hesi exit exam practice questions

A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A . Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr.

A . Prime IV tubing with 0.9% sodium chloride.

Nurses must be accountable for their actions. If a nurse is unable to insert an IV needle in a patient's arm after several attempts causing the patient pain, accountability would require her to do which of the following?check all answers that apply A) Apologize to the patient for causing any pain. B) Report the incident to risk management. C) Admit the mistake. D) Evaluate the outcome of this action.

A) Apologize to the patient for causing any pain. C) Admit the mistake. D) Evaluate the outcome of this action. -Accountability is the acceptance of responsibility for one's actions. A nurse is always responsible for his or her actions when providing care to a patient. The nurse should apologize, admit the mistake and evaluate the outcome of the action.

In terms of organ donation, which of the following statements is accurate?check all answers that apply A) CMS requires health care facilities to report all deaths to the regional organ procurement organization. B) The Uniform Anatomical Gift Act allows people to control the disposition of their organs after death. C) UNOS maintains the nation's organ transplant waiting list. D)When a potential donor is identified, CMS should be contacted.

A) CMS requires health care facilities to report all deaths to the regional organ procurement organization. B) The Uniform Anatomical Gift Act allows people to control the disposition of their organs after death. C) UNOS maintains the nation's organ transplant waiting list. -These are all accurate statements. When a potential donor is identified one should contact the local regional OPO. The OPO coordinates the donation process after a family consents to donation.

Which of the following incidents needs to be reported by a nurse? A) Client falls B) Errors in medication administration C) A visitor has symptoms of an illness D) needle stick injuries

A) Client falls B) Errors in medication administration C) A visitor has symptoms of an illness D) needle stick injuries -In addition to the above, an accidental omission of ordered therapies are issues that should be reported. Procedure-related injuries should also be reported.

When bandaging a client's ankle, the nurse should use which technique? A) Figure eight. B) Circular. C) Recurrent. D) Spiral reverse.

A) Figure eight -The Figure eight technique is used to bandage a joint, such as an ankle, elbow, wrist, or knee. The nurse uses the circular bandaging technique to anchor a bandage; the recurrent technique to bandage a stump, hand, or scalp; and the spiral reverse bandaging technique to accommodate the increasing circumference of a body part such as when in a cast.

The charge nurse is providing an in service to the staff. The nurse identifies an unintentional tort as which of the following? A) Gross negligence. B) Manslaughter. C)Invasion of privacy. D) Battery

A) Gross negligence -Unintentional tort includes negligence and malpractice. Gross negligence is a lack of knowledge or skill that should have been known by the nurse. Further, manslaughter is a type of crime. Invasion of privacy is also incorrect.

A nurse is cleaning a wound of a 33-year-old client. The nurse cleans the wound from the center of the incision and then outward, followed by lateral motions. Which of the following best identifies this type of wound cleansing? A) Horizontal. B) Vertical. C) Lateral. D) Dorsal.

A) Horizontal -Horizontal wound cleansing involves the cleaning of the wound from the center starting at the incision site, then moving outward and laterally. Other cleansing methods are vertical and drain/stab wound.

A 42-year-old with cancer has 3 months to live. Which of the following settings would the client MOST benefit from? A) Hospice care. B) Home health care. C) Inpatient hospitalization. D) Nursing home care.

A) Hospice care -Hospice is a form of palliative care where the organization focuses on the comfort of an individual during their final days. Hospice cares for terminally ill patients who are not expected to get well and only have a short time to live.

Nurse Smith is in the hallway talking to another nurse about the diagnosis of her patient, Mr. Miller. Mr. Miller's wife overhears the conversation and is devastated that her husband did not discuss his condition with her. Nurse Smith has committed which of the following? A) Invasion of privacy. B) Libel. C) Defamation of character. D) Slander.

A) Invasion of privacy. -Nurse Smith unintentionally revealed information about Mr. Miller to Mrs. Miller. This information was private and should not have been revealed.

The RN is preparing an intravenous infusion of phenytoin (Dilantin) as prescribed by the physician for the client with seizures. Which of the following solutions will the nurse use to dilute this medication? A) Normal saline (0.9%) solution. B) Dextrose 5% and half-normal saline (0.45%) solution. C) Dextrose 5% solution. D) Lactated ringer's solution.

A) Normal saline (0.9%) solution. -Phenytoin (Dilantin) should be administered by injection into a large vein by intermittent intravenous infusion. Normal saline (0.9%) solution is the preferred solution. Dextrose should be avoided because of medication precipitation.

The Patient Self-Determination Act is based on which of the following premises?check all answers that apply A) Patients who are informed of their rights are more likely to take advantage of them. B) If patients are more actively involved in decisions about their medical care, then that care will more closely respond to their needs. C) If patients are more actively involved in decisions about their medical care, then they are less likely to make legal claims against the health care provider. D) Patients may choose care that is less costly.

A) Patients who are informed of their rights are more likely to take advantage of them. B) If patients are more actively involved in decisions about their medical care, then that care will more closely respond to their needs. D) Patients may choose care that is less costly. -These are all legitimate premises of the act. The purpose of the Patient Self-Determination Act is to inform patients of their rights regarding decisions toward their own medical care, and ensure that these rights are communicated by the health care provider.

You are working as the nurse manager of a critical care unit and need to speak to the staff regarding the employment issue of tardiness. Nearly every day, two nurses have been 10-20 minutes late and missed part of the shift report. You have verbally counseled them regarding this with no results of improvement. What is the best approach? A) Provide the staff nurses a detailed notice of intent to terminate if any further incident of tardiness occurs. B) Ask the staff nurses to tell the manager about the facts surrounding the tardiness. C) Send the staff nurses to the Human Resource Department. D) Inform the staff nurses that, based on these tardiness issues, you must terminate their employment.

A) Provide the staff nurses a detailed notice of intent to terminate if any further incident of tardiness occurs. -In addition to the written one, you should be prepared to work with the nurses to develop a plan of action. The nurses must be notified in writing of the potential for termination based on tardiness.

When attending to the physical needs of a dying patient, the nurse would do which of the following?check all answers that apply A) Regularly perform routine personal care measures, such as bathing and grooming. B) Remember that sight is the last sense to be lost. C) Anticipate bowel and bladder incontinence as death nears. D) Avoid pain medications.

A) Regularly perform routine personal care measures, such as bathing and grooming. C) Anticipate bowel and bladder incontinence as death nears. -These are tasks that the nurse would do for a dying patient. The nurse should remember that hearing (not sight) is the last sense to be lost, and thus, not say anything that would not be appropriate for the patient to hear. The nurse would also administer pain medication as needed.

A nurse observes a physician reading the chart of one of her patients. She is confused because this physician is not involved in the patient's care. To be sure of this she checks the patient's chart and finds that she is right. What is the professional action that she should take? A) Report this event to the supervisor. B) Report this event to the hospital administration. C) Confront the physician herself. D) Take no action since all physicians have a right to look at any patient's chart.

A) Report this event to the supervisor. -Patient confidentiality is an extremely important consideration. Any breach of patient confidentiality per HIPPA (Health Insurance Portability and Accountability Act) must be reported. The professional action required is to adhere to the chain of command by reporting the event to the supervisor, not the physician or the hospital administration.

While caring for a toddlelwith croup, which initial sign of croup requires the nurse's mediate attention? A) Respiratory rate of 42 B) Lethargy for the past hour C) Apical pulse of 54 D) Coughing up copious secretions

A) Respiratory rate of 42

Which of the following diseases would require health care personnel to wear a personal respiratory mask?check all answers that apply A) TB B) major abscess C) diphtheria D) measles

A) TB D) measles -These are two diseases in which pathogenic agents are spread through particles that remain suspended in the air and can be inhaled or otherwise deposited to a host. Airborne precautions are needed for these diseases.

An infant has active acquired immunity. Which of the following statements best explains this type of immunity? A) The infant has received immunizations B) The mother transferred the immunity to the infant C) This is a childhood disease that the infant is recovering from that conferred immunity D) After exposure to hepatitis, the infant has received gamma globulin.

A) The infant has received immunizations -Active acquired immunity occurs when an infant, child or adult receives an immunization against a specific disease. -Natural active immunity occurs when the child, infant or adult has had the disease. -Natural passive immunity occurs with transfer of antibodies from the mother to the infant at birth or through breast milk. -Passive artificial immunity occurs with injection of gamma globulins; the response is immediate but short term

After a tonsillectomy, a child begins to vomit bright red blood. What would your initial action as a RN be? A) Turn the child to the side. B) Maintain NPO status. C) Administer the prescribed antiemetic. D) Notify the physician.

