. C) Reprogram the pump to deliver a bolus dose every eight minutes. D) Arrange for the client to be evaluated by the health care provider.
Correct Answer: B
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? A) What is your daily calorie consumption? B) What vitamin and mineral supplements do you take? C) Do you feel that you are overweight? D) Will a clear liquid diet be okay after surgery?
Correct Answer: B
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A) Autopsy of the body is prohibited. B) Blood transfusions are forbidden. C) Alcohol use in any form is not allowed. D) A vegetarian diet must be followed.
Correct Answer: B
A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the nurse to take? A) Ask about any past history of drug abuse or addiction. B) Measure the pulse volume and capillary refill distal to the infiltration. C) Compress the infiltrated tissue to measure the degree of edema. D) Evaluate the extent of ecchymosis over the forearm area.
Correct Answer: B
A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A) Irrigate the nasogastric tube with sterile normal saline. B) Reposition the client on her side. C) Advance the nasogastric tube an additional five centimeters. D) Administer an intravenous antiemetic prescribed for PRN use.
Correct Answer: B
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A) 9 a.m., 1 p.m., and 5 p.m. B) 8 a.m., 4 p.m., and midnight. C) Before breakfast, before lunch and before dinner. D) With breakfast, with lunch, and with dinner.
Correct Answer: B
A nurse is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? A) Albumin B) Globulin C) Thrombin D) Hemoglobin
Correct Answer: B
A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: A) Stimulating the urge to defecate. B) Lubricating the sigmoid colon and rectum. C) Dissolving the feces. D) Softening the feces
Correct Answer: B
An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone. B) Fowler's. C) Sims'. D) Supine.
Correct Answer: B
During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? A) The nurse also should have instituted a plan to increase activity. B) The nurse provided supportive nursing care for the well-being of the client. C) Debridement of the pressure ulcer should have been done before the dressing was applied. D) Treatment should not have been instituted until the health care provider's prescriptions were received.
Correct Answer: B
Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
Correct Answer: B
In what position should the nurse place a client recovering from general anesthesia? A) Supine B) Side-lying C) High Fowler D) Trendelenburg
Correct Answer: B
On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A) Assault. B) Battery. C) Malpractice. D) False imprisonment.
Correct Answer: B
The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? A) 42 gtt/min. B) 83 gtt/min. C) 125 gtt/min. D) 250 gtt/min.
Correct Answer: B
The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? A) 1 ml. B) 1.5 ml. C) 1.75 ml. D) 2 ml.
Correct Answer: B
The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A) Clamp the tube for 20 minutes. B) Flush the tube with water. C) Administer the medications as prescribed. D) Crush the tablets and dissolve in sterile water.
Correct Answer: B
The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A) A college-age track runner with a sprained ankle. B) A lactating woman nursing her 3-day-old infant. C) A school-aged child with Type 2 diabetes. D) An elderly man being treated for a peptic ulcer.
Correct Answer: B
The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A) Talk directly to the child instead of the mother. B) Continue asking the mother questions about the child. C) Ask another nurse to interview the mother now. D) Tell the mother politely to look at you when answering.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A) Tell the UAP to use a larger cuff at the next scheduled assessment. B) Reassess the client's blood pressure using a larger cuff. C) Have the unit educator review this procedure with the UAPs. D) Teach the UAP the correct technique for assessing blood pressure.
Correct Answer: B
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A) Reassure the client that he will become accustomed to the stoma appearance in time. B) Instruct the client that the stoma will become smaller when the initial swelling diminishes. C) Offer to contact a member of the local ostomy support group to help him with his concerns. D) Encourage the client to handle the stoma equipment to gain confidence with the procedure.
Correct Answer: B
What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A) It is more difficult to find a superficial vein in the feet and ankles. B) A decreased flow rate could result in the formation of a thrombosis. C) A cannulated extremity is more difficult to move when the leg or foot is used. D) Veins are located deep in the feet and ankles, resulting in a more painful procedure.
Correct Answer: B
When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A) Establish a new nursing diagnosis. B) Note which actions were not implemented. C) Add additional nursing orders to the plan. D) Collaborate with the healthcare provider to make changes.
