RN HESI Exit Exam Remediation

A client with hypertension has a prescription for 8 mg of candesartan cilexetil PO daily. The medication is available as a 16 mg tablet. How many tablets should the nurse administer? (Enter numeric value only, rounded to the tenth.)

0.5 Tablet

The nurse is preparing to administer an IM dose of 1 million units of penicillin G potassium (Buffered Penicillin G Potassium for Injection). The medication is available in powdered form and the vial is labeled, "Add 1.8 mL of diluent for a concentration of 500,000 units/mL." How many mL of medication should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

2mL

A male client tells the home health nurse that he takes two tablespoons of a liquid antacid every day. How many mL of medication should the nurse document? (Enter numeric value only.)

30mL Rationale: Each tablespoon = 15 mL.15 mL x 2 tablespoons = 30 mL.

The nurse is providing education to a client and family on hospice. Which information should the nurse provide about hospice care? a) "Hospice views dying as a natural process." b) "Hospice assists the family in finding a cure." c) "Pain medications are not given in hospice." d) "Hospice follows a naturopathic model of healing."

a) "Hospice views dying as a natural process."

A universal outcome for victims of rape is grief resolution. Which statement by the victim indicates that progress toward this outcome has been made? a) "I have begun to stop blaming myself for being raped." b) "If I had not worn that skirt to the party, the rape would not have happened." c) "I need to make sure that I do not go out alone anymore." d) "I feel ashamed that I could not defend myself against my attacker."

a) "I have begun to stop blaming myself for being raped."

The nurse is providing education to a pregnant client about how to prevent urinary tract infections (UTIs). Which statement by the client indicates the need for further education? a) "I should take a bath every day." b) "I should urinate frequently." c) "I should increase fluid intake." d) "I should avoid tight-fitting pants."

a) "I should take a bath every day."

The nurse is educating a client with premature rupture of membranes. Which statement from the client indicates that learning has occurred? a) "I will be monitored closely for signs of infection." b) "I will be placed on antibiotics for 3 days." c) "I can go home tomorrow as long as I don't go into labor." d) "I will begin taking corticosteroids at 34 weeks gestation."

a) "I will be monitored closely for signs of infection."

An adolescent client diagnosed with bulimia nervosa and an underlying depression is prescribed fluoxetine (Prozac) 10mg daily. The client asks, "What will this medicine do inside my brain?" The nurse is correct to provide which response? a) "It will regulate a neurotransmitter called serotonin." b) "It will raise the levels norepinephrine in your brain." c) "It will balance blood glucose and dopamine levels." d) "It will block the overproduction of the neurotransmitter GABA."

a) "It will regulate a neurotransmitter called serotonin."

During a family therapy session, the parents of a client diagnosed with anorexia nervosa ask if there is any neurobiological basis for this behavioral disorder. Which explanation by the therapist is accurate? a) "Research has discovered abnormal serotonin pathways." b) "Researchers feel that ingesting certain chemical additives triggers the disease." c) "Eating disorders develop when increased levels of adrenaline cause suppression of hunger." d) "Eating disorders are initially caused by infections of the gastrointestinal system."

a) "Research has discovered abnormal serotonin pathways." Rationale The etiology of eating disorders is varied and complex. From a neurobiological basis, brain scans have demonstrated alterations in the serotonin pathway. The alteration in serotonin can result in reduced impulse control, mood problems, and altered motivation for eating and enjoying food.

The nurse is teaching a pregnant client about the need for increased caloric intake during the second and third trimesters of pregnancy. Assuming the client had a normal pre-pregnancy weight, how many additional kilocalories per day should the nurse recommend? a) 300. b) 400. c) 500. d) 600.

a) 300. Rationale It is important that appropriate caloric intake is maintained throughout pregnancy to provide for adequate growth of the fetus and the health of the mother. It is recommended that caloric intake be increased by 300 kilocalories per day during the second and third trimesters of pregnancy.

When performing a literature review to develop a hospital policy, which resource takes a higher priority to inform the policy? a) A single randomized controlled trial, well-designed. b) A trial well-designed, but not randomized. c) A systematic review of well-designed qualitative studies. d) A single descriptive study citing evidence from a qualitative study.

a) A single randomized controlled trial, well-designed. Rationale Resources range from most reliable to least reliable. A single randomized controlled trial that is well-designed is the most evidence-based option and second only to meta-analysis of multiple randomized controlled trials.

Which behaviors indicate that the treatment plan for a client in alcohol rehabilitation has been effective? a) Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has spoken with employer about returning to work. b) Abstinent 15 days; states that the drinking problem has been overcome; plans to find a new line of work with new coworkers. c) Attends Alcoholics Anonymous daily; states that many of the members are real alcoholics; denies having any problems at work. d) Attends Alcoholics Anonymous once per week; states a willingness to stop drinking during the day; plans to drink occasionally after work.

a) Abstinent 10 days; states that sobriety is to be accomplished one day at a time; has spoken with employer about returning to work.

When caring for an infant with gastrointestinal reflux disorder (GERD), the nurse should be alert for which complication? a) Apnea. b) Weight gain. c) Abdominal distension. d) Swelling of the extremities.

a) Apnea.

A client who compulsively performs handwashing rituals throughout the day is being treated for obsessive compulsive disorder (OCD). Which behavior change indicates that treatment has been effective? a) Arrives at the dining hall on time for every meal for the last 2 days. b) Exhibits good hygiene habits for the last week. c) Reads educational material regarding his illness. d) Begins to wash the floors after returning from outside excursions.

a) Arrives at the dining hall on time for every meal for the last 2 days.

The nurse is preparing discharge instructions for a client who has been prescribed medications to suppress their T-cells activity due to "graft-versus-host- disease" status post bone marrow transplant. Which instructions should be included in the discharge instructions to prevent infection? Select all that apply a) Avoid crowds and other gatherings with large groups. b) Eat a least five servings of fresh fruit and vegetables a day. c) Take your temperature twice a day and report > 100°F (38°C). d) Do not drink water that has been standing longer than 15 minutes. e) Bathe or shower every other day using antimicrobial soap and shampoo.

a) Avoid crowds and other gatherings with large groups. c) Take your temperature twice a day and report > 100°F (38°C). d) Do not drink water that has been standing longer than 15 minutes.

The sibling of a young client with borderline personality disorder asks the nurse why the client has frequent mood changes. Which is the best response by the nurse to explain the neurobiological basis of this behavior? a) Brief shifts in mood are caused by an imbalance of nervous system chemicals that help regulate emotions. b) Shifts in mood are the result of an intolerance to certain chemicals found in food substances. c) Mood changes are due to the client's emotional immaturity and lack of insight into this behavior. d) Mood changes are common in clients during this phase of life due to hormonal changes.

a) Brief shifts in mood are caused by an imbalance of nervous system chemicals that help regulate emotions. Rationale Affective instability is characterized by brief shifts in mood. This condition is attributed to excessive limbic reactivity in the neurological circuits responsible for the regulation of the neurotransmitter, GABA.

While monitoring a client with adrenal insufficiency, the nurse notices that the client's vital signs are beginning to deteriorate. Which action should the nurse take? a) Call the physician. b) Complete a full physicial assessment. c) Encourage the client to ambulate. d) Decrease the rate of intravenous fluids.

a) Call the physician.

The nurse is counseling a pregnant client who is HIV positive. Which information should the nurse give to the client? a) Cesarean delivery is encouraged. b) The infant will receive oral zidovudine for 1 week after birth. c) HIV therapy should be discontinued until the second trimester. d) Breastfeeding is recommended.

a) Cesarean delivery is encouraged. Rationale It is important to test for HIV and understand the treatment options for the client and the fetus. The pregnant HIV positive women continue with their medication regime during the pregnancy and C-sections are usually scheduled for the 38th week of pregnancy. Although vaginal deliveries are a possibility for a client with HIV, cesarean delivery is highly encouraged to prevent transmission to the fetus.

The nurse uses an acuity-based model to determine staffing needs on the unit. The nurse determines the required level of care by evaluating the health status progress of the clients based on the admitting disease process. Which outcome is the nurse evaluating? a) Clinical. b) Functional. c) Risk reduction. d) Protective factor.

a) Clinical.

The nurse is caring for a 68-year-old nursing home client with human immunodeficiency virus (HIV). Which expected outcome is likely to occur as the client ages? a) Cognitive decline. b) Weight gain. c) Skin rash. d) Intolerance to antiviral medication.

a) Cognitive decline. Rationale Dementia associated with HIV/AIDS may be mistaken for Alzheimer's disease. Older adults with HIV are at higher risk for cognitive decline.

The nurse is caring for a pregnant client who has expressed concerns about her cravings for "nonfood" items. Which reported craving increases the client's risk for gestational diabetes? a) Corn starch. b) Ice chips. c) Baking soda. d) Tooth paste.

a) Corn starch. Rationale Pica refers to the consumption of nonfood substances, or food items that lack nutritional value. Consuming excessive amounts of corn starch may contribute to gestational diabetes.

While performing a skin assessment on an older adult client, the nurse notes that the client's skin is very dry and has an uneven color. Which change explains these findings? a) Decreased activity of apocrine and sebaceous glands. b) Decreased proliferative capacity. c) Decreased peripheral blood supply. d) Decreased melanin and melanocytes.

a) Decreased activity of apocrine and sebaceous glands.

Which physiological abnormality is associated with fibromyalgia? a) Decreased blood flow to the hypothalamus. b) Decreased levels of substance P in the spinal fluid. c) Increased tryptophan levels. d) Increased serotonin levels.

a) Decreased blood flow to the hypothalamus.

While caring for a pregnant client, the nurse explores ways the client can prioritize her role in her family and in her home. Which outcome shows that this intervention has been effective? a) Decreased episodes of fatigue. b) Decreased episodes of nausea. c) Increased maternal weight. d) Increased maternal sleep.

a) Decreased episodes of fatigue.

The nurse is preparing to educate a client with newly diagnosed diabetes. Which strategies are most effective in providing client education? Select all that apply a) Determine which extrinsic and intrinsic factors motivates the client. b) Assess the client's ability to retain and recall newly acquired information. c) Ensure the client teaching material is written at least 12th grade level. d) Limit the complexity at each teaching session based on client's attention span.

a) Determine which extrinsic and intrinsic factors motivates the client. b) Assess the client's ability to retain and recall newly acquired information. d) Limit the complexity at each teaching session based on client's attention span.

In palpating the liver of a female client, the nurse feels the edge of the liver as a firm, regular ridge as the client inhales. What action should the nurse take in response to this finding? a) Document the finding. b) Remove pressure immediately. c) Ask the client to hold her breath. d) Check for ascites.

a) Document the finding. Rationale Feeling the edge of the liver as a firm, regular ridge as the client inhales is a normal finding during an abdominal assessment. This normal finding should be documented in the healthcare record.

The nurse is coaching a client during labor. When should the nurse encourage the mother to push during the second stage of labor? a) During contractions. b) After the contraction. c) Before the contraction. d) In- between contractions.

a) During contractions.