A) Turn the child to the side. -After a tonsillectomy, should bleeding occur, the nurse would turn the child to the side and then notify the physician. An NPO status should be maintained and an antiemetic prescribed. However, the initial nursing action would be to turn the child over on their side.

In terms of disaster management, mitigation would encompass which of the following actions?check all answers that apply A) actions that can prevent the occurrence of a disaster B) collection of anticipatory provisions C) restoring economic stability to a community D) determining resources available for vulnerable individuals such as infants or disabled individuals

A) actions that can prevent the occurrence of a disaster D) determining resources available for vulnerable individuals such as infants or disabled individuals -These are part of the mitigation phase of disaster management. Collection of anticipatory provisions is part of the preparedness phase; and restoring economic stability is part of the recovery phase.

You are assessing a 68-year-old African-American male who maintains an active lifestyle. When he asks you about his risk for hypertension you tell him that which of the following factors puts him at a higher risk?check all answers that apply A) being over 65 years old B) having a low triglyceride level C) his active lifestyle D) his race

A) being over 65 years old D) his race -Being over 65 years old may have an impact on his risk for hypertension. His active lifestyle and a low triglyceride level will not put him at risk for hypertension. African-Americans have an increased risk for hypertension.

You have been assigned to be leader of a task that involves several other nurses and nursing assistants. You feel that connective leadership is the approach to use for this task. This means that you want to achieve results by which of the following?check all answers that apply A) collaboration B) strong control C) cooperation D) a hands-off approach

A) collaboration C) cooperation -Connective leadership draws on the leader's ability to bring others together as a means of effecting change. Leaders in this category realize that the whole is greater than the sum of its parts and achieve results through collaboration, cooperation, coordination, and collegiality.

Continuity of care in nursing occurs when discrete elements in the care pathway are connected, regardless of different episodes, interventions by many providers, or changes in the patient's health status. There are three common types of continuity in healthcare as well as in other disciplines. They include all except which of the following? A) consensual continuity B) information continuity C) management continuity D) relational continuity

A) consensual continuity -This is not a type of continuity in health care or other disciplines. The other three choices (information, management, and relational continuity) are the three most common types

The Code of Ethics for nurses does which of the following? A) delineate nursing's moral ideals B) provide guidelines for principled behavior C) set legal standards for safe nursing practice D) hold nurses morally accountable for their

A) delineate nursing's moral ideals B) provide guidelines for principled behavior D) hold nurses morally accountable for their -The Code of Ethics for nurses delineates nursing's moral ideals; provides guidelines for ethically principled behavior; and holds nurses morally accountable for their actions. Nurse practice acts set the legal standards for safe nursing practice.

The best approach to teaching a woman about electronic fetal monitoring is to do what? A) demonstrate how it works as it is being applied, and explain the tracings. B) give her a pamphlet to read. C) explain fetal monitoring during childbirth preparation classes. D) give factual information in the admission interview.

A) demonstrate how it works as it is being applied, and explain the tracings. -monstrate how it works as it is being applied, and explain the tracings. Not all mothers attend childbirth classes, so it would be inappropriate to assume they are knowledgeable about monitoring. Pamphlets are not the best approach because the mother might not read or be able to understand the information. They also do not allow the mother to ask questions. Only giving factual information upon admission does not allow the mother to ask questions or develop an understanding of how the monitor works.

You are talking to the parents of a teenager who has been admitted for treatment following a serious traffic accident. They have been at the hospital non-stop since the accident 48 hours ago and have had little sleep. You observe which of the following characteristics that are consistent with sleep deprivation? A) impaired cognitive functioning B) excessive perspiration C) discoloration of the skin D) hyperventilation

A) impaired cognitive functioning -Persons who are sleep-deprived often have a slowing of thought processes. The other choices have nothing to do with sleep-deprivation. Impaired cognitive functioning is the correct choice.

The JCAHO established National Patient Safety Goals in 2005. These goals include which of the following?check all answers that apply A) improving the effectiveness of communication among caregivers B) expanding the number of drug concentrations available in an organization C) standardizing abbreviations D) implementing a fall-reduction program

A) improving the effectiveness of communication among caregivers C) standardizing abbreviations D) implementing a fall-reduction program -These are all goals of JCAHO in the National Patient Safety Goals. The goal is to improve the safety of using medications by standardizing and limiting the number of drug concentrations available in an organization. Other medication goals include: identifying and reviewing a list of look-alike/sound-alike drugs; taking action to prevent errors involving the interchange of these drugs, and labeling all medications, medication containers, or other solutions in perioperative and other procedural settings.

The nurse is reviewing a client's arterial blood gas (ABG) report. Which ABG value reflects the acid concentration in the blood? A) pH. B) PaO2. C) PaCO2. D) HCO3-.

A) pH. -The pH value in an ABG report reflects the acid concentration in the blood. The partial pressure of arterial oxygen (PaO2) value indicates the amount of oxygen dissolved in the blood; the partial pressure of arterial carbon dioxide (PaCO2) value represents the amount of carbon dioxide dissolved in the blood. The bicarbonate (HCO3-) value indicates the amount of bicarbonate, or base, in the blood.

Which of the following persons would NOT be able to give informed consent for a procedure?check all answers that apply A) person with chronic dementia B) 17-year-old emancipated married female with a child c) emotionally incompetent person D) sedated client with limited cognitive abilities

A) person with chronic dementia c) emotionally incompetent person D) sedated client with limited cognitive abilities -None of these persons would be able to give a valid informed consent. An emancipated minor however, can give informed consent. Otherwise the person must be older than 18 years of age.

A nurse administers heparin subcutaneously. The nurse should perform which of the following actions to get rid of the needle? A) Place the needle in a sharp container or puncture proof container B) Discard the needle in the recycle bin C) Take the needle to the toilet and flush it D) Clip the tip of the needle and discard it in the trashcan

A) place the needle in a sharp container or puncture proof container. -In order to prevent accidental needle sticks, proper handling of needles includes discarding the needles in a puncture proof container for disposal. The nurse should never attempt to re-cap or clip a needle as this puts the individual at risk for an accidental needle stick.

Mr. Albertson is scheduled to have a barium enema in the afternoon. He has given his approval in writing (informed consent) for the procedures. This means that he has been informed of which of the following?check all answers that apply A) procedural information B) associated risks and benefits C) alternatives to the procedure D) financial aspects of the procedure

A) procedural information B) associated risks and benefits C) alternatives to the procedure -Financial aspects of the procedure are not a part of informed consent. The contents of an informed consent include the procedural information, associated risks and benefits, alternatives to the procedure, and the name of the person who will perform the procedure.

Which of the following would be a part of the biographical data in a patient's health history?check all answers that apply A) race B) sex C) sexual orientation D) education

A) race B) sex D) education -Biographical data includes: name, address, age, date of birth, sex, race, marital status, education, occupation, and financial status. Sexual orientation would be a part of the patient's personal history and not biographical data.

Which of the following safety techniques should the nurse teach the parents of a child with cerebral palsy? A) use safety belts while the child is in a stroller B) use range of motion exercises to reduce contractures C) provide the child with a high calorie supplement D) perform developmental assessments to identify a delay in development

A) safety belts while the child is in a stroller. -Cerebral palsy is a condition of movement and posture that is caused from an abnormality of the brain. In order to promote safety for children who have cerebral palsy, parents can use of safety belts while the child is in a stroller or wheelchair. Also, parents can use adaptive car seats to transport children with cerebral palsy safely. Further, the use of a helmet for children who experience seizures can help keep them safe from injury.

You are preparing a patient for gall bladder surgery. Which of the following tasks would be a part of preoperative care?check all answers that apply A) taking a preoperative history B) teaching the patient about postoperative care C) assuring that all necessary tests have been performed D) adhering to asepsis

A) taking a preoperative history B) teaching the patient about postoperative care C) assuring that all necessary tests have been performed -All of these choices would be a part of the preoperative care. Adhering to asepsis would be a part of intraoperative care.

Modular nursing is similar to which of the following?check all answers that apply A) team nursing B) primary nursing C) functional nursing D) client-focused care

A) team nursing -Modular nursing is similar to team nursing, but takes into account the structure of the unit The unit is divided into modules allowing nurses to care for a group of clients who are geographically close by.