Correct Answer: B
Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? A) Chlorothiazide (Diuril) B) Acetazolamide (Diamox) C) Bendroflumethiazide (Naturetin) D) Demecarium bromide (Humorsol)
Correct Answer: B
While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? A) Immediately stop the infusion. B) Lower the height of the enema bag. C) Advance the enema tubing 2 to 3 inches. D) Clamp the tube for 2 minutes, then restart the infusion.
Correct Answer: B
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. A) Difficulty in swallowing B) Diminished sensation of pain C) Heightened response to stimuli D) Impaired hearing of high-frequency sounds E) Increased ability to tolerate environmental heat
Correct Answer: B,C
A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. A) After reporting severe pain B) On admission to the hospital C) Upon entering the operating room D) Before transfer to a rehabilitation facility E) At time of scheduling for the surgical procedure
Correct Answer: B,D
The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. A) Dyspnea B) Flushed face C) Precordial pain D) Increased pulse rate E) Increased blood pressure
Correct Answer: B,D
A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: A) Respiratory rate. B) Amount of oxygen in the blood. C) Percentage of hemoglobin-carrying oxygen. D) Amount of carbon dioxide in the blood
Correct Answer: C
A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the nurse should do when caring for this client is to: A) Encourage fluids. B) Administer oxygen. C) Take the temperature. D) Collect a sputum specimen
Correct Answer: C
A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant Entercoccus (VRE). After notifying the physician, which action should the nurse take to decrease the risk of transmission to others? A) Insert a urinary catheter. B) Initiate droplet precautions. C) Move the client to a private room. D) Use a high efficiency particulate air (HEPA) respirator during care.
Correct Answer: C
A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the nurse monitor this client? A) Curling ulcer B) Renal shutdown C) Metabolic acidosis D) Hemolysis of red blood cells
Correct Answer: C
A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? A) Notify healthcare provider and request to change the IV infusion to hypertonic D10W. B) Decrease in the infusion rate of the current IV and report to the healthcare provider. C) Document in the medical record that these normal findings are expected outcomes. D) Obtain potassium chloride 20 mEq in anticipation of a prescription to add to present IV.
Correct Answer: C
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A) Record the coughing incident. No further action is required at this time. B) Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
Correct Answer: C
A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong? A) Isotonic B) Isomeric C) Hypotonic D) Hypertonic
Correct Answer: C
A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? A) Trust B) Growth C) Belonging D) Independence
Correct Answer: C
A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? A) Droplet precautions B) Reverse isolation C) Surgical asepsis D) Medical asepsis
Correct Answer: C
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: A) A loss of skin elasticity and a decrease in libido B) Impaired fat digestion and increased salivary secretions C) Increased blood pressure and decreased hormone production D) An increase in body warmth and some swallowing difficulties
Correct Answer: C
A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon? A) Incisional pain B) Absent bowel sounds C) Urine output of 20 mL/hour D) Serosanguineous drainage on the dressing
Correct Answer: C
A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review? A) Nursing's Social Policy Statement B) State law regarding protection of minors C) ANA Standards of Clinical Nursing Practice D) References regarding a child's right to consent
Correct Answer: C
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A) asks relevant questions regarding the dressing change. B) states he will be able to complete the wound care regimen. C) demonstrates the wound care procedure correctly. D) has all the necessary supplies for wound care.
Correct Answer: C
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A) Healthcare provider notified of failure to collect specimens for prescribed blood studies. B) Blood specimens not collected because client no longer wants blood tests performed. C) Healthcare provider notified of client's refusal to have blood specimens collected for testing. D) Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified
Correct Answer: C
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A) A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B) The nurse assigned to care for the client who was at lunch at the time of the fall. C) The nurse who transferred the client to the chair when the fall occurred. D) The charge nurse who completed rounds 30 minutes before the fall occurred.
Correct Answer: C
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A) Position the client on the right side of the bed in reverse Trendelenburg. B) Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C) Reposition in a Sim's position with the client's weight on the anterior ilium. D) Raise the side rails on both sides of the bed and elevate the bed to waist level.
Correct Answer: C
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A) It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B) Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C) It is OK if you don't want to talk about your surgery. I will be available when you are ready. D) I will ask a woman who has had a mastectomy to come by and share her experiences with you.
Correct Answer: C
Client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the nurse emphasize when informing the client about exposure to radiation? A) The dosage is kept at a minimum. B) Only a small part of the body is irradiated. C) The client's physical condition is not a risk factor. D) Nutritional environment of the affected cells is a risk factor.