The nurse is assisting in the care of a client who is in labor. The nurse notices that when the client pushes, the fetal heart rate slowly declines for 20 seconds before returning to baseline. How should the nurse identify this alteration in fetal heart rate? a) Early deceleration. b) Late deceleration. c) Variable decelerations. d) Prolonged decelerations.

a) Early deceleration.

A client is status-post liposuction procedure on their hips and thighs. Which post-op complications should the nurse assess for in this client? Select all that apply a) Emboli. b) Infection. c) Hematoma. d) Fat necrosis. e) Depigmentation.

a) Emboli. b) Infection. c) Hematoma

What qualities should a professional nurse possess? Select all that apply a) Ethical. b) Advocacy. c) Cheerfulness. d) Flamboyancy. e) Accountability.

a) Ethical. b) Advocacy. e) Accountability.

The nurse is counseling the parents of a child with adrenocortical insufficiency. The nurse should educate the parents about the signs and symptoms of which condition that can occur as a result of prolonged hydrocortisone therapy? a) Gastric ulcers. b) Weight loss. c) Drowsiness. d) Decreased blood pressure.

a) Gastric ulcers. Rationale Corticosteroids, such as hydrocortisone, may cause impaired gastric mucus production and gastric bicarbonate secretion. Prolonged use of hydrocortisone may result in abdominal pain and increased vulnerability to ulceration.

A nurse travels to different parts of the country and changes nursing assignments every 4 months. What should the nurse do to ensure that culturally competent nursing care is delivered? Select all that apply a) Gather health disparities information about the region. b) Review the occurrence and prevalence of illnesses for that region. c) Become familiar with the different cultural practices of the region. d) Become acquainted of the generalizations of particular ethnic groups. e) Partner with local healers to educate them about Western medicine.

a) Gather health disparities information about the region. b) Review the occurrence and prevalence of illnesses for that region. c) Become familiar with the different cultural practices of the region.

A client has been prescribed Vincristine for the treatment of acute lymphoblastic leukemia. The prescribed dose is 1.25mg intravenously (IV) once a week. The medication is available in 1mg/10mL normal saline. How should the nurse prepare to administer this medication? a) Give 12.5 mL directly through IV over one minute. b) Infuse medication over 30 minutes via a syringe pump. c) Dilute into a 50mL bag of normal saline and infuse 120mL/hour. d) Add to 1000mL bag of D5W and infuse at 100mL/hour.

a) Give 12.5 mL directly through IV over one minute.

The nurse is providing nutritional counseling to a pregnant adolescent client who needs to increase her fiber intake. Learning has occurred if the client identifies which type of food as a good source of fiber? a) Green leafy vegetables. b) Fish and seafood. c) Refined grains. d) Dairy products.

a) Green leafy vegetables. Rationale The nurse should discuss the importance of adding a variety of healthy foods to the diet. Learning has occurred if the client identifies green leafy vegetables as a good source of fiber. Constipation is a common discomfort of pregnancy and a diet of fiber should help alleviate that problem. Green leafy vegetables are also a good source of vitamin A and C.

The nurse is assessing a client who has reported 7 episodes of diarrhea in the past 24 hours. What questions would determine a possible causative factor of the diarrhea? Select all that apply a) Have you been experiencing any stress or anxiety lately? b) Does the diarrhea have a strong, unpleasant odor to it? c) What type of food have you eaten within the last 36 hours? d) What medications and supplements are you currently taking? e) When did you last urinate and what was the color and amount of the urine?

a) Have you been experiencing any stress or anxiety lately? b) Does the diarrhea have a strong, unpleasant odor to it? c) What type of food have you eaten within the last 36 hours? d) What medications and supplements are you currently taking?

While caring for a client during labor, the nurse notices early decelerations on the fetal heart rate monitor. The nurse should recognize which factor as the cause? a) Head compression from fundal pressure. b) Uterine tachysystole. c) Umbilical vein compression. d) Spontaneous fetal movements.

a) Head compression from fundal pressure.

Which intervention should the nurse implement to assist a child and the family to reduce the risk of an asthma exacerbation? a) Help them recognize triggers. b) Encourage peak pulmonary flow measurement. c) Demonstrate use of MDI spacer. d) Provide emergency treatment plan.

a) Help them recognize triggers.

A 15-year-old female student visits the school nurse to ask about date rape and pregnancy. She confides to the nurse that her boyfriend forced her to have sex against her will. Which initial intervention is the priority for the nurse to implement? a) Identify the student's immediate concerns and feelings. b) Administer a pregnancy test. c) Teach methods of birth control. d) Explain safe sex practices.

a) Identify the student's immediate concerns and feelings.

The nurse reads an article about new trends in nursing career settings, such as shopping malls and fields that employ migrant workers. The article also notes a shift in emphasis toward advocacy and research. Which factor has prompted these innovative trends in nursing? a) Increased scope of practice secondary to client needs. b) Increased nursing and health care provider shortages. c) Increased awareness of nursing capabilities. d) Increased cost effectiveness.

a) Increased scope of practice secondary to client needs.

An 85-year-old client is bought to the emergency department after a fall at home. The client appears confused, malnourished, and is severely dehydrated. The client appears reluctant to explain how the fall happened. The client's daughter speaks for the client and does not allow the client to answer questions. Based on this information, which nursing intervention is a priority? a) Interview the client alone and assess for abuse. b) Take the history from the daughter because the client is confused. c) Provide the daughter with nutritional counseling. d) Request a psychiatric evaluation for the client.

a) Interview the client alone and assess for abuse.

A child who is recovering from surgery for removal of a Wilms tumor develops abdominal pain and distension, absence of bowel sounds, and vomiting. Which complication should the nurse suspect? a) Intestinal obstruction. b) Abdominal peritonitis. c) Pyloric stenosis. d) Infectious gastritis.

a) Intestinal obstruction. Rationale Surgical intervention for Wilms tumor involves removal of the tumor, which requires either a partial or radical nephrectomy. Small bowel obstruction is one of the most common postoperative complications following removal of a Wilms tumor.

The charge nurse is educating a new nurse on the care of clients with trauma. Which statement is true of blunt trauma? a) It can be caused by falls from a high level. b) It is the least common of all traumas. c) It is a form of penetrating trauma. d) It is categorized as either a medium- or high-velocity injury. e) It can be caused by falls from a high level. f) It can be caused by falls from a high level.

a) It can be caused by falls from a high level.

In what ways does the Health Insurance Portability and Accountability Act (HIPAA) protect individuals? Select all that apply a) It gives clients the right to consent to disclosure of their records. b) It gives the clients the ability to choose private rooms only. c) It keeps individuals from losing health insurance when changing jobs. d) It ensures the message boards in rooms include the plan of care to ensure continuity. e) It requires nurses to maintain reasonable privacy when communicating with or about clients.

a) It gives clients the right to consent to disclosure of their records. e) It requires nurses to maintain reasonable privacy when communicating with or about clients.

The treatment team discusses plans regarding two clients who both exhibit self-mutilating behavior. The nurse expresses concerns about the decision to use restraints on one client, while assigning one-to-one supervision for the other. Which ethical principal is the nurse concerned about violating? a) Justice. b) Autonomy. c) Beneficence. d) Fidelity.

a) Justice.

A 24-year-old client diagnosed with diabetes type I has missed several doses of insulin, states that they are not feeling well and has a fruity odor on their breath. Which condition should the nurse suspect? a) Ketoacidosis. b) Biliary atresia. c) End-stage renal disease. d) Emphysema.

a) Ketoacidosis.

The nurse is reviewing the bone marrow aspiration results of a client which revealed abnormal high amount of blast cells present. This client will most likely be diagnosed with which condition? a) Leukemia. b) Hemophilia. c) Hodgkin's Lymphoma. d) Autoimmune thrombocytopenic purpura.

a) Leukemia.

A female client diagnosed with posttraumatic stress disorder after a rape tells the health care provider that she feels anxious all the time. The client is learning yoga to help with her anxiety, but she is still unable to relax. Which medication is indicated to support the client's stress management routine by providing short-term relief of anxiety? a) Lorazepam (Ativan). b) Quetiapine (Seroquel). c) Olanzapine (Zyprexa). d) Zolpidem (Ambien).

a) Lorazepam (Ativan).

Which presentation is typically seen in a child with hyperthyroidism? a) Nervousness, palpitations, weight loss. b) Fever, weight gain, decreased appetite. c) Abdominal pain, vomiting, constipation. d) Diminished reflexes, dyspnea, bradycardia.

a) Nervousness, palpitations, weight loss.

While auscultating the abdomen of a thin older-adult client, the nurse detects a pulsatile mass. What is the correct action for the nurse to take? a) Notify the physician. b) Call an emergency code. c) Document the findings. d) Roll the patient onto his right side.

a) Notify the physician.

The nurse calculates a client's body mass index (BMI). The client's height is 6 feet and 6 inches (198cm) and the BMI is 30. How should the nurse categorize this BMI? a) Obesity. b) Overweight. c) Underweight. d) Normal weight.

a) Obesity. Rationale A BMI of 30-39 is considered obesity according to the U.S. National Institutes of Health.

The parents of a 13-year-old male client are concerned that he may not have started puberty. The client's stage of puberty is assessed using the Tanner scale of development. Which type of test is performed to determine this child's Tanner stage? a) Orchidometry. b) Radiological examination. c) Bone densitometry. d) Muscle mass calculation.

a) Orchidometry. Rationale Tanner's staging is used to assess puberty milestones and compare individuals. In males, the stages are partly based on testes volume, which is measured with an orchidometer.

The nurse is assessing a client with a deep puncture wound, accompanied with swelling and erythema noted at the base of frontal (L) knee; the area is hot to touch; and the client complains of constant, throbbing pain which increases with movement. Client's current temperature is 101.6°F (38.7°C) and their leukocytes are double the normal value and the erythrocyte sedimentation rate (ESR) reflects a normal value. The presenting clinical signs and symptoms are indicative of which condition? a) Osteomyelitis. b) Ewing's sarcoma. c) Rheumatoid arthritis. d) Compartment syndrome.

a) Osteomyelitis.

The nurse is assessing a client with stage 4 chronic kidney disease and partially compensated metabolic acidosis. Which arterial blood gas result should the nurse anticipate? a) PaCO2 26, HCO3 19, pH 7.30. b) PaCO2 52, HCO3 24, pH 7.25. c) PaCO2 41, HCO3 20, pH 7.38. d) PaCO2 42, HCO3 25, pH 7.40.

a) PaCO2 26, HCO3 19, pH 7.30.

Which interventions should the nurse encourage the client to do to improve their mood? Select all that apply a) Participate in daily cardio aerobic exercises. b) Develop a strong support system in the workplace. c) Add more caffeinated beverages to the diet. d) Increase intake of fruits and vegetables. e) Create an environment that promotes restful sleep.

a) Participate in daily cardio aerobic exercises. d) Increase intake of fruits and vegetables. e) Create an environment that promotes restful sleep.