There are several characteristics of self-directed work teams. Which of the following is NOT one of these characteristics?check all answers that apply A) top-down communication B) consensus C) ongoing diverse training D) internal competition

A) top-down communication D) internal competition -Top-down communication and internal competition are not a characteristics of a self-directed work team. Bottom-up communication and external competition are characteristics. Other characteristics (in addition to those mentioned in this question) include: big picture, mobility, empowerment, challenge/innovation, and work and celebration.

A client with tuberculosis is seen in the emergency room. The client had fell off of a forklift while loading material onto a truck. Which of the following actions should the nurse perform? A) use standard and airborne precautions B) provide the client with gloves before the examination by the physician C) instruct the client to not speak with anyone except the healthcare provider D) administer the client a mantoux test to confirm tuberculosis

A) use standard and airborne precautions. -The nurse should use the same standard precautions with the client that has tuberculosis as she would with all clients that come into the emergency room. Also, beside the standards precautions, the nurse should use airborne precautions for this client. Airborne precautions is used to keep the agent that causes tuberculosis from spreading to other clients who are in the emergency room.

The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention? A. Decrease in the level of consciousness B. Loss of bladder control C. Altered sensation to stimuli D. Emotional lability

A. Decrease in the level of consciousness -A further decrease in the level of consciousness may indicate an increase in intracranial pressure leading to inadequate oxygenation of the brain. A decrease in LOC may also reveal the presence of a transient ischemic attack which may warn of impending thrombotic CVA.

Damage to the VII cranial nerve results in: A. Facial pain B. Absence of ability to smell C. Absence of eye movement D. Tinnitus

A. Facial pain -The facial nerve is cranial nerve VII. If damage occurs, the client will experience facial pain. The sensory portion, or intermediate nerve, has the following components: (1) taste to the anterior two-thirds of the tongue; (2) secretory and vasomotor fibers to the lacrimal gland, the mucous membranes of the nose and mouth, and the submandibular and sublingual salivary glands; (3) cutaneous sensory impulses from the external auditory meatus and region back of the ear.

A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium.

A. Increased creatine.

A patient has taken an overdose of aspirin. Which of the following should a nurse must closely monitor for during acute management of this patient? A. Onset of pulmonary edema B. Metabolic alkalosis C. Respiratory alkalosis D. Parkinson's disease type symptoms

A. Onset of pulmonary edema -Aspirin overdose can lead to metabolic acidosis and cause pulmonary edema development. Early symptoms of aspirin poisoning also include tinnitus, hyperventilation, vomiting, dehydration, and fever. Late signs include drowsiness, bizarre behavior, unsteady walking, and coma. Abnormal breathing caused by aspirin poisoning is usually rapid and deep. Pulmonary edema may be related to an increase in permeability within the capillaries of the lung leading to "protein leakage" and transudation of fluid in both renal and pulmonary tissues.

You are supervising a senior nursing student who is caring for a patient with a right hemisphere stroke. Which action by the student nurse requires that you intervene? A. The student instructs the patient to sit up straight, resulting in the patient's puzzled expression. B. The student moves the patient's tray to the right side of her over-bed tray. C. The student assists the patient with passive range-of-motion (ROM) exercises. D. The student combs the left side of the patient's hair when the patient combs only the right side.

A. The student instructs the patient to sit up straight, resulting in the patient's puzzled expression. -Patients with right cerebral hemisphere stroke often present with neglect syndrome. They lean to the left and when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse would need to remind the student of this phenomenon and discuss the appropriate interventions.

The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is: A. Verify correct placement of the tube B. Check that the feeding solution matches the dietary order C. Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D. Ensure that feeding solution is at room temperature

A. Verify correct placement of the tube -Proper placement of the tube prevents aspiration and entrance of food content into the lungs. The definitive way to ascertain the position of the nasogastric tube is through visualization by an x-ray. Another method is to aspirate stomach contents and check its pH (usually pH 1 to 5). Aspirated stomach content can also be tested for bilirubin to confirm it is placed in the stomach.

The best method of evaluating the amount of peripheral edema is: A. Weighing the client daily B. Measuring the extremity C. Measuring the intake and output D. Checking for pitting

A. Weighing the client daily

While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). The nurse should document this as what? A) A first heart sound (S1). B) A third heart sound (S3). C) A fourth heart sound (S4). D) A murmur.

B) A third heart sound (S3) -An S3 is heard following an S2, which commonly occurs in clients experiencing heart failure and results from increased filling pressures. An S1 is a normal heart sound made by the closing of the mitral and tricuspid valves. An S4 is heard before an S1 and is caused by resistance to ventricular filling. A murmur is heard when there is turbulent blood flow across the valves.

Which of the following is NOT an appropriate statement in regard to hand hygiene?check all answers that apply A) Health care personnel should wash with soap and water, not alcohol-based hand rubs when hands are visibly soiled. B) Alcohol-based hand rubs do not reduce the number of microorganisms on the skin as well as soap and water. C) Allergic contact dermatitis due to alcohol hand rubs is very uncommon but will sometimes be encountered. D) The use of gloves does not eliminate the need for hand hygiene. E) Alcohol-based hand rubs are likely to cause skin irritation.

B) Alcohol-based hand rubs do not reduce the number of microorganisms on the skin as well as soap and water. E) Alcohol-based hand rubs are likely to cause skin irritation. -These are not appropriate statements. Alcohol-based hand rubs significantly reduce the number of microorganisms on the skin. They are fast acting, and are less likely to cause skin irritation and are recommended by the CDC in addition to traditional handwashing.

The professional nurse is certain to be involved in managing change. Lewin identified four rules that should be followed when change is necessary. Which of the following is one of these rules?check all answers that apply A) Change should be implemented as quickly as possible to avoid confusion. B) Change should be implemented only for good reason. C) Change should never be unexpected or abrupt D)All people who may be affected by the change should be involved in planning for the change.

B) Change should be implemented only for good reason. C) Change should never be unexpected or abrupt D)All people who may be affected by the change should be involved in planning for the change. Each of these is one of Lewin's rules regarding change. The other choice, properly stated should read that change should always be planned and implemented gradually.

In planning the initial assessment of each client report, what is the best approach? A) You must do a thorough history of the hospitalization and review for trends in care, responses to therapy, and currency of medication orders. B) Do an assessment to determine the current status of the client, the development of complications, and see if there are any necessary changes in nursing care. C) A complete physical head-to-toe should be done with emphasis on current health care problems. D) Review all the laboratory results for the past 24 hours to determine changes that have occurred in the condition of the client and to develop an effective plan for nursing care.

B) Do an assessment to determine the current status of the client, the development of complications, and see if there are any necessary changes in nursing care. -An initial focused assessment should be conducted. This will help determine the current status of the client with regard to nursing care needs.

After receiving the wrong medication, the client's breathing stops. The nurse initiates the code protocol, and the client is emergently intubated. As soon as the client's condition stabilizes, the nurse completes an incident report. What should the nurse do next? A) Place the incident report on the client's chart. B) Document the incident in the nurse's notes. C) Document in the nurse's notes that an incident report was completed. D) Make a copy of the incident report for the client.

B) Document the incident in the nurse's notes. The incident report, also known as an unusual occurrence report, is a confidential document completed for the agency's risk management personnel. Incident reports are not part of the client's record. The incident should be documented factually in the client's record, but the documentations should not mention the incident report. Incident reports should not be copied for anyone. Also, the incident report should not be placed in the client's medical record

When delegating a task to another staff member it would be appropriate to recommend which of the following?check all answers that apply A) Stress details, not results. B) Establish measurable and concrete objectives. C) Develop reporting systems. D) Teach them how to solve problems.

B) Establish measurable and concrete objectives. C) Develop reporting systems. D) Teach them how to solve problems. -All of these are appropriate recommendations. You should stress results, not details. Be more concerned with the final outcome than with all of the day-to-day details. This provides autonomy to the one to whom the task was delegated.

Which of the following statements about herbal therapies is NOT accurate?check all answers that apply A) Do not give herbs to infants or young children. B) Herbs can be helpful if trying to get pregnant. C) Avoid using herbs to treat a serious medical condition, such as heart disease. D) Herbs can be taken in any dosage; they are not toxic

B) Herbs can be helpful if trying to get pregnant. D) Herbs can be taken in any dosage; they are not toxic -These two statements are not accurate. A person should avoid taking herbs if pregnant or attempting to get pregnant or if nursing. A person should adhere to the recommended dosage. If herbal preparations are taken in high doses, they can be toxic.