Correct Answer: C
During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? A) Request another nurse to complete the physical assessment. B) Ask the client to stop crying and tell the nurse what is wrong. C) Acknowledge the client's distress and tell her it is all right to cry. D) Leave the room so that the client can be alone to cry in private.
Correct Answer: C
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? A) ½ tablet. B) 1 tablet. C) 1½ tablets. D) 2 tablets.
Correct Answer: C
The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: A) faint, barely detectable. B) slightly weak, palpable. C) normal. D) bounding.
Correct Answer: C
The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A) Remain calm with the client and record abnormal results in the chart. B) Notify the medication nurse immediately if the pulse or blood pressure is low. C) Report the results of the vital signs to the nurse. D) Reassure the client that the vital signs are normal.
Correct Answer: C
The nurse is caring for a client that is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? A) Protein B) Glucose C) Ketones D) Uric Acid
Correct Answer: C
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10 percent dextrose and water at 54 ml/hr. D) Obtain a stat blood glucose level and notify the healthcare provider.
Correct Answer: C
The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A) Thalamus. B) Hypothalamus. C) Frontal lobe. D) Parietal lobe.
Correct Answer: C
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A) Tossed salad, low-sodium dressing, bacon and tomato sandwich. B) New England clam chowder, no-salt crackers, fresh fruit salad. C) Skim milk, turkey salad, roll, and vanilla ice cream. D) Macaroni and cheese, diet Coke, a slice of cherry pie.
Correct Answer: C
The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A) If I exercise at least two times weekly for one hour, I will lower my cholesterol. B) I need to avoid eating proteins, including red meat. C) I will limit my intake of beef to 4 ounces per week. D) My blood level of low density lipoproteins needs to increase.
Correct Answer: C
The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? A) Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. B) Develop a chart for the client, listing the times the medication should be taken. C) Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. D) Instruct the client and client's children to put medications in a weekly pill organizer
Correct Answer: C
The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? A) Occipital headache B) Periorbital crepitus C) Expectoration of blood D) Changes in vocalization
Correct Answer: C
The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: A) Force urine to back up into the kidneys. B) Suppress production of urine. C) Cause the device to pull away from the skin. D) Tear the ileal conduit
Correct Answer: C
The triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? A) Multipara in active labor B) Middle-aged woman with substernal chest pain C) Older adult male with a partially amputated finger D) Adolescent boy with an oxygen saturation of 91%
Correct Answer: C
What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients? A) Rehabilitation needs are met best by the client's family and community resources. B) Rehabilitation is a specialty area with unique methods for meeting clients' needs. C) Immediate or potential rehabilitation needs are exhibited by clients with health problems. D) Clients who are returning to their usual activities following hospitalization do not require rehabilitation.
Correct Answer: C
When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: A) Evidence B) Tort discovery C) Proximate cause D) Common cause
Correct Answer: C
When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A) Complimentary healing practices interfere with the efficacy of the medical model of treatment. B) Conventional medications are likely to interact with folk remedies and cause adverse effects. C) Many complimentary healing practices can be used in conjunction with conventional practices. D) Conventional medical practices will ultimately replace the use of complimentary healing practices.
Correct Answer: C
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. B) Hearing air pass in the stomach after injecting air into the tubing. C) Examining a chest x-ray obtained after the tubing was inserted. D) Checking the remaining length of tubing to ensure that the correct length was inserted.
Correct Answer: C
Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? A) Expresses concern about the meaning and importance of life B) Remains angry at God for the continuation of the illness. C) Accepts that punishment from God is not related to illness. D) Refuses to participate in religious rituals that have no meaning.
Correct Answer: C
Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. A) Difficulty in swallowing B) Increased sensitivity to heat C) Increased sensitivity to glare D) Diminished sensation of pain E) Heightened response to stimuli
Correct Answer: C,D
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply. A) Diplopia B) Skin rash C) Leg cramps D) Tachycardia E) Muscle weakness
Correct Answer: C,E
A client has been diagnosed as brain dead. The nurse understands that this means that the client has: A) No spontaneous reflexes B) Shallow and slow breathing C) No cortical functioning with some reflex breathing D) Deep tendon reflexes only and no independent breathing
Correct Answer: D
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A) Contact the healthcare provider and complete a medication variance form. B) Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C) Notify the charge nurse and complete an incident report to explain the missed dose. D) Give the missed dose at 1300 and change the schedule to administer daily at 1300.