The employee health nurse administers a hepatitis B immunoglobulin to the worker who suffered a needlestick injury with a contaminated needle. Which form of immunity is provided by this treatment? a) Passive immunity. b) Active immunity. c) Adaptive immunity. d) Natural active immunity.

a) Passive immunity. Rationale Antibody-mediated immunity involves antigen-antibody interaction to neutralize, eliminate, or destroy foreign proteins. Passive immunity is provided by administration of the hepatitis B immunoglobulins. Passive immunity occurs when the antibodies are transferred to a person's body after first being made in the body of another person or animal.

The nurse is caring for a victim of severe emotional violence inflicted by her husband. The client states that the abuse occurs most often when her husband is intoxicated, and that he is always remorseful afterwards. She also tells the nurse that her husband's father was an alcoholic who beat him and his mother. What evidence exists that the husband is at risk of becoming a perpetrator of physical abuse? a) Past childhood abuse. b) Feelings of remorse. c) Temporary behavioral changes. d) Excessive alcohol consumption.

a) Past childhood abuse.

A client with a recent stroke to the left side of the brain has decreased function in one side of the body, decreased in visual fields, and diplopia. Which interventions should the nurse include in the client's plan of care? Select all that apply a) Place an eye patch over the affected eye. b) When moving towards the client, approach from the right side. c) Support client in using both sides of the body. d) Teach the client to visually scan by turning the head from side to side. e) At mealtime, place all utensils, drink and food on the client's left side.

a) Place an eye patch over the affected eye. c) Support client in using both sides of the body. d) Teach the client to visually scan by turning the head from side to side. e) At mealtime, place all utensils, drink and food on the client's left side.

The nurse explains to a new staff member that the goals of the therapeutic milieu for eating disorder are designed to help a client establish more adaptive behavioral patterns and develop normal eating habits. Which environmental characteristics of the milieu should the nurse include? a) Precise meal times, adherence to the selected menu, observation during and after meals, and regularly scheduled weighing. b) Client freedom to decide when and what to eat, observation before and after meals, and no weighing for the first week. c) Menus that can be altered to suit the client's taste, observation before and after meals, and regular weighing. d) Client freedom to design the meals, infrequent observation to allow the client some space, and daily weighing.

a) Precise meal times, adherence to the selected menu, observation during and after meals, and regularly scheduled weighing.

The nurse is providing care for a client who is showing Goodell's sign upon assessment. What does this sign indicate? a) Pregnancy. b) Premature labor. c) Impaired intrauterine growth. d) Quickening.

a) Pregnancy.

The emergency department nurse is providing care for a rape victim. Which action represents an essential element of care for this client? a) Providing nonjudgmental care. b) Conveying outrage that this occurred. c) Sympathizing with the client's sense of shame. Encouraging the client to divulge all the details

a) Providing nonjudgmental care.

A client being treated for depression is sharing a story with an assigned counselor regarding his divorce. He smiles and states that he is not really hurt about her leaving him for a coworker because he knows that she really loves him and is just trying to make him jealous. Which defense mechanism is the client displaying? a) Reaction formation. b) Sublimation. c) Idealization. d) Rationalization.

a) Reaction formation. Rationale Reaction formation is the defense mechanism an individual displays in an attempt to deal with unacceptable feelings. Clients using this defense mechanism displays opposite feelings, such as insisting that they are happy when they are actually hurting.

The nurse is assessing a client for hypoxia. What signs and symptoms should the nurse expect? Select all that apply a) Restlessness, anxiousness and pallor in color. b) Heart rate drops and client becomes hypotensive. c) Client reports feeling dizzy and lightheaded. d) Increase in pulse and blood pressure. e) Difficulty concentrating and client appears fatigue.

a) Restlessness, anxiousness and pallor in color. c) Client reports feeling dizzy and lightheaded. d) Increase in pulse and blood pressure. e) Difficulty concentrating and client appears fatigue.

During a homecare visit, the nurse is assessing an elderly client diagnosed with bipolar depression who lives alone. The client appears disheveled and is wearing slippers on the wrong feet. The nurse observes various throw rugs, old food containers, and other trash scattered throughout the house. No smoke detectors are visible. The client is unable to recall the date or time of year and not able to have a coherent conversation. Which nursing diagnosis is the priority concern? a) Risk for injury. b) Self-care deficit. c) Nutritional deficit. d) Risk for depression.

a) Risk for injury.

What are strategies nurses could implement to help decrease the stressors in their lives? Select all that apply a) Setting realistic goals. b) Avoiding procrastination. c) Prioritizing tasks or issues. d) Setting boundaries. e) Multitasking of responsibilities.

a) Setting realistic goals. b) Avoiding procrastination. c) Prioritizing tasks or issues. d) Setting boundaries.

A 16-year-old female is bought to the emergency department following a suicide attempt. The client reports to the nurse that she is doing poorly in school, is engaging in high-risk sexual activity, and has a history of running away from home. Which assessment is the priority at this time? a) Sexual abuse. b) Pregnancy. c) Physical abuse. d) Sexually transmitted infections.

a) Sexual abuse.

A child's favorite food is fish, but the child's parent is concerned about mercury content. Which types of fish should the nurse list as highest in mercury? a) Shark, swordfish, king mackerel, and tilefish. b) Salmon, herring, and canned light tuna. c) Cod, orange roughy, and trout. d) Tilapia, shrimp, mahi mahi, and halibut.

a) Shark, swordfish, king mackerel, and tilefish.

When teaching a client how to manage gout, which food should the nurse tell the client to avoid? a) Shrimp. b) Legumes. c) Broccoli. d) Bananas.

a) Shrimp.

The nurse is caring for a client who has a fiberglass long leg cast on the right leg. Which nursing actions should be implemented in the cast care of this client? SATA a) Smelling the cast and feeling for the presence of hot spots on the cast. b) Checking neurovascular status of the right exposed foot and toes every four hours. c) Using a soft cotton-tipped 6-inch swab to help scratch beneath the cast. d) Placing the nurse's finger in the client's cast while performing cast care. e) Covering the perineal area of the cast with plastic before client uses the fracture bedpan.

a) Smelling the cast and feeling for the presence of hot spots on the cast. b) Checking neurovascular status of the right exposed foot and toes every four hours. d) Placing the nurse's finger in the client's cast while performing cast care. e) Covering the perineal area of the cast with plastic before client uses the fracture bedpan. Rationale Cast care should include ensuring the cast is not too tight, by placing a finger between the client's skin and cast; by protecting the cast from being soiled by placing a protective plastic covering in the perineal area before the client uses a bedpan; by smelling for a foul odor coming from the cast; by palpating for hot spots on the cast every shift; and by performing neurovascular checks distal to the cast every four hours. Nothing should be placed in the cast to facilitate scratching beneath the cast.

The nurse is caring for a 30-year-old client who is pregnant with twins. The client, who is in her second trimester, had a low prepregnancy weight and is currently being treated for a urinary tract infection. For which condition should the nurse monitor? a) Spontaneous preterm labor. b) Preeclampsia. c) Supine hypotension. d) Gestational diabetes.

a) Spontaneous preterm labor.

The nurse is providing care to a female Hispanic client who is experiencing decreased kidney function and a dry, scaly raised rash on her face that looks like a "butterfly" and slight deformities of the joints of her hands. The client has a past history of pericarditis. Based on these clinical signs and symptoms, nurse anticipates the client's medical diagnosis to be what? a) Systemic lupus erythematosus (SLE). b) Rheumatoid arthritis. c) Psoriasis. d) Eczema.

a) Systemic lupus erythematosus (SLE). Rationale Systemic lupus erythematous (SLE) is an autoimmune chronic inflammatory connective tissue disease. The clinical manifestations consist of a dry, scaly raised rash that has a butterfly appearance on the face, joint involvement of deformities and altered range of motion, muscular aches and atrophy, fever, kidney and pulmonary involvement. This disease affects women 10xs more than men and women of color are more often than women of Euro-American descent.

During an assessment which clinical features would lead the nurse to suspect the client is experiencing delirium? Select all that apply a) Talks incoherently either fast or slow. b) Affect is superficial, inappropriate, and labile. c) Progression of cognitive impairment is abrupt. d) Orientated to person, but not to place or time. e) Alertness fluctuates between lethargy and hypervigilance.

a) Talks incoherently either fast or slow. b) Affect is superficial, inappropriate, and labile. e) Alertness fluctuates between lethargy and hypervigilance.

The nurse is preparing to administer dinoprostone (Cervidil) under the direction of the health care provider. Which assessment finding should the nurse relay to the health care provider? a) Temperature of 101??? F (38.3??? C). b) Irregular uterine contractions every 5-8 minutes. c) Heart rate of 100 bpm. d) Early decelerations lasting 20 seconds.

a) Temperature of 101??? F (38.3??? C).

When doing an assessment of sensory nerve function, which test should the nurse omit if the pain sensation is normal? a) Temperature. b) Light touch. c) Vibration. d) Position.

a) Temperature. Rationale The temperature assessment is conducted to determine if an individual can demonstrate a distinction between a "hot" and "cold" and is only appropriate to use for further evaluation if the pain test indicates any areas of numbness or increase sensitivity.

The visiting nurse is assessing a client with early-stage dementia who has recently been prescribed donepezil (Aricept). Which information obtained from the client's family member demonstrates that the medication is effective? a) The client is showering and getting dressed with minimal assistance. b) The client uses confabulation to cover up memory loss. c) The client did not attend the family reunion last weekend. d) The client arranges to have groceries delivered.

a) The client is showering and getting dressed with minimal assistance.

The nurse is caring for a pregnant client who has been diagnosed with preeclampsia. The nurse has taught the client how to check her blood pressure at home. Which expected outcome should the nurse plan for this client? a) The client will report abnormal blood pressures to the health care provider. b) The client will lie down after a high blood pressure reading. c) The client will reduce sodium intake after a high blood pressure reading. The client will discuss high blood pressure readings at schedule appointments

a) The client will report abnormal blood pressures to the health care provider.

The nurse is interviewing for an open position at one of the city's older hospital . Which factor should make the nurse most suspicious that retention efforts may be lacking at this facility? a) There are many open positions. b) The equipment is outdated. c) There are minimal educational opportunities. d) The pay scale is comparatively low.

a) There are many open positions. Rationale Evidence indicates that nursing shortages and low staff satisfaction is directly related to a facility's inability or unwillingness to retain existing staff. Therefore, a large number of open positions in an established facility is the best evidence that reflects of poor retention efforts on the part of the facility.

The nurse is assessing a client who was out in the woods and developed a rash twenty-four hours later. The rashes are present on both lower legs and outer aspects of their hands and forearms. The appearance of these rashes are red with linear streaks of papules and vesicles which are draining clear light yellow fluid. What type of hypersensitivity/allergy reaction is this? a) Type IV: Delayed involving the release of sensitized T-cells with an antigen. b) Type I: Immediate in which the reaction of the IgE antibody on mast cells with an antigen. c) Type II: Cytotoxic in which the reaction of the IgG with the host's cell membranes and antigen. d) Type III: Immune Complex-mediated involving the formation of immune complex of antigen and antibody.

a) Type IV: Delayed involving the release of sensitized T-cells with an antigen. Rationale Type IV: Delayed hypersensitivity is the result of the reaction of sensitized T-cells with antigen and release of lymphokines, which activates macrophages and induces inflammation. Clinical examples of these types of reactions are seen with exposure to poison ivy or oak; graft rejection; positive TB skin tests and the disease sarcoidosis

The interdisciplinary treatment team is designing a plan for a client with antisocial personality. The client's behaviors include lying to other clients, flattering the primary nurse, verbally abusing a client who has Alzheimer's disease, and being argumentative at counseling sessions. Which behavior is the priority for the treatment team to address? a) Verbal abuse of another client. b) Lying to the other clients. c) Flattering his primary nurse. d) Arguing during counseling sessions.

a) Verbal abuse of another client.