Which of the following is an example of a natural disaster? A) Terrorist attack. B) Hurricane. C) Active shooter D) Forest Fire.

B) Hurricane. D) Forest Fire. -Hurricanes and forest fires, as well as earthquakes, floods, landslides and tornadoes, are examples of natural disasters.

Which of the following is defined as the length of time between the contact with an infection and the manifestation of the disease? A) Pathogen. B) Incubation. C) Portal of entry. D)Portal of exit.

B) Incubation -A pathogen is a microorganism that produces disease. The portal of entry is the area of the body at which the microorganism enters the individual. Portal of exit is the area of the body at which the microorganism exits the individual.

The nurse is assisting the doctor with a sterile procedure. The nurse notices that the doctor's hand touches a non-sterile area for a moment. What should this nurse do? A) Inform the doctor after the procedure is complete. B) Inform the doctor immediately of the break in sterile procedure and provide him with new sterile gloves. C) Report the incident to the supervisor. D) File an incident report immediately after the procedure.

B) Inform the doctor immediately of the break in sterile procedure and provide him with new sterile gloves. -The patient's well-being is most important. To prevent infection the break in sterile procedure must be addressed immediately. There is no way to prevent infection if the incident is reported after the procedure is complete.

You are a nurse who is new to the unit. You want to manage your time effectively in order to provide safe and effective care to your patients. All of the following would be appropriate guidelines for you to follow to manage your time effectively EXCEPT:check all answers that apply A) Begin client rounds at the beginning of the shift, collecting data on each patient. B) Leave all documentation to be done at the end of the shift. C) Do not write down your tasks, obligations or activities as this takes time away from the patients. D) Anticipate resource needs and gather supplies before beginning a task.

B) Leave all documentation to be done at the end of the shift. C) Do not write down your tasks, obligations or activities as this takes time away from the patients. -You would not do either of these to manage your time wisely. You should organize paperwork and continuously document task completion and necessary client data throughout the day. You would also identify tasks, obligations, and activities and write them down to organize your work day.

The nurse asks the client, "How many packs of cigarettes did you say you smoke a week?" The client answers, "One pack." Where should the nurse record this information? A) Physical assessment. B) Medical history. C) Diagnosis section. D) System review form

B) Medical history Information regarding the client's activities of daily living are documented in the client's medical record in the medical history section. Items that are considered activities of daily living are nutritional patterns, elimination routine, sleep, and personal activities such as smoking, drug use, alcohol use, exercise and sexual history.

Which of the following is used when frequent dressing changes for a wound are needed? A) Penrose drain. B) Montgomery straps. C) Jackson-Pratt catheter. D) Hemovac.

B) Montgomery straps. -Montgomery straps are used with dressings for wounds to make dressing changes quicker because of not needing to remove and put on new tape when changing a dressing. Further, Montgomery straps are a preferred approach when having to change dressings often. Also, these straps reduce skin irritation because tape, which can pull the skin, causes irritation.

The unit in which you work has a team nursing delivery system. This delivery system is characterized by all of the following EXCEPT:check all answers that apply A) Each team is led by a nurse team leader. B) One primary nurse is responsible for managing and coordinating the client's care. C) The registered nurse assumes total responsibility for planning and delivering care to a client. D) The team leader determines the work assignment.

B) One primary nurse is responsible for managing and coordinating the client's care. C) The registered nurse assumes total responsibility for planning and delivering care to a client. -In team nursing, the team is led by a team leader who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client's plan of care. The team leader determines the work assignment. When one primary nurse is responsible for managing and coordinating the client's care, this is relationship-based practice (primary nursing). In client-focused care the registered nurse assumes total responsibility for planning and delivering care to a client.

Which of the following is a client's rights document that reflects acknowledgment of a client's right to participate in her or his health care with an emphasis on client autonomy? A) Health and Insurance Portability and Accountability Act (HIPAA). B) Patient's Bill of Rights. C) Nurse Practice Act. D) Advocacy Right for all Patients Act.

B) Patient's Bill of Rights. -This document provides a list of the rights of the client and responsibilities that the hospital cannot violate. The client's rights affect the relationship between the client and health care provider and between the client and the health care delivery system. HIPAA describes how personal health information may be used and how the client can obtain access to the information. The Nurse Practice Acts govern nursing practice. There is no Advocacy Right for All Patients Act.

Which of the following is defined as the area of the body at which the microorganism exits the individual? A) Droplet transmission. B) Portal of exit. D) Incubation. D) Portal of entry.

B) Portal of exit -Droplet transmission refers to the method in which microorganisms are inhaled. In this case, the microorganisms leave the host on a liquid particle and is then breathed in by another. Incubation refers to the length of time between the contact with an infection and the manifestation of the disease. The portal of entry is the area of the body at which the microorganism enters the individual.

A client transported on a stretcher is being restrained. The nurse understands to perform which of the following actions if a belt is attached to the stretcher? A) Leave the belt unfastened. B) Secure the belt over the client's abdomen. C) Secure the belt over the client's ankles. D) Drape the belt across the client's chest.

B) Secure the belt over the client's abdomen -When restraining a client to promote safety and prevent injury, the nurse should secure the belt over the client's hips or abdomen, if one exists on the stretcher. The belt has to be used even if the nurse has the side rails up on the sides of the stretcher.

Which of the following constitutes invasion of the client's privacy? A) Instructing the client on a diabetic diet with daughter involved after obtaining verbal permission. B) Taking photographs of a client for the hospital bulletin board. C) Releasing records to the home health agency after the client has signed consent to do so. D) Discussing the client's status with the nurse coming on duty for the next shift.

B) Taking photographs of a client for the hospital bulletin board. -Taking photographs of the client without a signed consent to do so is a violation of the client's privacy. Discussing the client's diet with verbal permission is allowed, as it is release of records to care providers with consent to do so. Nursing personnel that will be caring for the client have authorized access to the client's health information. Other examples of invasion of privacy and violations include publication of information about the client, leaving the curtain or room door open during a treatment, leaving the client's record at bedside for visitors review, and interviewing a client where others can hear the conversation.

When working in the emergency department, the RN encounters a client with frostbite on the right hand. Which of the following would the nurse note on assessment of the client's hand? A) Fiery red skin with edema in the nail beds. B) White color of the skin, which is insensitive to touch. C) A pink, edematous hand. D) Black fingertips surrounded by an erythematous rash.

B) White color of the skin, which is insensitive to touch -Findings associated with frostbite include a whitish skin color, skin that is hard and cold, and decreased touch sensation. As thawing occurs, flushing of the skin, blisters and blebs, and tissue edema will appear. The other answers (a, c, and d) are incorrect

2. A nurse has just received a medication order which is not legible. Which statement best reflects assertive communication? A) "I cannot give this medication as it is written. I have no idea of what you mean." B) Would you please clarify what you have written so I am sure I am reading it Correctly C I am having difficulty reading your handwriting. It would save me time if you would be more careful." D) "Please print in the future so I do not have to spend extra time attempting to read your writing

B) Would you please clarify what you have written so I am sure I am reading it Correctly

When we force our own beliefs on an individual from another culture this is known as which of the following?check all answers that apply A) cultural diversity B) cultural imposition C) cultural assimilation D) cultural competence

B) cultural imposition -Cultural imposition is a tendency to impose one's own beliefs, values, and patterns of behavior on individuals from another culture. Instead we should cultivate cultural awareness which would include learning about the cultures of others and asking clients about their health care practices and preferences.

Elisabeth Kübler-Ross identified five stages that a person has in response to death and dying. Which of the following is a stage?check all answers that apply A) abandonment B) denial C) anger D) discussion

B) denial C) anger -Abandonment and discussion are not one of Kübler-Ross's stages of dying. These five stages in order are: denial and isolation; anger; bargaining; depression; and acceptance.

A 20-year-old client is admitted for diarrhea. Which of the following is a nursing outcome? A) bowel motility B) fluid balance C) hardening of the stool D) prevent bleeding

B) fluid balance. -Diarrhea is the loose stool that is not formed. Because of the elimination of liquid stool, the client may suffer dehydration and electrolyte imbalance. Therefore, treatment of diarrhea includes determining the cause.