Correct Answer: D
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? A) Tell the client it is nothing to worry about. B) Talk with the client further to identify the specific cause of the problem. C) Instruct the client to attempt to avoid situations that cause irritation. D) Interview the client to determine whether other mood swings are being experienced.
Correct Answer: D
A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity? A) It increases production of short-lived antibodies. B) It accelerates antigen-antibody union at the hepatic sites. C) The lymphatic system is stimulated to produce antibodies. D) The antigen is neutralized by the antibodies that it supplies
Correct Answer: D
A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? A) Obtain the pre-transfusion hemoglobin level. B) Prime the tubing and prepare a blood pump set-up. C) Monitor vital signs q15 minutes for the first hour. D) Ensure the accuracy of the blood type match.
Correct Answer: D
A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? A) Explain that anyone who speaks her language can answer her questions. B) Provide a translator only in an emergency situation. C) Ask a family member or friend of the client to translate. D) Request and document the name of the certified translator.
Correct Answer: D
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? A) Prolonged use can cause dark concentrated urine. B) The medication is best absorbed when taken on an empty stomach. C) Take the medication with aluminum hydroxide to minimize GI upset. D) Drinking alcohol daily can cause drug-induced hepatitis
Correct Answer: D
A health care provider prescribes 10 mL of a 10% solution of calcium gluconate for a client with a severely depressed serum calcium level. The client also is receiving digoxin (Lanoxin) 0.25 mg daily and an intravenous (IV) solution of D5W. The nurse's next action is based on the fact that calcium gluconate: A) Can be added to any IV solution B) Must be administered via an intravenous piggyback C) Is non-irritating to surrounding tissues D) Potentiates the action of the digoxin preparation
Correct Answer: D
A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A) demonstrates loss of remote memory. B) exhibits expressive dysphasia. C) has a diminished attention span. D) is disoriented to place and time.
Correct Answer: D
A nurse in the surgical intensive care unit is caring for a client with a large surgical incision. The nurse reviews a list of vitamins and expects that which medication will be prescribed because of its major role in wound healing? A) Vitamin A (Aquasol A) B) Cyanocobalamin (Cobex) C) Phytonadione (Mephyton) D) Ascorbic acid (Ascorbicap)
Correct Answer: D
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? A) Oral psyllium (Metamucil) B) Oral potassium supplement C) Parenteral half normal saline D) Parenteral albumin (Albuminar)
Correct Answer: D
A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? A) Tell the neighboring client to stop singing. B) Close the doors to both clients' rooms at night. C) Give the complaining client the prescribed as needed sedative. D)Move the neighboring client to a room at the end of the hall
Correct Answer: D
A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? A) Ask the client if he is okay. B) Call security from the room. C) Find out if there is anyone else in the room. D) Ask security to make sure the room is safe
Correct Answer: D
An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? A) Obtain an interpreter to explain the procedure to the client. B) Encourage the client to make her own decision regarding surgery. C) Ask the family members to provide an interpretation of the surgeon's explanation to the client. D) Tell the surgeon that the son will decide after explanation of the proposed surgery is provided.
Correct Answer: D
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A) Massage any reddened areas for at least five minutes. B) Encourage active range of motion exercises on extremities. C) Position the client laterally, prone, and dorsally in sequence. D) Gently lift the client when moving into a desired position.
Correct Answer: D
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request.
Correct Answer: D
An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A) Generalized dry skin. B) Localized dry skin on lower extremities. C) Red flush over entire skin surface. D) Rashes in the axillary, groin, and skin fold regions
Correct Answer: D
During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A) Provide additional coffee on the client's breakfast tray. B) Exchange the client's grape juice for cranberry juice. C) Bring the client additional fruit at mid-morning. D) Encourage additional oral intake of juices and water.