The nurse is assessing the thyroid of a client with suspected hyperthyroidism. Which action should the nurse avoid while performing this assessment? a) Vigorous palpation of the gland. b) Displacement of the trachea. c) Auscultation of the carotid artery. d) Movement of the vocal cords.

a) Vigorous palpation of the gland.

A 75-year-old client reports a gradual increase in hearing loss. Which nutrients should the nurse recommend to the client to help prevent further hearing loss? a) Vitamin B12 and vitamin D. b) Zinc and copper. c) Vitamin A and vitamin C. d) Potassium and calcium.

a) Vitamin B12 and vitamin D.

The nurse is performing discharge instruction for a client with moderate congestive heart failure (CHF). Which statement by the client demonstrates the teaching was successful? a) "I can add salt to one meal each day." b) "I should season my chicken with rosemary and garlic." c) "I can have up to two glasses of wine daily." d) "Pickles are a good snack to replace electrolytes."

b) "I should season my chicken with rosemary and garlic."

The nurse case manager is preparing a discharge plan for a client who has had a total hip arthroplasty. What is the most important device the client should have at home as part of the post-op care of the hip prosthesis? a) Crutches. b) A raised toilet seat. c) An assistive ambulatory walker. d) Grab bars throughout the home.

b) A raised toilet seat. Rationale Clients who have a total hip arthroplasty (hip replacement) need to ensure that they do not flex their hips beyond 90° in order not to put strained on the hip prosthesis and cause it to dislodge out of place. Using a raised toilet seat will prevent the client flexing more than 90° (hyper flexing) when they sit down to use the toilet.

What should a nurse ensure is done for a client who is placed in a hip spica cast to prevent abdominal distention, epigastric pain, nausea and vomiting caused by a partial or complete intestinal obstruction? a) Obtaining a prescription for a stool softener. b) A square hole in the stomach area of the cast is cut out. c) Encouraging the client to drink 1.5-2 liters of fluid/day. d) Providing a diet with whole grains, raw fruit and vegetables.

b) A square hole in the stomach area of the cast is cut out.

A client contracted measles as a child. How will the client's healthy immune system respond to repeated exposure to measles as an adult? a) No change in the immune response time or intensity. b) A stronger and faster immune response will occur. c) A rebound reaction and delayed response will happen. An overwhelmed response followed by an inactive response

b) A stronger and faster immune response will occur.

A child recently treated for strep throat presents with gross hematuria, facial swelling, and elevated blood pressure. Laboratory tests reveal proteinuria and azotemia. Which condition should the nurse suspect? a) Acute pyelonephritis. b) Acute glomerular nephritis. c) Nephrotic syndrome. d) IgA nephropathy.

b) Acute glomerular nephritis. Rationale Acute glomerulonephritis (GN) usually manifests after strept throat or other streptococcal infection. Typical signs of acute GN include gross hematuria, facial edema, hypertension, and proteinuria.

The nurse is assessing the femoral insertion site of a client who recently had a cardiac catheterization. The client reports discomfort at the site. According to the standing orders, which action should the nurse implement? (Click on the chart tab for additional information. Please scroll to the bottom right corner to view all information contained in the client's medical record.) Vital signs: 1.Every 15 mins x4; then every 30 mins x 4; then every 1 hour x 2 and then 4 times daily while awake. 2. Notify Cardiologist for symptomatic hypotension; systolic BP less than 90; heart rate less than 50 beats/minute. Activity: 1.Bedrest for 6 hours; HOB less than 30 degrees for 6 hours 2.(R) leg straight for 6 hours with a 5 pounds weighted sandbag at femoral insertion site. Medications: 1. Aspirin (ASA) 325mg (1) tablet PO daily 2. Acetaminophen 300mg/ codeine phosphate 30mg (Tynelol #3) 1 to 2 tablet PO every 4 to 6 hours as needed Additional prescriptions: 1.Check cath insertion site ; distal pulses to cath insertion site; (R) leg extremity for color, temperature and movement with vital signs. 2. If bleeding occurs at femoral puncture site; apply manual pressure and notify physician if bleeding doesn't stop after 5 minutes. a) Notify the healthcare provider. b) Administer acetaminophen/ codeine phosphate. c) Place an ice pack to area of discomfort. d) Apply manual pressure to insertion site.

b) Administer acetaminophen/ codeine phosphate.

A child diagnosed with Wilms tumor is being treated with dactinomycin. What class of drug is this medication? a) Mitotic inhibitor. b) Antitumor antibiotic. c) Corticosteroid. d) Alkylating agent.

b) Antitumor antibiotic. Rationale Dactinomycin, also known as actinomycin D, is an anti-tumor antibiotic used in the treatment of a variety of cancers, including Wilms tumor.

The health care provider prescribed intermittent nasogastric tube (NGT) feedings to supplement an older client's oral nutritional intake. The nurse should administer the NGT feeding slowly in order to reduce the risk of which hazard? a) Flatulence. b) Aspiration. c) Distention. d) Indigestion.

b) Aspiration.

A client is brought to the emergency department with an apparent gunshot wound. The client is stable and is experiencing minimal pain. Which action should the nurse take next? a) Record drug allergies. b) Assess entrance and exit wounds. c) Determine blood type. d) Draw samples for lab work.

b) Assess entrance and exit wounds.

A client states that the family members living at home consist of a mother and father, two children from the mother's previous marriage, one child from the father's previous relationship and two children from this marriage. The nurse would document this family unit using what term? a) Nuclear family. b) Blended family. c) Extended family. d) Single-parent family.

b) Blended family.

An emergency department nurse is triaging an unaccompanied, unconscious client. Upon inspection the nurse notices some paradoxical movement of the anterior lower chest area. The client's blood pressure is 88/54mmHg. The heart rate is 112 beats per minute and the client's oxygen saturation via pulse oximetry is 91% on room air. Based on these findings which condition should the nurse suspect? a) Lung tumor. b) Broken ribs. c) Pneumothorax. d) Pulmonary infiltrates.

b) Broken ribs. Rationale The client's presenting symptom of paradoxical movement of the thorax cavity is indicative of broken ribs or one rib that is fractured in more than one place. This condition is referred to as a "flail chest". The paradoxical chest movement is often accompanied by client complaints of pain, especially when coughing or trying to breath deeply. Other symptoms include dyspnea, cyanosis, tachycardia and hypotension depending upon how severe the injury.

A teenager is admitted to the hospital diagnosed with anorexia nervosa. Which condition should the nurse evaluate the client for? a) Osteoarthritis. b) Cardiac arrhythmia. c) Asthma. d) Bowel ischemia.

b) Cardiac arrhythmia. Rationale Anorexia nervosa (AN) is an eating disorder characterized by self-imposed starvation and extremely low body weight. Cardiac arrhythmias are common in clients with AN due to electrolyte imbalances related to the self-imposed starvation

A 67-year-old client takes amitriptyline hydrochloride (Elavil) to manage neuropathic pain associated with diabetic neuropathy. The client has developed severe xerostomia since starting this medication. Which strategy should the nurse recommend for relief of xerostomia? a) Use a dehumidifier at night. b) Chew sugar-free gum. c) Increase dietary sodium. d) Increase caffeine intake.

b) Chew sugar-free gum.

A nursing team is reviewing its quality improvement plan. Which source of data will answer the question, "Are there fewer nosocomial infections this year"? a) Nurses' quarterly clinical performance evaluations. b) Client's outcomes from delivery of care processes. c) Post discharge client satisfaction surveys. d) Recommendations from the hospital's review committee.

b) Client's outcomes from delivery of care processes.

The nurse should monitor for which clinical indicator when caring for an older client with cholelithiasis and obstructive jaundice? a) Blanching of the skin. b) Dark urine. c) Dark brown stool. d) Coffee-ground emesis.

b) Dark urine.

The nurse is monitoring a client who has just returned from a liver biopsy. Which sign should alert the nurse that a serious complication has occurred as a result of this procedure? a) Confusion. b) Decreased blood pressure. c) Nausea and vomiting. d) Hematoma at the incision site.

b) Decreased blood pressure. Rationale A liver biopsy is performed by inserting a needle into an area of the liver to remove a small sample of tissue. Because the liver is highly vascular, a small amount of bleeding is expected; however, a drop in blood pressure may indicate that a significant amount of bleeding has occurred.

The nurse is reviewing medication information with an older client who was prescribed famotidine (Pepcid) for dyspepsia. Which information should the nurse include regarding the effects of this medication? a) Reduces gastrointestinal peristalsis. b) Decreases secretions in the stomach. c) Relieves cramping and bloating. d) Neutralizes gastric acidity.

b) Decreases secretions in the stomach.

The nurse is caring for a client who has just been placed on lisinopril for treatment of hypertension. The nurse should educate the client about what common side effect of this medication? a) Frequent urination. b) Dizziness. c) Dry skin. d) Increased hunger.

b) Dizziness.

During asucultation of the client's peripheral lung fields, the nurse hears vesicular breath sounds. What action should the nurse take in response to this assessment? a) Listen again after the client coughs. b) Document the normal finding. c) Assess for signs of fluid overload. d) Notify the healthcare provider.

b) Document the normal finding.

Autism spectrum disorders (ASD) primarily manifest in children at what developmental stage? a) Infancy. b) Early childhood. c) School-age. d) Adolescence.

b) Early childhood.

The nurse is preparing a client education class at the adult senior center about strokes. Which mnemonic should be used to teach to assess for the warning signs of a stroke? a) RACE. b) FAST. c) STOP. d) ABCD.

b) FAST.

The client has been diagnosed with iron deficiency anemia. The nurse should anticipate that the client will need which medication? a) Hyoscyamine. b) Ferrous sulfate. c) Fiber supplements. d) Lactulose.

b) Ferrous sulfate.

A client is 28 weeks pregnant. Her obstetrical history consists of two spontaneous abortions before 20 weeks; one elective abortion at 10 weeks; one child who was born at 38 weeks and another child born at 27 weeks gestation. The children are now ages 5 and 3 years old. The nurse is using the GTPAL recording system to document obstetric history. How should the nurse document the GTPAL in this client's electronic medical record (EMR)? a) G5-T1-P1-A2-L2. b) G6-T1-P1-A3-L2. c) G6-T2-P0-A3-L2. d) G5-T1-P1-A3-L2.

b) G6-T1-P1-A3-L2. Rationale The EMR should indicate: G6-T1-P1-A3-L2. G= Gravida number of pregnancies total = 6 (include current pregnancy).T= Term; 1 term infant at 38 weeksP= Premature; 1 premature infant at 27 weeksA= Abortion; 2 spontaneous abortions and 1 elective abortionL=Living; 2 living children

A 72-year-old man is brought to the emergency department by ambulance with fever and abdominal pain. He had a colon resection 1 week prior due to colon cancer, and his wife states that he seems "slower," and that he experiences dizziness upon standing. He had an IV placed prior to arrival, and the health care provider suspects sepsis. Which intervention is the priority? a) Initiate a sepsis bundle. b) Give a rapid crystalloid fluid bolus as ordered. c) Start broad-spectrum antibiotics as ordered. d) Replace the pre-hospital IV.

b) Give a rapid crystalloid fluid bolus as ordered.