Which of the following acts would be considered negligence?check all answers that apply A) restraining a patient against his will B) failure to use sterile technique when indicated C) threatening a patient who refuses to take his medication D) administering an injection without the patient's consent

B) frailure to use sterile technique when indicated -This is considered negligence. Negligence is conduct that falls below the standard of care. The other choices are intentional torts, not negligence.

In an interest-based conflict, the leader acts essentially in which of the following roles?check all answers that apply A) authority figure B) neutral third party C) power authority D) mediator

B) neutral third party D) mediator -In dealing with an interest-based conflict, a leader acts essentially as a mediator and a neutral third party who helps the parties resolve their issues and bring closure to the conflict. There is much more negotiation and give-and-take than in the resolution process for an identity-based conflict.

Early intervention to prevent skin injuries in at-risk patients includes cleaning the skin as soon as it becomes wet, and bathing the patient regularly. All of the following are appropriate guidelines for doing this EXCEPT:check all answers that apply A) avoiding soap that dries the skin B) using water as hot as the patient can stand C) using the cream on dry, scaly skin D) rubbing reddened areas over bony prominences

B) using water as hot as the patient can stand D) rubbing reddened areas over bony prominences -These are not appropriate guideline. When clean skin or bathing a patient, use warm, not hot, water. Avoid rubbing reddened areas over bony prominences.

A client presents to the clinic with suspected gastritis. The client also vomited several times while in the examination room. Which of the following is an example of objective data which is used in the nursing assessment? A) pain in the abdomen B) vomiting blood C) nausea in the stomach D) burning sensation in the chest after eating

B) vomiting blood. -Objective data are things that the nurse, for instance, can see or measure as well as signs of a medical condition that can be tested. For example, the client's vomiting with blood in the vomit is an objective sign that the nurse can see in the office. On the other hand, subjective data are symptoms which are things that only the client can feel or know, such as pain in the abdomen, itching, burning sensations in the chest or throat or nausea.

A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal? A. 11-year-old male: 90 BPM, 22 RPM, 100/70 mmHg B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg C. 5-year-old male: 102 BPM, 24 RPM, 90/65 mmHg D. 6-year-old female: 100 BPM, 26 RPM, 90/70 mmHg

B. 13-year-old female: 105 BPM, 22 RPM, 105/50 mmHg -The normal range of vital signs for 11 to 14-year-olds: Heart rate: 60-105 BPM; Respiratory rate: 12-20 CPM; Blood pressure: Systolic-85-120, diastolic- 55-80 mmHg; Body temperature: 98.0 degrees Fahrenheit (36.6 degrees Celsius) to 98.6 degrees Fahrenheit (37 degrees Celsius). The client's diastolic pressure is lower than the normal range. Both her respiratory rate and heart rate are slightly increased.

When prioritizing care, which of the following clients should the nurse Olivia assess first? A. A 17-year-old client 24-hours post appendectomy. B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome. C. A 50-year-old client 3 days post myocardial infarction. D. A 50-year-old client with diverticulitis.

B. A 33-year-old client with a recent diagnosis of Guillain-Barre syndrome -Guillain-Barre syndrome is characterized by ascending paralysis and potential respiratory failure. The order of client assessment should follow client priorities, with disorder of airways, breathing, and then circulation.

Nurse Bea is assessing a male client with heart failure. The breath sounds commonly auscultated in clients with heart failure are: A. Tracheal B. Fine crackles C. Coarse crackles D. Friction rubs

B. Fine crackles -Fine crackles are caused by fluid in the alveoli and commonly occur in clients with heart failure.

With which of the following disorders is jugular vein distention most prominent? A. Abdominal aortic aneurysm B. Heart failure C. Myocardial infarction D. Pneumothorax

B. Heart failure -Elevated venous pressure, exhibited as jugular vein distention, indicates a failure of the heart to pump.

Which of the following landmarks is the correct one for obtaining an apical pulse? A. Left intercostal space, midaxillary line B. Left fifth intercostal space, midclavicular line C. Left second intercostal space, midclavicular line D. Left seventh intercostal space, midclavicular line

B. Left fifth intercostal space, midclavicular line -The correct landmark for obtaining an apical pulse is the left intercostal space in the midclavicular line. This is the point of maximum impulse and the location of the left ventricular apex.

A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer.Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client's room. B. Limit the client's visitors to 30 min per day. C. Discard the client's linens in a double bag. D. Discard the radioactive source in a biohazard bag

B. Limit the client's visitors to 30 min per day.

Which of the following statements explains the main difference between rheumatoid arthritis and osteoarthritis? A. Osteoarthritis is gender-specific, rheumatoid arthritis isn't. B. Osteoarthritis is a localized disease rheumatoid arthritis is systemic. C. Osteoarthritis is a systemic disease, rheumatoid arthritis is localized. D. Osteoarthritis has dislocations and subluxations, rheumatoid arthritis doesn't.

B. Osteoarthritis is a localized disease; rheumatoid arthritis is systemic -Osteoarthritis is a localized disease, rheumatoid arthritis is systemic.

A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? A. Place an ice pack over the cast. B. Palpate the pulse distal to the cast. C. Teach the client to keep the cast clean and dry. D. Position the casted extremity on a pillow.

B. Palpate the pulse distal to the cast.

The nurse is caring for a client hospitalized with a facial stroke. Which diet selection would be suited to the client? A. Roast beef sandwich, potato chips, pickle spear, iced tea B. Split pea soup, mashed potatoes, pudding, milk C. Tomato soup, cheese toast, Jello, coffee D. Hamburger, baked beans, fruit cup, iced tea

B. Split pea soup, mashed potatoes, pudding, milk The client with a facial stroke will have difficulty swallowing and chewing, and these food items mentioned provides the least amount of chewing. Consult with a speech therapist to evaluate gag re?exes; assist in teaching alternate swallowing techniques, advise the patient to take smaller boluses of food, and inform the patient of foods that are easier to swallow; provide thicker liquids or pureed diet as indicated.

A client with frequent urinary tract infections asks the nurse how she can prevent the recurrence. The nurse should teach the client to: A. Douche after intercourse B. Void every 3 hours C. Obtain a urinalysis monthly D. Wipe from back to front after voiding

B. Void every 3 hours -Voiding every 3 hours prevents stagnant urine from collecting in the bladder, where bacteria can grow.

A pregnant client calls the obstetrics office where you work and tells you she is having leg cramps that awaken her at night. In order to provide relief, the RN understands that it is important to tell what to the client? A) "Point your foot away from your body while flexing the knee whenever a cramp occurs." B) "Point your foot away from your body while extending the knee when the cramps occur." C) "Bend your foot toward your body and extend the knee when the cramps occur." D) "Bend the foot toward the body while flexing the knee when the cramps occur."

C) "Bend your foot toward your body and extend the knee when the cramps occur." -Leg cramps occur often when a pregnant client stretches her leg and flexes her foot. To stretch the affected muscle, she should dorsiflex her foot while extending her knee to prevent the muscle from contracting. The other answers are all ineffective measures and will not provide relief from cramping.

You are the health education nurse providing instructions to a group of clients regarding skin care prevention measures. Which of the following statements, if made by a client, would indicate the need for further teaching? A) "I will use sunscreen when doing outdoor activities." B) "I will wear a hat, opaque clothing, and sunglasses when I am in the sun." C) "I will avoid sun exposure after 3 P.M." D) "I will examine my body monthly for suspicious lesions."

C) "I will avoid sun exposure after 3 PM." -The RN should instruct that clients should avoid sun exposure between the hours of 11 AM and 3 PM. The other answers (a, b, and d) all indicate that the client has understanding of preventive instructions regarding sun exposure.

Which of the following is the first step to utilizing any fire extinguisher? A) "Sweep the fire from side to side." B) "Aim at the base of the fire." C) "Pull the pin." D) "Squeeze the handles."

C) "Pull the pin" -Choice A is the fourth and final step to using a fire extinguisher. Choice B is the second step and Choice D, the third step.

The nurse recognizes that labor is divided into how many stages? A) 2 B) 3 C) 4 D) 5

C) 4 Labor is divided into four stages: first stage, onset of labor to full dilation; second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1 hour postpartum. The first stage is divided into three phases: early, active, and transition.

4. A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should A) Administer a placebo B) Encourage increased fluid intake C) Administer the prescribed analgesia D) Recommend relaxation exercises for pain control

C) Administer the prescribed analgesia

Which of the following is defined as violence toward another via punching, knocking down, etc? A) Invasion of privacy. B) False imprisonment. C) Assault and battery. D) Libel.