Correct Answer: D
Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? A) To avoid strain on the incision B) To promote drainage of the wound C) To provide stimulation for the client D) To reduce edema at the operative site
Correct Answer: D
Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? A) Anger B) Denial C) Depression D) Acceptance
Correct Answer: D
The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? A) Risk for pressure ulcer B) Risk for impaired skin integrity C) Impaired skin integrity, related to infrequent turning and repositioning D) Impaired skin integrity, related to the effects of pressure and shearing force
Correct Answer: D
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions. D) Re-oxygenate the client before attempting to suction again.
Correct Answer: D
The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A) 31 gtt/min. B) 62 gtt/min. C) 93 gtt/min. D) 124 gtt/min.
Correct Answer: D
The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A) The belief is held that the "evil eye" enters the child if anything cold is ingested. B) After surgery the child probably has refused all foods except broth. C) Eating broth strengthens the child's innate energy called "chi." D) Hot remedies restore balance after surgery, which is considered a "cold" condition.
Correct Answer: D
The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? A) Institute the prescribed blood transfusion because the client's survival depends on volume replacement. B) Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. C) Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. D) Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought
Correct Answer: D
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: A) 4 to 8 hours B) 12 to 24 hours C) 24 to 48 hours D) 72 to 96 hours
Correct Answer: D
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A) That means you have derived the maximum benefit, and the heat can be removed. B) Your blood vessels are becoming dilated and removing the heat from the site. C) We will increase the temperature 5 degrees when the pad no longer feels warm. D) The body's receptors adapt over time as they are exposed to heat.
Correct Answer: D
What is the maximum length of time a nurse should allow an intravenous (IV) bag of solution to infuse? A) 6 hours B) 12 hours C) 18 hours D) 24 hours
Correct Answer: D
When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? A) Negligence B) Malpractice C) Breach of duty D) False imprisonment
Correct Answer: D
Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A) Apply a condom catheter. B) Apply a skin protectant. C) Encourage increased fluid intake. D) Assess for bladder distention.
Correct Answer: D
Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A) Height in inches or centimeters. B) Weight in kilograms or pounds. C) Triceps skin fold thickness. D) Upper arm circumference.
Correct Answer: D
The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: A) A physiological response to stress B) A conscious defense against anxiety C) An intentional attempt to gain attention D) An unconscious means of reducing stress
Correct Answer: D
After gastric surgery a client has a nasogastric tube in place. What should the nurse do when caring for this client? A) Monitor for signs of electrolyte imbalance. B) Change the tube at least once every 48 hours. C) Connect the nasogastric tube to high continuous suction. D) Assess placement by injecting 10 mL of water into the tube
Correct Answer: A
An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A) Inquire about the source and type of pain. B) Examine the nose for congestion and discharge. C) Take vital signs for temperature elevation. D) Explore the abdominal area for distension.
Correct Answer: A
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply. A) Tremors B) Lethargy C) Palpitations D) Visual disturbances E) Decreased pulse rate
Correct Answer: A,C
A client who is suspected of having tetanus asks a nurse about immunizations against tetanus. Before responding, what should the nurse consider about the benefits of tetanus antitoxin? A) It stimulates plasma cells directly. B) A high titer of antibodies is generated. C) It provides immediate active immunity.
Correct Answer: B
A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? A) Anger B) Denial C) Bargaining D) Acceptance
Correct Answer: D
An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5% dextrose in water is to be administered over a 20-minute period. The tubing has a drop factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to run? Record the answer using a whole number. ______ gtts/min
38
A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? 1 Tell the client it is nothing to worry about. 2 Talk with the client further to identify the specific cause of the problem. 3 Instruct the client to attempt to avoid situations that cause irritation. 4 Interview the client to determine whether other mood swings are being experienced.
4
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
Correct Answer: 150
A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? A) White blood cell (WBC) count of 15,000 mm3 B) Negative protein in the urine C) Blood urea nitrogen (BUN) of 20 mg/dL D) Prothrombin of 12.0 seconds
Correct Answer: A
At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A) At the beginning, middle, and end of the shift. B) After client priorities are identified for the development of the nursing care plan. C) At the end of the shift so full attention can be given to the client's needs. D) Immediately after the assessments are completed
Correct Answer: D
The nurse is caring for a client with diabetes insipidus. The nurse should anticipate the administration of:
Desmopressin
Glucagon is used primarily to treat a patient with
Hypoglycemia
After being sick for 3 days, a client with a history of diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). The nurse should evaluate which diagnostic test results to prevent arrhythmias?
Serum Potassium