Which characteristics have been associated with substance abuse? Select all that apply a) Self reflection. b) Grandiosity. c) Manipulation. d) Low risk taking. e) Dysfunctional anger.

b) Grandiosity. c) Manipulation. e) Dysfunctional anger.

The nurse is leading a committee which is evaluating sentinel events across all nursing units. Which situation should the committee review as a sentinel event? a) Needlstick injuries when they have occurred at least 10 times in a year. b) Hemolytic transfusion reactions involving major blood group incompatibilities. c) Loss of power to the surgical suites during en electrical storm. d) Dissatisfaction comments noted on client surveys.

b) Hemolytic transfusion reactions involving major blood group incompatibilities. Rationale A sentinel event is a client safety event defined by The Joint Commission as an unexpected occurrence involving death or serious physical or psychological injury or the risk of injury.

The nurse is assigned to care for an irritable and fatigue 11-year-old child who has been unable to gain weight despite excessive consumption of calories. While talking to the client, the nurse noticed the child appeared to be restless and demonstrated a slight tremor, and possessed physical characteristics of bulging eyes, and a goiter. Which condition should the nurse suspect? a) Hypoparathyroidism. b) Hyperthyroidism. c) Hyperparathyroidism. d) Hypothyroidism.

b) Hyperthyroidism. Rationale Graves disease is the most common cause of hyperthyroidism in children, which most often presents between six (6) to fifteen (15) years of age. Signs typically include unexplained weight loss, excessive hunger, prominent or bulging eyes, enlarged thyroid (goiter), and tachycardia, along with emotional lability and restlessness.

The nurse is caring for a client who takes a sulfonylurea. Which is the greatest risk in taking this medication? a) Hyperglycemia. b) Hypoglycemia. c) Hypocalcemia. d) Hypercalcemia.

b) Hypoglycemia.

The nurse is performing an admission assessment on an older client who has been admitted for severe partial-thickness and full-thickness burns of their legs and buttocks. Which condition is the client at greatest risk developing initially? a) Blood dyscrasia. b) Hypovolemic shock. c) Severe respiratory congestion. d) Opportunistic infection.

b) Hypovolemic shock. Rationale Hypovolemic shock produced by burns occurs most often in people with large partial-thickness or full-thickness burns. It is caused primarily by a shift of plasma from the vascular space into the interstitial space.

A two year old client experiencing an anaphylactic reaction and respiratory distress with laryngeal spasms is being prepared for an endotracheal tube (ETT) placement. The healthcare provider has ordered 0.5mL of epinephrine 1:10,000 to be given STAT. The attempts to place an intravenous catheter were unsuccessful. What is another appropriate route to administer the epinephrine during this anaphylactic emergency? Select all that apply a) Orally. b) Interosseous. c) Intramuscularly. d) Subcutaneously. e) Endotracheal tube.

b) Interosseous. c) Intramuscularly. e) Endotracheal tube. Rationale Ideally during an anaphylactic reaction intravenously administration of epinephrine would be the best route. In the event, an intravenous route is not available, epinephrine can be administered order of preference for faster absorption, tibial interosseous, followed by endotracheal tube after the dose has been diluted in 2.5mL of normal saline before being administered down the ETT. Intramuscularly would be your last option if no other access was available due to the slow absorption rate.

Which complication typically occurs in clients with hypovolemic shock? a) Increased urine output. b) Metabolic acidosis. c) Widening pulse pressure. d) Bradycardia.

b) Metabolic acidosis.

The nurse is treating a 7-year-old female client for a broken arm. After noticing several bruises elsewhere, the nurse asks how the injuries were sustained. The client states that her father gets mad sometimes but does not mean to hurt her or her mom. The lead nurse believes the client is lying and tells the nurse to forget the information. Which action should the nurse take? a) Forget the information as instructed. b) Notify child services or administration per policy. c) Discuss the information in more detail with the child. d) Speak with the parents to uncover the truth.

b) Notify child services or administration per policy.

The UAP is assisting a client getting into the shower. The charge nurse answers a call from the cast clinic to immediately send the UAP's other assigned client to the clinic. Which action should the nurse take? a) Ask the UAP to find another team member to take the client to the clinic. b) Notify the delegating nurse of the current request from the cast clinic. c) Instruct the UAP to take the client to clinic after helping the other client taking a shower. d) While the client is showering the UAP should take the other client to cast clinic.

b) Notify the delegating nurse of the current request from the cast clinic. Rationale The charge nurse should notify the delegating nurse of the situation. The third principle of delegation is "The person to whom the assignment was delegated cannot delegate that assignment to someone else... the delegating nurse needs to be notified and reassign the task..."

The nurse is responsible for client discharge needs using a case management and primary care delivery model. When should the nurse begin planning for referrals and community resources required at discharge? a) Prior to admission. b) On admission. c) At notification of pending discharge. d) At discharge.

b) On admission.

During an assessment which clinical features would lead the nurse to suspect a client has dementia? Select all that apply a) Progression of cognitive impairment is abrupt. b) Orientated to person, but not to place or time. c) Impaired judgment and difficulty with abstract ideas. d) Alertness fluctuates between lethargy and hypervigilance. e) Affect is superficial, inappropriate and labile.

b) Orientated to person, but not to place or time. c) Impaired judgment and difficulty with abstract ideas. e) Affect is superficial, inappropriate and labile.

The nurse is coaching a client and family to resolve a current conflict around providing care to an older parent. Which steps are most effective in resolving the conflict? Select all that apply a) Review and discuss past issues and conflicts. b) Plan and determine a strategy to fix the issue. c) Determine who is at fault for the issue or problem. d) Identify and analyze the issue or problem. e) Negotiate roles and expectations on how to fix the issue.

b) Plan and determine a strategy to fix the issue. d) Identify and analyze the issue or problem. e) Negotiate roles and expectations on how to fix the issue.

The nurse is delegating vital signs for several stable clients to an unlicensed assistant personnel. Using the 4 C's method, which is the best direction to ensure directions are understood? a) Please obtain a temperature, pulse, respirations, and blood pressure for all clients in rooms 201 to 203. b) Please obtain and document the temperature, pulse, respirations, and blood pressure for each client in rooms 201, 202, and 203. c) Please obtain and document all vital signs for all clients in rooms 201, 202, and 203. d) Please obtain all vital signs for all clients in rooms 201 to 203.

b) Please obtain and document the temperature, pulse, respirations, and blood pressure for each client in rooms 201, 202, and 203.

A nurse is reviewing a client's medical history in their electronic medical record (EMR). Which of the following factors is attributed to an increase risk in the development of premature severe atherosclerosis? a) Familial history of the disease. b) Poorly managed diabetes mellitus. c) BMI of 36%, sedentary job; and lack of exercise. d) Smoking history of 20+ years; (1.5) packs per day.

b) Poorly managed diabetes mellitus.

The nurse noticed that the prescribed 12 units of NPH/aspart (75/25) insulin appeared cloudy when drawn up into the insulin syringe. What action should the nurse take? a) Discard the drawn up dose of insulin and insulin vial. b) Proceed to administer the prescribed drawn up insulin. c) Withdraw 9 units from an NPH vial and 3 units from a vial of aspart insulin.. d) Place the vial on the counter and allow the insulin to settle and clear up.

b) Proceed to administer the prescribed drawn up insulin. Rationale NPH and premixed insulin should be cloudy when mixed properly. The nurse should expect the dose of 75/25 premixed insulin to be cloudy.

The homehealth nurse is caring for an older client with frailty and failure to thrive (FTT). Which type of nutrients should the nurse recommend to their care provider to increase in the client's diet and intake? a) Carbohydrates. b) Proteins. c) Fats. d) Vitamins.

b) Proteins.

The nurse is caring for an adolescent client with transient thyroid enlargement. In addition to evaluating the size of the nodules, which intervention should the nurse include? a) Refer the client for surgical intervention. b) Reassure the client that the condition is often temporary. c) Explain that the enlargement will continue to grow. d) Provide warm compresses for swelling.

b) Reassure the client that the condition is often temporary.

While assessing a client's health history, the nurse notes that the client has been prescribed levonorgestrel and ethinyl estradiol (Lutera). Which health outcome would indicate this medication is effective? a) Pregnancy. b) Regularity of menstrual cycles. c) Enlargement of mammary tissues. d) Increase maturation of ovarian follicle.

b) Regularity of menstrual cycles.

The nurse recognizes signs that a 9-month-old toddler may be living in an abusive home. Which action is the priority for the nurse? a) Encourage the child to speak freely. b) Report the suspected abuse to local authorities. c) Document from head to feet, the physical signs of abuse. d) Test the child for sexually-transmitted diseases.

b) Report the suspected abuse to local authorities.

When caring for a client with pressure ulcers, the nurse should be alert for which complication? a) Pneumonia. b) Sepsis. c) Osteoporosis. d) Ascites.

b) Sepsis.

Which action should the nurse take when caring for a child with epiglottitis? a) Examine the throat with tongue depressor. b) Set up emergency airway equipment at bedside. c) Place the child in supine position. d) Perform a throat culture.

b) Set up emergency airway equipment at bedside.

Which type of pharmacological agent is used to treat children with attention deficit hyperactivity disorder (ADHD)? a) Proton inhibitor. b) Stimulant. c) Calcium channel blocker. d) Beta-antagonist.

b) Stimulant.

The nurse should identify which factor as the leading contributor to basal cell carcinoma? a) Dark skin. b) Sun exposure. c) Radiation therapy. d) Genetic disease.

b) Sun exposure.

The nurse working on a geriatric unit notices that many of the clients with Alzheimer's disease and dementia develop increased confusion and agitated behaviors later in the day. Which term is used to describe this behavior? a) Delirium. b) Sundowning. c) Regression. d) Depression.

b) Sundowning.

What is the preferred treatment for an adolescent client with gigantism? a) Fusion of the epiphyseal plates. b) Surgical removal of the pituitary adenoma. c) Infusion of immunoglobulin factor 1. d) Radiation therapy of the pituitary gland.

b) Surgical removal of the pituitary adenoma.

The nurse is caring for a confused and withdrawn older client who was admitted for malnutrition and dehydration. The nurse suspects that elder abuse and neglect may be present. Which element is required before abuse or neglect can be reported? a) Proof. b) Suspicion. c) Witness's written testimony. d) Client's written consent.

b) Suspicion.

In assessing the scrotum of a male client, which finding would need to be reported to the healthcare provider? a) Asymmetric appearance. b) Taut appearance of skin surface. c) Deeper pigmentation of the underside. d) Presence of sebaceous cysts.

b) Taut appearance of skin surface. Rationale The skin surface of the scrotum should appear coarse, rather than taut, which may indicate swelling or edema and should be reported to the healthcare provider.