C) Assault and battery Assault and battery is simply defined as when a patient is touched without his or her consent. This touching does not necessarily have to result in an injury.

A 55-year-old has cardiovascular disease. Which of the following is a nursing goal to prevent complications? A) Assess the client for respiratory depression. B) Assess the client for urinary retention. C) Assess the client for orthostatic hypotension. D) Assess the client for skin rashes

C) Assess the client for orthostatic hypotension. -Orthostatic hypotension is known to increase the risk for cardiovascular disease and complications in individuals who are already diagnosed with cardiovascular disease. In order to prevent complications of cardiovascular disease, one of the goals of the nurse is to assess the client for physical effects that may affect the cardiovascular system. These effects include orthostatic hypotension, a decrease in cardiac reserve, venous stasis, thrombi, and an increase in cardiac workload.

The nurses are discussing a client's condition in the elevator. The employer of the mentioned client overhears the conversation and fires the client. The nurses may be liable for which accusation? A) Assault. B) Battery. C) Breach of confidentiality. D) Neglect.

C) Breach of confidentiality -breach of confidentiality occurs when a nurse shares information that can cause harm to an individual. Assault is an act that results in fear that one will be touched without consent. Battery involves unconsented touching of another person. Neglect is the failure to do what is deemed reasonable in a situation.

To assess the effectiveness of cardiac compressions during adult cardiopulmonary resuscitation (CPR), the nurse should palpate which pulse site? A) Radial. B) Apical. C) Carotid. D) Brachial.

C) Carotid -During CPR, the carotid artery pulse is the most accessible and may persist when the peripheral pulses no longer are palpable because of decreases in cardiac output and peripheral perfusion. Chest compressions performed during CPR preclude accurate assessment of the apical pulse.

An elderly man is brought into the emergency room from a nursing home complaining of back pain. The nurse notices several bruises on his back. When the nurse asks him about the bruises he refuses to tell her how they happened. After addressing his knee complaint, what should the nurse's next step be?check all answers that apply A) Involve the police. B) Contact the social services unit to report the unexplained bruises. C) Report to the patient's physician. D) Press the patient for more information.

C) Contact the social services unit to report the unexplained bruises. -A nurse must be an advocate for his or her patient. If there is any chance that elder abuse is involved, it should be investigated by the social services agency. The fact that the patient was evasive about the reasons for the bruises should alert the nurse as to possible abuse.

Marcia is a student nurse who has a job as a nurse's aid while she is studying to be a registered nurse. She is assigned a patient who needs an intramuscular medication. This is not in the job description for nurse's aids but the staff nurse is busy and Marcia has already learned how to administer intramuscular medication. What should she do? A) Go ahead and administer the medication. B) Ask the patient if he or she will permit her to administer the medication and do so with the patient's permission. C) Do not administer the medication because it is not part of her job description. D) Since she has already learned how to do this in nursing school she can administer the medication as long as the staff nurse says it is all right.

C) Do not administer the medication because it is not part of her job description. -A nursing student may not perform a task as a nurse's aid that is not part of the job description of a nurse's aid even though she has been taught how to do it in nursing school. She can be held liable for mistakes as well as the staff nurse, supervisor and the hospital. Even if the staff nurse allows the student nurse to perform the administration of the intramuscular medication, she cannot do it.

All of the following statements about the Health Insurance Portability and Accountability Act (HIPAA) are correct EXCEPT:check all answers that apply A) HIPAA describes how personal health information (PHI) may be used. B) HIPAA describes how a client can obtain access to PHI. C) Even if a client believes that privacy rights have been violated, a claim may not be filed. D) PHI includes individually identifiable information that relates to a client's past, present, or future health.

C) Even if a client believes that privacy rights have been violated, a claim may not be filed. -This is not correct. The client has various rights as a consumer of health care under HIPAA. The client may file a complaint if the client believes that privacy rights have been violated.

The nurse assesses a 80-year-client with hot, dry skin that is flushed. Which of the following best identifies the client's condition? A) Paresthesia. B) Hypothermia. C) Heatstroke. D) Drowning.

C) Heatstroke. -Heatstroke is hot, dry, and flushed skin along with an elevated body temperature over 105 degrees Fahrenheit. Additional signs and symptoms the nurse may identify during assessment are dizziness, seizures, headache and nausea.

The nurse is providing dietary teaching for the parents of a child with celiac disease. This child should avoid what? A) Vegetables. B) Fruits. C) Prepared puddings. D) Rice.

C) Prepared puddings -A child with celiac disease must not consume food containing gluten and therefore should avoid prepared puddings, commercially prepared ice cream, malted milk, and all food and beverages containing wheat, rye, oats, or barley. The other choices do not contain gluten and are permitted when on a gluten free diet.

HESI EXIT EXAM 2021/2022 1. in planning care for a 6 month-old infant, what must the nurse provide to assist in the development of trust? A) Food B) Warmth C) Security D) Comfort

C) Security

All of the following are appropriate guidelines for prioritizing client teaching EXCEPT:check all answers that apply A) First determine what the client already knows. B) Review the learning objectives established for the client. C) Tell the client what is most important. D) Teach quickly and concisely so as not to lose the client's attention.

C) Tell the client what is most important. D) Teach quickly and concisely so as not to lose the client's attention. -These are not appropriate guidelines. Determine what the client perceives as important. Assess the client's anxiety level and the time available to teach. Do not rush the teaching.

To treat cervical cancer, a client has an applicator of radioactive material placed in the vagina. Which of the following would indicate a radiation hazard? A) The client is maintained on strict bed rest. B) The head of the bed is at a 30 degree angle. C) The client receives a complete bed bath each morning. D) The nurse checks the applicator's position every 4 hours.

C) The client receives a complete bed bath each morning -The client should not receive a complete bed bath while the applicator is in place. She should not be bathed below the waist because of the risk of radiation exposure to the nurse. During this treatment, the client should remain on strict bed rest, but the head of her bed may be raised to a 30 - 45 degree angle. The nurse should check the applicator's position every 4 hours to ensure that it remains in the proper place.

Which of the following is the most common source of airway obstruction in an unconscious victim? A) A foreign object. B) Saliva or mucus. C) The tongue. D) Edema.

C) The tongue -The muscles in many cases that control the tongue relax, causing the tongue to obstruct the airway. When this occurs, the nurse should use the head-tilt, chin-lift maneuver to cause the tongue to fall back in place. If a neck injury is suspected, the jaw-thrust maneuver must be performed.

A nurse on the cardiac care unit sees that there is a seminar on evidence-based cardiac care. What is the most important reason for this nurse to attend the seminar? A) She needs to take a certain amount of continuing education to retain her license. B) She can fit it into her schedule without compromising patient care. C) This seminar will aid the nurse in keeping up with current clinical knowledge in her area. D) She is the only one on the unit that has not taken this continuing education course.

C) This seminar will aid the nurse in keeping up with current clinical knowledge in her area. -Evidence-based practice in any area is constantly developing. The most compelling reason for this nurse to attend the seminar is to stay current. Advances in the cardiac-care area are essential for this type of nurse to know.

If a nurse is caring for a patient with measles which type of precautions are required? A) droplet precautions B) contact precautions C) airborne precautions D) no specific precautions are needed

C) airborne precautions -Measles is one of the microorganisms that require airborne precautions. A nurse treating a patient with measles must wear a mask and a clean gown. This is necessary to prevent transmission of the organism to herself or others.

An informed consent that includes the procedural information and the name of the person who will perform the procedure is missing which of the following items of information?check all answers that apply A) names of nurses who will care for the patient B) postoperative care procedure C) alternatives to the procedure D) associated risks and benefits

C) alternatives to the procedure D) associated risks and benefits -Informed consent is the voluntary authorization by a patient to a care provider to do something to the patient. Contents of an informed consent include procedural information, associated risks and benefits, alternatives to the procedure, and the name of the person who will perform the procedure. Generally, physicians have the responsibility to obtain informed consents.

A 25-year-old patient comes from a culture where pain must be very severe before a person will accept relief. The family of the patient has always adhered to this belief, however, the patient who has been having moderate pain of 5 on a scale of 0 - 10 consents to pain relief despite the family's beliefs. Which of the following ethical principles best supports this decision? A) beneficence B) justice C) autonomy D) fidelity

C) autonomy -This patient has exhibited autonomy which is the ethical principle that individuals have the right to make decisions for themselves. Beneficence refers to a nurse's duty to do what is in the best interest of the patient. Justice is the fair, equitable and appropriate treatment. Fidelity is keeping faithful to ethical principles.

An 84 year old male is returning from the operating room (OR) after an inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? A) jugular vein distention B) right upper quadrant pain C) bibasilar fine crackles D) dependent edema

C) bibasilar fine crackles. -Bibasilar fine crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload. Jugular vein distention, right upper quadrant pain, and dependent edema are caused by right-sided heart failure, usually a chronic condition.

The nurse's ability to work and interact effectively with people of all cultures is known as which of the following?check all answers that apply A) cultural sensitivity B) cultural diversity C) cultural competency D) cultural range

C) cultural competency -Cultural competency is the ability to work and interact effectively with people of other cultures. Culture is not limited to a specific ethnic background or racial heritage, but rather is an adapted way of life that is learned from families and other social interactions.

All of the following must be proved by a patient who claims to have been injured by the negligence of the nurse EXCEPT:check all answers that apply A) duty B) breach of duty C) fear of harm D) damages or harm

C) fear of harm -Fear of harm is not one of the elements that must be proved for negligence. Professional malpractice or professional negligence requires a plaintiff to introduce proof of duty, breach of duty, proximate cause, and damages or harm.

Which of the following is important when restraining a violent client? A) have three staff members present one for each side of the body and one for the head B) always tie restraints to side rails C) have an organized, efficient team approach after the decision is made to restrain the client D) secure restraints to the gurney with knots to prevent escape.

C) have an organized, efficient team approach after the decision is made to restrain the client -Emergency department personnel should use an organized, team approach when restraining violent clients of that no one is injuried in the process. The leader, located at the client's head, should take charge; four staff members are required to hold and restrain the limbs. For safety reasons, restraints should be fastened to the bed frame instead of the side rails. For quick release, loops should b used instead of knots

A client is receiving magnesium sulfate. Which of the following observations should the nurse report to the physician immediately? A) nausea B) vomiting C) lack of deep tendon reflexes D) blurred vision

C) lack of deep tendon reflexes. -Adverse reactions that are expected with magnesium sulfate include, vomiting, nausea and the client having blurred vision. However, the lack of a deep tendon reflexes is associated with magnesium toxicity, which should be reported immediately to the physician along with a decrease in the client's urine output that is under 30 mL/hr. Also, the nurse should stop the administration of the magnesium sulfate until otherwise directed by the physician.

According to Duvall, what serves as a marker for most of a family's developmental stage? A) the youngest child's age B) the mother's age C) the oldest child's age D) the father's age

C) oldest child's age. -The oldest child's age serves as a marker for a family's development stages, except in the last two stages, when children are no longer present. The mother's youngest child, and father's age are not markers, according to Duvall.

The nurse observes a play group of 2 year old children. The nurse would expect to see: A) four children playing dodge ball B) three children playing tag C) two children side by side in the sandbox building sand castles D) one child digging a hole and another child blowing bubbles

C) two children side by side in the sandbox building sand castles. -Two year olds exhibit parallel play; that is they engage in similar activity side by side. Playing dodge ball and tag are examples of interactive play, common to school age children. A 2 year old would not blow bubbles.

A client is in the intensive care unit after undergoing a kidney transplant. Which of the following should the nurse monitor every 30 minutes to identify signs of kidney rejection? A) white blood cell count B) sedimentation levels C) urine output D) cardiac output

C) urine output. -Every 30-60 minutes the nurse should monitor and record the urine output of a client who has had a kidney transplant. The urine output is one of the main signs to identify kidney rejection and to evaluate if the kidney is functioning properly. When the body rejects a transplanted kidney, the symptoms include a reduction in urine output and an increase in the BUN and serum creatinine levels.

A male client with a gunshot wound requires an emergency blood transfusion. His blood type is AB negative. Which blood type would be the safest for him to receive? A. AB Rh-positive B. A Rh-positive C. A Rh-negative D. O Rh-positive

C. A Rh-negative -Human blood can sometimes contain an inherited D antigen. Persons with the D antigen have Rh-positive blood type; those lacking the antigen have Rh-negative blood. It's important that a person with Rh-negative blood receives Rh-negative blood.

A thirty-five-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate. Which of the following would you most likely suspect? A. Atherosclerosis B. Diabetic nephropathy C. Autonomic neuropathy D. Somatic neuropathy

C. Autonomic neuropathy -Autonomic neuropathy (also known as Diabetic Autonomic Neuropathy) affects the autonomic nerves, which control the bladder, intestinal tract, and genitals, among other organs. Paralysis of the bladder is a common symptom of this type of neuropathy, as manifested by bladder urgency and inability to start urination.

A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in the instructions? A. Walk barefoot whenever possible. B. Use a heating pad to keep feet warm. C. Avoid crossing the legs. D. Use antibacterial ointment to treat skin lesions at risk of infection.

C. Avoid crossing the legs. -Patients with peripheral vascular disease should avoid crossing the legs because this can impede blood flow. PVD, also known as arteriosclerosis obliterans, is primarily the result of atherosclerosis. The atheroma consists of a core of cholesterol joined to proteins with a fibrous intravascular covering. The atherosclerotic process may gradually progress to complete occlusion of medium-sized and large arteries. The disease typically is segmental, with significant variation from patient to patient.

When teaching a client with coronary artery disease about nutrition, the nurse should emphasize: A. Eating three (3) balanced meals a day B. Adding complex carbohydrates C. Avoiding very heavy meals D. Limiting sodium to 7 gms per day

C. Avoiding very heavy meals -Eating large, heavy meals can pull blood away from the heart for digestion and is dangerous for the client with coronary artery disease. Too much plaque may accumulate in the arteries and block the delivery of blood and oxygen in major organs of the body.

A male client is admitted to the emergency department following an accident. What are the first nursing actions of the nurse? A. Check respiration, circulation, neurological response B. Align the spine, check pupils, and check for hemorrhage C. Check respirations, stabilize the spine, and check the circulation D. Assess level of consciousness and circulation

C. Check respirations, stabilize the spine, and check the circulation -Checking the airway would be the priority, and a neck injury should be suspected. Airway patency and adequate respiratory effort are both essential for normal oxygenation and ventilation within the body so that normal physiological processes can proceed without metabolic derangement.

Which of the following conditions is most commonly responsible for myocardial infarction? A. Aneurysm B. Heart failure C. Coronary artery thrombosis D. Renal failure

C. Coronary artery thrombosis -Coronary artery thrombosis causes occlusion of the artery, leading to myocardial death. Myocardial infarction occurs when a coronary artery is so severely blocked that there is a significant reduction or break in the blood supply, causing damage or death to a portion of the myocardium (heart muscle).

A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptoms would you not expect to see in this patient? A. Numbness in hands and feet B. Muscle cramping C. Hypoactive bowel sounds D. Positive Chvostek's sign

C. Hypoactive bowel sounds -Normal serum calcium is 8.5 - 10 mg/dL. The patient is hypocalcemic. Increased gastric motility, resulting in hyperactive (not hypoactive) bowel sounds, abdominal cramping and diarrhea is an indication of hypocalcemia. Hypocalcemia is said to be present when the total serum calcium concentration is less than 8.8 mg/dl. The disorder may be acquired or inherited but its presentation can vary- from asymptomatic to life-threatening. Hypocalcemia is commonly seen in hospitalized patients and for the most part, is mild in nature and only requires supportive treatment.

A client who has been diagnosed with hypertension is being taught to restrict intake of sodium. The nurse would know that the teachings are effective if the client states that: A. I can eat celery sticks and carrots B. I can eat broiled scallops C. I can eat shredded wheat cereal D. I can eat spaghetti on rye bread

C. I can eat shredded wheat cereal Wheat cereal has a low sodium content. Sodium controls fluid balance in the body and maintains blood volume and blood pressure. Eating too much sodium may raise blood pressure and cause fluid retention, which could lead to swelling of the legs and feet or other health issues.

Nurse Michelle should know that the drainage is normal four (4) days after a sigmoid colostomy when the stool is: A. Green liquid B. Solid formed C. Loose, bloody D. Semiformed

C. Loose, bloody -Normal bowel function and soft-formed stool usually do not occur until around the seventh day following surgery. The stool consistency is related to how much water is being absorbed.