The healthcare provider recommends that a client take 10 mL of an over-the-counter liquid cold preparation. To most accurately measure the medication at home, the nurse should instruct the client to use which type of household measurement device? a) Tablespoon. b) Teaspoon. c) One quarter cup. d) Bulb syringe.

b) Teaspoon.

A nurse riding public transportation notices a child experiencing an asthma attack. The mother of the child pulls out of her purse a medicated discus dispenser of salmeterol xinafoate, a long-acting beta2 agonist, and immediately administers to the child. What is the anticipated outcome of the administration of this medication to this child? a) Asthmatic symptoms should resolve within 5 to 10 minutes after administration of medication. b) The child's asthma attack will be unresponsive to the administration of the medication. c) The medication administration will cause an increased in the child's heart rate. The bronchioles and alveoli in response to the medication will dilate and lung expansion will increase.

b) The child's asthma attack will be unresponsive to the administration of the medication.

The nurse administered cyclobenzaprine (Flexeril) to a client approximately one hour ago. Which situation is an expected therapeutic outcome? a) The client's temperature has decreased and is now afebrile. b) The client states the pain level has gone from 8 to 3. c) The client states that heartburn pain and gas have diminished. d) The client's erythema has subsided and skin is pale pink in color.

b) The client states the pain level has gone from 8 to 3.

How is the client's confidentiality maintained when a nurse inputs client data into the electronic medical record? a) The client must give consent each time before the nurse inputs or retrieves any data. b) The nurse must log into the electronic medical record using a secured password prior to data entry. c) Because the client is admitted to the hospital, it is assumed consent is given to any employee of the hospital. d) The nurse must print a copy of the client data, date and sign the printed copy, and place it in client's chart.

b) The nurse must log into the electronic medical record using a secured password prior to data entry.

The nurse is assigned to a health care informatics team to evaluate electronic acuity systems. While the nurse reports the committee's progress to the unit, a coworker asks why the systems are not accounting for nurse competencies as part of the clinical decision support. Which response by the nurse correctly explains the role of these classification systems? a) They assist in determining nursing care hours but are not clinical decision supports with a competency framework. b) They assist in forecasting direct care hours but are not meant as a scheduling or staffing system. c) They are directly given information from the electronic medical record, such as in a prototype evaluation system. d) They are complex, factorial, and weighted databases that only look at client information.

b) They assist in forecasting direct care hours but are not meant as a scheduling or staffing system.

A client is admitted with coffee ground emesis. This symptom is indicative of which diagnosis? a) Lower GI bleed. b) Upper GI bleed. c) Appendicitis. d) Diverticulitis.

b) Upper GI bleed Rationale Stomach enzymes breaks down any blood from an upper GI bleed, which leads the vomitus to appear as dark coffee ground emesis. Coffee ground emesis is a clinical sign of an upper GI bleed.

The nurse is having difficulty locating the pedal pulses of an older client diagnosed with peripheral artery disease. Which action should the nurse perform to help locate the client's pulse? a) Apply additional pressure using three fingers. b) Use a Doppler device to locate the pulse. c) Elevate the legs above the level of the heart. d) Ask another nurse to find the pulse.

b) Use a Doppler device to locate the pulse.

The lead nurse observes that multiple nursing tasks were left uncompleted at the end of a shift on the critical care unit. The nurse then provides feedback to a novice nurse regarding strategies for improvement. Which statement by the lead nurse demonstrates the use of reflective encouragement? a) What were the exact steps performed today that led to this situation? b) What are some things that could have been handled differently? c) What goals should be put in place to remedy the incorrect actions? d) What should the healthcare provider have done differently?

b) What are some things that could have been handled differently?

A 72-year old client diagnosed with Lyme disease has been prescribed doxycycline (Vibramycin) for 21 days. Which statement by the client indicates a correct understanding of precautions when taking doxycycline? a) "I can take this with my iron pills." b) "I should take this with meals." c) "I should avoid the sun." d) "I should take this with milk."

c) "I should avoid the sun."

A client with a body mass index (BMI) of 27 asks the nurse how much weight she should gain during her pregnancy with a single fetus. Which range should the nurse recommend? a) 28-to-40 lbs (12.7 to 18.1 kg). b) 25-to-35 lbs (11.3 to 15.9 kg). c) 15-to-25 lbs (6.8 to 11.3 kg). d) 11-to-20 lbs (4.9 to 9.1 kg).

c) 15-to-25 lbs (6.8 to 11.3 kg).

A client is suspected to have an adrenal gland dysfunction. Which diagnostic laboratory test would be used to measure hormone levels and their metabolites to determine a gland's endocrine function? a) Stimulation test. b) Suppression test. c) 24-hour urine test d) Venous Sampling Test.

c) 24-hour urine test

The health care provider prescribes levodopa/carbidopa (Sinemet) for an older client with Parkinson disease. Which instruction should the nurse teach the client in regards to taking this medication? a) With the largest meal of the day. b) With a high-protein meal. c) 30 to 60 minutes before eating. d) Only when symptoms occur.

c) 30 to 60 minutes before eating.

The nurse is assessing an agitated three-year-old child who is leaning forward with their chin thrust out, mouth open, and tongue protruded with copious amount of drooling present. The client's vital signs are tympanic temperature of 103.1°F (39.5°C), pulse of 110 beats per minute and respiratory rate of 28 per minute. Which condition should the nurse suspect? a) Croup. b) Bronchiolitis. c) Acute epiglottitis. d) Gastroesophageal reflux.

c) Acute epiglottitis.

The nurse receives a prescription to administer 80 mg of furosemide (Lasix) PO to a child who weighs 44 pounds. The recommended maximum dose is 6 mg/kg. What action should the nurse take? a) Review the prescription with the healthcare provider. b) Administer half of the prescribed medication dose. c) Administer the medication as prescribed. d) Document the unusually high dosage.

c) Administer the medication as prescribed.

A client has been diagnosed with asthma. The nurse should anticipate that the client will need which medication? a) Oral prednisone. b) Azithromycin. c) Albuterol. d) Solu-medrol.

c) Albuterol.

The nurse is caring for an older client being treated for a cardiac condition who has developed "dry eyes". Which medication may be contributing to this condition? a) Procainamide (Procanbid). b) Iron supplements. c) Atenolol (Tenormin). d) Lipitor (Atorvastatin).

c) Atenolol (Tenormin). Rationale Dry eyes is an annoying side effect of some medications that can cause a client to feel like they have something in their eye or a continuous scratchy sensation. This condition can cause eye strain and discomfort to a client. Clients prescribed Atenolol for hypertension are at risk of developing dry eyes as a side effect of the medication.

A 7-year-old child is referred for evaluation due to poor performance in school assignments and disruptive behavior. The parents report that the child has difficulty waiting in lines, is often "on the go," and is unable to sit still at school and at home. What behavioral disorder should be suspected? a) Oppositional defiant disorder. b) Generalized anxiety disorder. c) Attention deficit hyperactivity disorder. d) Conduct disorder.

c) Attention deficit hyperactivity disorder.

The nurse is evaluating a client who is receiving parenteral nutrition. An assessment reveals decreased oxygenation saturation levels, shortness of breath, coughing, and decreased blood pressure. The nurse is correct to take which action? a) Remove the central catheter and insert a chest tube. b) Obtain an order for intravenous antibiotics. c) Clamp the catheter and position the patient in a left-sided Trendelenburg position. d) Perform blood glucose monitoring and retest the levels in 15-30 minutes.

c) Clamp the catheter and position the patient in a left-sided Trendelenburg position Rationale The client's symptoms indicate a potential air embolism, which may result from part of the catheter system being open or removed without being clamped. The nurse should clamp the catheter, position the client on the left side in Trendelenburg position, call the health care provider, and administer oxygen as needed.

The nurse is reviewing medication education with a client who was prescribed triamcinolone (Dermasorb) for the treatment of eczema. Which statement by the client indicates the client misunderstands safe administration? a) Apply to affected areas, avoiding contact with the eyes. b) Continue to apply medication for a few days after area has cleared. c) Cover weeping or denuded areas with an occlusive dressing after medication application. d) Affected areas treated with the medication can burn easily with sunlight exposure.

c) Cover weeping or denuded areas with an occlusive dressing after medication application.

While performing the initial physical examination of a newborn, the nurse elicits a positive Ortolani test. Which skeletal defect does this indicate? a) Septic arthritis. b) Legg-Calve-Perthes disease. c) Developmental dysplasia of the hip. d) Slipped capital femoral epiphysis.

c) Developmental dysplasia of the hip.

A client on the unit is scheduled for weighing. The nurse asks an unlicensed assistant to weigh a client. The assistant acknowledges and accepts the assignment. The nurse six hours later reviews the client's record and notes a 4.2 kg difference in weight from the previous day. The nurse should be most concerned with which right of delegation? a) Circumstance. b) Person. c) Direction/communication. d) Supervision.

c) Direction/communication.

During a physical exam, the nurse observes the external genitalia of an older adult female. The nurse notes that the client's pubic hair is thin and sparse. What follow-up action should the nurse take in response to this finding? a) Review the client's metabolic profile. b) Conduct a nutritional assessment. c) Document the finding in the medical record. d) Determine if the client uses estrogen cream.

c) Document the finding in the medical record. Rationale Changes in estrogen production following menopause result in many physical changes, including a reduction and thinning of pubic hair in the older adult woman. The nurse should document this normal finding in the client's medical record.

A client is being discharged with a prescription for hyoscyamine for irritable bowel syndrome (IBS). Which side effect of this medication should the nurse prepare the client for? a) Diarrhea. b) Blurred vision. c) Dry mouth. d) Increased tear production.

c) Dry mouth. Rationale Anticholinergic side effects are common with hyoscyamine. The nurse should prepare the client for symptoms such as dry mouth.

When counseling a client with a pressure ulcer, which type of diet should the nurse recommend to promote wound healing? a) Low sodium. b) High fiber. c) High protein. d) Low fat.

c) High protein.

The nurse is conducting an admission assessment on an 86-year-old client. Which finding is the nurse likely to observe as a result of age-related change? a) Isolated diastolic hypertension. b) Increased perspiration. c) Hypoactive bowel sounds. d) Thickening of the epidermis.

c) Hypoactive bowel sounds.

To reduce the risk of postoperative infection, the nurse should teach the client how to use which medical device? a) Pulse oximeter. b) CPAP machine. c) Incentive spirometer. d) Apnea monitor.

c) Incentive spirometer.

During rounds, the nurse checks a client's IV infusion. The client is to receive 1000 mL of Lactated Ringer's Solution over 8 hours. The IV administration set delivers 60 drops/mL. The nurse determines that the IV is currently infusing at a rate of 100 drops/minute. What action should the nurse take? a) Decrease the drop rate. b) Continue the current drop rate. c) Increase the drop rate. d) Temporarily stop the IV.

c) Increase the drop rate.

The lead nurse is concerned that current staffing methods may no longer be effective. This concern is based on clinical and human resource staffing effectiveness indicators. Which indicators are directly related to staffing effectiveness? a) Increased interventions, complex treatments, physician orders, and readmissions. b) Increased adverse drug events, client complaints, physician orders, and client acuity. c) Increased call-outs, client complaints, length of stay, and postoperative infections. d) Increased upper gastrointestinal bleeds, family complaints, readmissions, and complex treatments.

c) Increased call-outs, client complaints, length of stay, and postoperative infections.

An unlicensed assistant personnel (UAP) is providing a bed bath to a client who is 48 hours post radical neck dissection due to oral cancer. Upon turning the client to the side, the UAP notices the client's neck dressing start to ooze bright red blood. The UAP immediately applies pressure to the neck dressing and calls the nurse. What should the nurse do first? a) Raise the head of the client's bed to 45° and flex the client's knees. b) Switch out their gloved hand for the UAP's non -gloved hand. c) Instruct the UAP to gently take their hand off the client's dressing. d) Maintain direct pressure on dressing and transport client to the operating room.

c) Instruct the UAP to gently take their hand off the client's dressing.

Which nursing actions are required when performing a transcutaneous electrical nerve stimulation (TENS) procedure with a client? Select all that apply a) Place clients with pacemakers on cardiac monitors during procedure. b) To avoid trauma, do not place the electrodes over or near injury site. c) Instruct the client to adjust the intensity of TENS stimulation for pain relief. d) Ensure and review there is a healthcare provider's prescription for the TENS. e) Remove any hair or lotions from the skin where the electrodes are to be placed.

c) Instruct the client to adjust the intensity of TENS stimulation for pain relief. d) Ensure and review there is a healthcare provider's prescription for the TENS. e) Remove any hair or lotions from the skin where the electrodes are to be placed. Rationale TENS procedure requires a healthcare provider's prescription. Anything that could interfere with the electrical current pathway needs to be remove from the skin. The client is to adjust the intensity of the current until pain relief is achieved. Clients with pacemakers or arrhythmias are never to use TENS.

A client is having a surgical procedure to relieve their lower back pain caused by a herniated disk. Which surgical procedure if repeated several times may necessitate the client to have a spinal fusion? a) Allografts. b) Diskectomy. c) Laminectomy. d) Laser thermodiskectomy.

c) Laminectomy. Rationale The lamina of the spine is the posterior curvature wall of the vertebrae, enclosing the spinal cord. A laminectomy is removal of part of the laminae and facer joints of the vertebrae to allow the surgeon access to the disc space. If the laminectomy procedure is repeated several times it may cause the spine to become unstable, so a spinal fusion may have to perform.

What is the most important thing a nurse must do when working with an electronic medical record (EMR)? a) Navigate the EMR program correctly. b) Input client data in a timely manner. c) Log off the EMR when leaving the computer terminal. d) Update EMR applications and security features when prompted.

c) Log off the EMR when leaving the computer terminal.

A client's assessment findings of hoarseness and audible wheezing noted at 2-3 feet (0.61-0.91 meters); trachea deviation towards the left; breathing pattern with prolonged exhalation followed by periods of shallow breathing; tenderness and increased fremitus with light palpation on the left side of the thorax cavity's base; and an occupation history as an oil refinery plant manager for the past ten years would be indicative of which condition? a) Flail chest. b) Emphysema. c) Lung cancer. d) Pneumothorax.

c) Lung cancer. Rationale Cigarette smoking is a major risk factor and responsible for 85% of all lung cancer deaths. The other 15% causes of lung cancer are due to environmental exposure to asbestos, petroleum distillates, radiation, tar, and uranium. Pulmonary signs and symptoms of lung cancer can be the presence of hoarseness; wheezing; decreased or absent breath sounds; prolonged exhalations alternating with periods of shallow breathing; rapid shallow breathing; areas of tenderness or masses palpated on chest wall; increase fremitus in areas of tumors; decreased or absent fremitus with bronchial obstruction; tracheal deviation; pleural friction rub; asymmetry of diaphragm movement and use of respiratory accessory muscles.

During a literature review for a research study, the nurse discovers a separate study has already proved the proposed hypothesis to be true. Which action should the nurse take regarding the proposed research study? a) Discontinue the research. b) Revise the hypothesis of the current study so it is unique. c) Perform the current study as a replication study. d) Contact the authors of the original study for permission to continue.

c) Perform the current study as a replication study. Rationale Because of inherent scientific error that may exist within all research studies, hypotheses require more than one test to support their accuracy. A critical weakness with nursing research is a lack of replication. Retesting a hypothesis that has been shown to be true strengthens the findings of the earlier study and supports the use of those findings to influence clinical practice.

A mother of a two-month-old, asked the nurse what was the purpose of the administration the polio vaccine. The nurse should inform the mother that the polio vaccination series is supposed to help prevent which condition? a) Morbid obesity. b) Deteriorated mental state. c) Permanent paralysis. d) Metastatic cancer.

c) Permanent paralysis.

In assessing the flexion of a client's neck, which action should the nurse instruct the client to perform? a) Tilt the chin toward the ceiling. b) Move the chin toward each shoulder.. c) Press the chin against the chest. d) Direct one ear toward the shoulder.

c) Press the chin against the chest.

A nurse is assigned the care of a client who is presently experiencing hypovolemic shock. The client's MAP has decreased by 20 mmHg from its baseline, tissue ischemia and anoxia of non-vital organs is occurring, pulses are weak, urine output is absent and the client's skin is cool and moist. The client appears to be confused and extremely anxious. Which stage of hypovolemic shock do these clinical signs and symptoms indicate? a) Initial stage. b) Refractory Stage. c) Progressive stage. d) Non-progressive stage.

c) Progressive stage.

A client has been prescribed levodopa-carbidopa (Sinemet) for the treatment of Parkinson's disease. Which foods should the nurse instruct the client to limit while taking this medication? a) Fats. b) Non-nutritive sweeteners. c) Protein. d) Carbohydrates.

c) Protein.

The nurse is assessing a client who reports a history of hypertension, cirrhosis due to alcoholism, high cholesterol, and human papillomavirus. Which medical condition increases the risk of cancer of the reproductive organs? a) Uncontrolled hypertension. b) End-stage liver disease. c) Sexually transmitted diseases. d) Chronic hyperlipidemia.

c) Sexually transmitted diseases.

A client receives a bone marrow transplant (engraftment) from a matched donor from the bone marrow donor registry. What data determines that the engraftment was successful? a) The client's bone marrow starts to produce their own red blood cells. b) The client's antibodies take over and macrophage the donor's donated cells. c) The analysis of the client's bone marrow reveals only the donor's cells are present. d) The presence of the client's white blood cells, red blood cells and platelet counts beginning to rise.

c) The analysis of the client's bone marrow reveals only the donor's cells are present.

Which type of medication is often prescribed to treat eczema exacerbations? a) Oral steroids. b) Topical antibiotics. c) Topical steroids. d) Oral antibiotics.

c) Topical steroids.

A six-year-old client, who received a kidney transplant presents with signs including fever, decreased urine output, and tenderness over the transplanted organ. Laboratory results reveal an elevated serum creatinine level. This presentation is likely due to which cause? a) Immunosuppression medications. b) Obstructive uropathy. c) Transplant rejection. d) Nephrotic syndrome.

c) Transplant rejection. Rationale Transplant rejection is caused by the recipient's immune system response to foreign tissue. Signs that may alert the nurse to rejection of a kidney transplant include fever, tenderness over the graft area, decreased urine output, and elevated serum creatinine.

A child is brought to the clinic because of concerns about the child's excessive thirst, frequent urination, and failure to gain weight despite an adequate intake of calories. Which disorder should the nurse suspect? a) Cushing syndrome. b) Hypothyroidism. c) Type 1 diabetes mellitus. d) Congenital adrenal hyperplasia.

c) Type 1 diabetes mellitus.

The charge nurse is preparing for an influx of clients due to a large motor vehicle collision on the highway. Which question should the nurse ask emergency medical personnel to help determine mechanism of injury? a) What are the existing medical conditions? b) How old are the victims? c) Were the victims wearing seat belts? d) How are the road conditions?

c) Were the victims wearing seat belts?

How should a nurse instruct a client on the proper use of the incentive spirometer? a) Inhale holding the breath then blow continuously into the mouthpiece. b) Take small quick breaths and exhale through the mouthpiece. c) Wrap lips around the mouthpiece and inhale through the mouthpiece. d) Inhale deeply through the nose and exhale through the mouthpiece.

c) Wrap lips around the mouthpiece and inhale through the mouthpiece. Rationale Clients should be instructed to wrap lips around the mouthpiece and inhale through mouthpiece. The nurse should instruct the client to take a slow, deep breath and maintain a constant flow, like pulling through a straw. This technique helps maintain maximal inspiration and reduces risk for progressive collapse of a client's alveoli.

An older client reports to the nurse about having constipation. Which response should the nurse use to clarify the client's report of constipation? a) "Describe your daily activity." b) "Describe what you normally eat daily." c) "Describe the frequency of your bowel movements." d) "Describe the characteristics of your stools."

d) "Describe the characteristics of your stools."

The nurse is caring for a client who is 6 months pregnant. Which statement by the client indicates that she is in the expected phase of the maternal-child relationship? a) "I'm excited to be pregnant." b) "I can't wait to be a mother." c) "I think my child will be a girl." d) "I'm going to have a baby."

d) "I'm going to have a baby."

The nurse is educating a high-risk client about prevention of coronary artery disease (CAD). Which statement should the nurse include? a) "Omega fats should be minimize in your daily use." b) "Consume at least 1800 mg of sodium per day ." c) "Reduced the amount of soy products in your diet." d) "Limit the intake of sweetened beverages."

d) "Limit the intake of sweetened beverages."

A 35-year-old male client who has recently begun competitive weight lifting and asks the nurse about using human growth hormone (HGH) to help build muscle mass. The nurse should inform the client that HGH may cause which adverse effects? a) Myocardial infarction, seizure, and psychosis. b) Tendopathy, rhabdomyolysis, and tendon rupture. c) Tremors, cerebrovascular accident, and arrhythmia. d) Acromegaly, glucose intolerance, and heart problems.

d) Acromegaly, glucose intolerance, and heart problems.

A client diagnosed with kidney stones is experiencing a urine output decrease of less than 0.5ml/kg per hour; increase BUN and creatinine levels; decrease glomerular filtration rate; flank pain and wheezes and crackles in their lungs, along with 2+ pitting edema in their extremities. Which complication is the client most likely developing? a) Cystitis. b) Urolithiasis. c) Pyelonephritis. d) Acute kidney injury.

d) Acute kidney injury. Rationale The client has already been diagnosed with urolithiasis which are the diagnosed kidney stones. The client is presenting signs and symptoms of acute kidney injury as a result of the kidney stones causing obstruction(s). Decrease in urine output less than 0.5m/kg per hour; abnormal or sharp increase of BUN and creatinine levels; decrease in their GFR and signs and symptoms of fluid overload as evidence of pulmonary edema and peripheral edema and flank pain.

The nurse is conducting a health promotion presentation about stroke prevention for a group of residents in a retirement community. Which should the nurse identify as a modifiable risk factor for stroke? a) Gender. b) Race. c) Age. d) Diet.

d) Diet.

A client who is status post thyroidectomy 12 hours ago appears to be becoming increasingly anxious and is complaining about being uncomfortable and extremely thirsty. The nurse notes the client is lying in bed supine with the head of the bed elevated 30°; their neck dressing appears to be dry and intact; and NS @60ml/hr is infusing without any signs and/or symptoms of infiltration. Which intervention should the nurse implement first? a) Offer the client their prescribed pain medication. b) Obtain a prescription to obtain a serum calcium level. c) Reassure the client and state to them it appears you are anxious. d) Gently roll the client to the side and inspect the back of their neck area.

d) Gently roll the client to the side and inspect the back of their neck area. Rationale The nurse needs to gently roll the client to the side and inspect back of their neck area to ensure they are not bleeding. A client is at risk of hemorrhaging within the first 24 hours status post a thyroidectomy. One of the first signs of hemorrhaging is "thirst". Signs of restlessness or agitation and anxiety can also be a sign of hemorrhaging after an invasive procedure.

The nurse is gently talking with a client to create a relaxed state and to decrease pain. Which relaxation strategy involves this approach and focuses on positive external images such as a client's favorite place? a) Yoga. b) Meditation. c) Mindfulness. d) Guided imagery.

d) Guided imagery.

Newborn screening for hypothyroidism is performed on a 3-day-old infant. Which laboratory test results support a diagnosis of congenital hypothyroidism? a) High TSH levels with high T4 levels. b) Low TSH levels with low T4 levels. c) Low TSH levels with high T4 levels. d) High TSH levels with low T4 levels.

d) High TSH levels with low T4 levels.

A transitional care model is being implemented on the unit. A staff nurses ask the lead nurse why money is being spent to hire a transitional care nurse (TCN) instead of hiring more unit staff. Which response by the lead nurse best explains the benefits of transitional care models to the unit staff? a) TCN and staff go to the client home and community for 2-3 months at a lower salary than unit staff. b) TCN and staff use case management techniques to improve outcomes at a limited cost. c) Hiring a TCN decreases client and family complaints, which decreases staff stress and turnover. d) Hiring a TCN decreases readmissions for complex clients, which improves unit staffing issues.

d) Hiring a TCN decreases readmissions for complex clients, which improves unit staffing issues.

A venous doppler study is ordered to determine the cause of swelling in a client's right lower leg. Which action should the nurse perform to prepare the client for this test? a) Advise the client to avoid eating or drinking. b) Insert a large bore IV. c) Administer sedation. d) Inform the client that the test is not painful.

d) Inform the client that the test is not painful.

A client with Graves' disease has been prescribed methimazole. Which explanation by the nurse correctly describes how this medication works? a) It increases absorption of thyroid hormone. b) It increases availability of thyroid hormone. c) It helps the body use thyroid hormone more effectively. d) It interferes with production of thyroid hormone.

d) It interferes with production of thyroid hormone.

The facility manager posts a memo stating that the copy and paste function of the electronic medical record will be immediately disabled for all staff. Which is the most plausible reason for this action? a) It creates opportunities to plagiarize. b) It causes duplicate documentation. c) It allows documentation that is too simple. d) It results in erroneous entries.

d) It results in erroneous entries.

Which factor contributes to the development of secondary hypertension? a) Sepsis. b) Sodium consumption. c) Low body mass index. d) Kidney disease.

d) Kidney disease. Rationale Hypertension is classified as primary or secondary, depending on the underlying cause. Secondary hypertension is associated with disease states such as renal disease, adrenal tumors, and thyroid disease.

The nurse organizes and facilitates a smoking cessation support group in the community. Which group characteristic should the nurse focus the most on? a) Group productivity. b) Group cohesion. c) Task functions. d) Maintenance functions.

d) Maintenance functions.

Which nursing intervention should the nurse implement when caring for a child with nephrotic syndrome? a) Take vital signs every 2 hours. b) Restrict the number of visitors. c) Reposition the client every 2 hours. d) Monitor fluid intake and urine output.

d) Monitor fluid intake and urine output. Rationale Due to the pathophysiology of nephrotic syndrome, decreased colloidal osmotic pressure in the capillaries is decreased, resulting in overall body edema. Treatment usually includes infusion of 25% albumin and use of diuretics to help pull fluids out of the interstitial tissues back into the vascular system. Fluid intake and urine output should be carefully monitored to prevent hypervolemia and edema and monitor the efficacy of the medical interventions.

The nurse is caring for a client who is showing signs of a tension pneumothorax. Which intervention should the nurse be prepared to implement? a) Application of occlusive dressing b) Emergency thoracotomy. c) Insertion of chest tube. d) Needle thoracostomy.

d) Needle thoracostomy.

An older client is admitted to the hospital following a fall. The nurse reviews the electrocardiogram (ECG) rhythm strip and notes that the PR intervals are 0.16 seconds. Which interpretation by the nurse is correct? a) First-degree atrioventricular (AV) block. b) Second-degree atrioventricular (AV) block. c) Impending myocardial infarction. d) Normal cardiac rhythm.

d) Normal cardiac rhythm.

The nurse's assessment indicates the need to test a female client for chlamydia. Which type of urine test should be ordered to confirm this diagnosis? a) Specific gravity. b) Microscopic examination. c) Leukocyte esterase. d) Nucleic acid amplification.

d) Nucleic acid amplification. Rationale Chlamydia is a sexually transmitted disease caused by Chlamydia trachomatis bacteria. A diagnosis of chlamydia may be confirmed by a nucleic acid amplification test (NAAT), which uses a series of reactions to identify bacterial nucleic acids; NAATs can be performed on urine samples.

The lead nurse notes an increase in post-operative infections on the unit, despite the use of case management and clinical pathways. Based on the disadvantages of case management, which is the most likely explanation? a) Team members are not communicating. b) The case manager is not unit-based. c) A nurse is not the case manager. d) Nurses are focusing too much on checklists.

d) Nurses are focusing too much on checklists.

A 10-year-old client with asthma arrives at an urgent care clinic with apparent bronchial constriction. Which class of drugs should the nurse expect to be administered for this condition? a) Methylxanthines. b) Anticholinergics. c) Long-acting beta2 agonists. d) Oral corticosteroids.

d) Oral corticosteroids.

The nurse is assessing a client's cranial nerves. How can the nurse test cranial nerve VI? a) Perform the pupillary response to light. b) Perform the Webber and Rinne tests. c) Perform the shoulder shrug against resistance. d) Perform the six cardinal fields of gaze test.

d) Perform the six cardinal fields of gaze test.

During the health history, a client describes a symptom to the nurse. Which information about the symptom is best obtained by use of a numeric scale? a) Radiation. b) Quality. c) Timing. d) Severity.

d) Severity. Rationale The severity of a symptom, which is a subjective description of how "bad" the symptom feels to the client, can be rated by a scale such as a numeric or picture scale, allowing for more consistent, ongoing evaluation of improvement or worsening of the symptom's severity. Pain is a good example of how severity might be ranked using a scale.

The nurse is caring for a client with suspected basal cell carcinoma. The nurse should prepare the client to undergo which procedure to confirm the diagnosis? a) Gram stain. b) Mohs surgery. c) Scraping with KOH. d) Skin biopsy.

d) Skin biopsy.

The nurse performs an intake assessment for home and community services while understanding the disabled adult client is knowledgeable per the Intersystem model. The nurse asks the client about facilitators, barriers, and personal goals for community living. Which disability model is the nurse using to provide care for this client? a) Medical. b) Rehabilitation. c) Moral. d) Social construct.

d) Social construct. Rationale Knowledgeable nurses assist knowledgeable clients per the Intersystem Model, which requires adjusting the lens through which the client is viewed and treated; the client is an expert on responses to interventions and the nurse promotes health through collaboration and advocacy based on this knowledge. The social construct model recognizes health promotion and community participation depends upon the perceptions of self and others, as well as the environment and community barriers.

The nurse is initiating an IV transfusion of packed red blood cells for a client with sickle cell anemia. Shortly after the transfusion starts, the client becomes very agitated, begins breathing rapidly, and complains of lower back pain. Which action should the nurse implement first? a) Notify the health care provider. b) Obtain the client's vital signs. c) Infuse normal saline solution through a separate IV line. d) Stop the blood transfusion.

d) Stop the blood transfusion. Rationale Tachypnea, lower back pain, and agitation (caused by feelings of "impending doom" and confusion) are signs of a hemolytic transfusion reaction, a life-threatening complication that can occur when blood products are not compatible with the client's blood. The nurse must stop the transfusion immediately to prevent the reaction from progressing any further.

The nurse should be familiar with which federal legislation that mandates the protection of client's personal health information? a) The Wagner National Health Act of 1939. b) The Patient Protection and Affordable Care Act of 2010. c) The Consolidated Omnibus Budget Reconciliation Act of 1985. d) The Health Insurance Portability and Accountability Act of 1996.

d) The Health Insurance Portability and Accountability Act of 1996.

A client from a nursing home is admitted with diagnoses of diabetes mellitus, chronic pancreatitis and alcoholism. The healthcare provider has prescribed the client pancrelipase (Creon, Pancrease). How should the nurse document the effectiveness of this prescribed medication? a) The absence or presence of delirium tremors. b) The character and quality of abdominal pain. c) Glucometer readings before and after each meal. d) The number, frequency and consistency of stools per day.

d) The number, frequency and consistency of stools per day. Rationale Pancrelipase is a pancreatic enzyme to aid in the digestion of carbohydrates, protein and fat due to pancreatic insufficiency from the chronic pancreatitis. To evaluate the effectiveness, the nurse should record the number, frequency and consistency of the client's daily stools. If the medication is being effective the stools should become less frequent and have less steatorrhea.

The nurse is preparing a client for an esophagogastroduodenoscopy (EGD) following an episode of acute gastrointestinal bleeding. The client asks why the EGD is being performed. Which reason should the nurse give? a) To rule out malignancy. b) To remove intestinal obstructions. c) To cauterize the site. d) To locate the source of bleeding.

d) To locate the source of bleeding.

The nurse is examining a client for possible anemia. The client complains of fatigue and weight loss and appears pallor in color with slight jaundiced and has a beefy red tongue. The client also complains about poor balance and their fingers and toes feeling tingling and numb.The client's signs and symptoms are indicative of which type of anemia? a) Aplastic anemia. b) Iron deficiency anemia. c) Folic acid deficiency anemia. d) Vitamin B12 deficiency anemia.

d) Vitamin B12 deficiency anemia.

The nurse is teaching a breast-feeding class. Which recommended supplement for breast-fed babies should the nurse discuss with the class? a) Vitamin A. b) Vitamin B. c) Vitamin C. d) Vitamin D.

d) Vitamin D.

The nurse is auscultating the lung fields of a client who has been diagnosed with emphysema. The nurse notes high-pitched, whistling sounds throughout all lobes of the lung. Which term best describes this lung sound? a) Stridor. b) Crackles. c) Rhonchi. d) Wheezing.

d) Wheezing.