The nurse should visit which of the following clients first? A. The client with diabetes with a blood glucose of 95mg/dL B. The client with hypertension being maintained on Lisinopril C. The client with chest pain and a history of angina D. The client with Raynaud's disease

C. The client with chest pain and a history of angina -The client with chest pain should be seen first because this could indicate a myocardial infarction. Despite many advances in treatment, acute MI still carries a mortality rate of 5-30%; the majority of deaths occur prior to arrival to the hospital. In addition, within the first year after an MI, there is an additional mortality rate of 5% to 12%. The overall prognosis depends on the extent of heart muscle damage and ejection fraction.

A mother complains to the nurse that her 4-year-old son often "lies." What is the nurse's best response? A) "Let the child know that he will be punished for lying." B) "Ask him why he is not telling the truth." C) "It is probably due to his vivid imagination and creativity." D) "Acknowledge him by saying, That is a pretend story."

D) "Acknowledge him by saying, That is a pretend story" -It is important to acknowledge the child's imagination, while also letting him know in a nice way that what he has said is not real. Punishment is not appropriate for a 4-year-old child using his imagination, and accusing him of lying is a negative reinforcement. The child is not truly lying in the adult sense. Imagination and creativity need to be acknowledged.

A rubella immunization is given to a postpartum client when her rubella titer is A) 0.0625 B) 0.0555555555556 C) 1:100 D) 1:7

D) 1:7. A client's immunity to rubella is measured through a serology test called the hemagglutination- inhibition test. Clients who have a hemagglutination- inhibition of 1:10 or more has an immunity to rubella. If the results are less than 1:10, the client would need to have a rubella immunization on postpartum before discharge or approaximately six weeks after delivery the infant so she does not contract rubella which can also put the newborn at risk.

Sulfisoxazole (Gantrisin), 1 GM orally three times a day is prescribed for a female client with a urinary tract infection. The label on the medication reads "500 mg tablets." The RN must determine what the dose is. How many tablets would she give this client? A) 1/2 of a tablet B) 1 tablet C) 1 1/2 tablets D) 2 tablets

D) 2 tablets

3. What is the most important consideration when teaching parents how to reduce risks in the home? A) Age and knowledge level of the parents B) Proximity to emergency services C) Number of children in the home D) Age of children in the home

D) Age of children in the home

The RN is assigned to a client who was admitted for appendicitis and who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. When the nurse finds that the client's abdomen is distended and the bowel sounds are diminished, what should she do? A) Administer prescribed pain medication. B) Reposition the client and apply a heating pad on warm to the client's abdomen. C) Call and ask the operating room team to perform the surgery as soon as possible. D) Notify the physician.

D) Notify the physician. -Due to the severity of the signs and symptoms presented, the RN should suspect peritonitis and notify the physician. Giving pain medication is not appropriate and administering heat could facilitate rupture. It is not in the nurse's scope of practice to call the surgical unit, although the physician would move up the time of surgery with these conditions.

Nurses require leadership skills. Of the following leadership types, which consists of flexible leaders who utilize a combination of the other leadership types depending on the most effective way of completing the task? A) Laissez-faire B) Autocratic C) Democratic D) Situational

D) Situational -A laissez-faire leader relinquishes some control to the members of the group. An autocratic leader dominates the group rather than seeking suggestions from the group. The type of leader in Choice C actively seeks input from members of the group.

A two day old newborn with the diagnosis of intrauterine growth retardation is observed by the nurse to be irritable, fist-sucking, and having a high-pitched shrill cry. Based on these signs and symptoms, which nursing action should the RN do FIRST? A) Schedule feeding times every two to four hours. B) Encourage eye contact with the infant during feedings. C) Discourage stimulation of the baby by rocking gently. D) Tightly swaddle the infant into a flexed position.

D) Tightly swaddle the infant into a flexed position. -By swaddling the infant into a flexed position, the infant feels comfort and security. An infant with intrauterine growth retardation from drug withdrawal may manifest symptoms of high-pitched shrill cry, decreased sleep, tachypnea, diaphoresis, excessive mucus, vomiting, irritability, and uncoordinated sucking. Eye contact may overstimulate the infant, rocking helps the infant feel more comfortable but would not be done first and small frequent feedings are preferable, but not done first.

Which of the following patients would be most likely to perceive direct eye contact as a show of hostility or aggression?check all answers that apply A) a 42-year-old Arab male B) a 65-year-old Native American female C) a 21-year-old Asian female D) a 30-year-old Appalachian male

D) a 30-year-old Appalachian male -A 30-year-old Appalachian male is likely to perceive direct eye contact as a show of hostility or aggression. This is simply a cultural difference that health care personnel should be aware of. Asians, Native Americans, and Arabs may feel that eye contact is impolite or improper.

When the nurse helps the patient and his family interpret information from other health care providers in order for them to make a decision about health-related needs, he is acting in which of the following capacities?check all answers that apply A) change agent B) researcher C) educator D) advocate

D) advocate -The nurse has a number of roles, one of which is advocating for the patient. When the nurse helps the patient and his family interpret information from other health care providers in order for them to make a decision about health-related needs, he is acting as an advocate. By doing this the nurse is ensuring the health, welfare, and safety of the patient.

In which of the following cases would a nurse be allowed to disclose confidential information?check all answers that apply A) if the patient's family asks for it B) if the patient is incompetent C) if the nurse thinks that it is in the best interest of the patient D) if the patient is a danger to himself or others E) if the patient authorizes it

D) if the patient is a danger to himself or others E) if the patient authorizes it -Confidential information can be disclosed under certain circumstances. For example, the nurse must disclose such information when authorized by a patient (but only to the extent authorized), when a patient is a danger to himself or others, or when required by law for a reportable communicable disease or suspected abuse.

A nurse who is working the night shift is taking medication to a patient which includes a sleeping aid and blood pressure medication. What should the nurse do before she administers the medication? A) instruct the patient as to why she is being given these medications B) ask the patient if these are the usual medications that she is given at night C) match the patient's name and room number D) match the patient's name and date of birth on his wristband with the same information on the medication order

D) match the patient's name and date of birth on his wristband with the same information on the medication order -Prior to medication administration, two unique patient identifiers must be used. The identifier must be something that is unique to the patient such as name and birth date. Things like room number or place of birth are not acceptable

The nurse is assessing a client who may be in the early stages of dehydration. Early manifestations of dehydration include: A) coma or seizures B) sunken eyeballs and poor skin turgo C) increased hearth rate with hypotension D) thirst or confusion

D) thirst or confusion. -Early signs and symptoms of dehydration include thirst, irritability, confusion, and dizziness. Coma, seizures, sunken eyeballs, poor skin turgor and increased heart rate with hypotension are all later signs.

An RN in the postoperative department has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour? A) temperature of 37.6° C (99.6° F). B) Blood pressure of 100/70 mm Hg. C) Serous drainage on the surgical dressing. D) Urinary output of 20 mL/hr.

D) urinary output of 20 mL/hr -The urine output of an adult should be maintained at a minimum of 30 mL/hr. A lesser output for 2 consecutive hours would indicate renal insufficiency and should be reported to the physician. A temperature higher than 37.7° C (100.0° F) or lower than 36.1° C (97° F) and a falling blood pressure are immediate concerns and should be reported. Light to moderate serous drainage at a surgical site is expected and should not be reported.

Nurse Alexandra teaches a client about elastic stockings. Which of the following statements, if made by the client, indicates to the nurse that the teaching was successful? A. "I will wear the stockings until the physician tells me to remove them." B. "I should wear the stockings even when I am asleep." C. "Every four hours I should remove the stockings for a half hour." D. "I should put on the stockings before getting out of bed in the morning."

D. "I should put on the stockings before getting out of bed in the morning." -Promote venous return by applying external pressure on veins.

Among the following components thorough pain assessment, which is the most significant? A. Effect B. Cause C. Causing factors D. Intensity

D. Intensity -Intensity is the major indicative of severity of pain and it is important for the evaluation of the treatment. Severity of pain may include the intensity graded by the patient or the impact pain has on function. Intensity may be assessed with certain scales that will be reviewed below. The impact on function may include changes with activities of daily living, activity level, and work-related duties. Pain may have an impact on sleep, mood, appetite, or social relationships.

A young adult is 20 years old and has been recently admitted to the hospital. According to Erikson, which of the following stages is the adult in? A. Trust vs. mistrust B. Initiative vs. guilt C. Autonomy vs. shame D. Intimacy vs. isolation

D. Intimacy vs. isolation -Intimacy vs Isolation takes place during young adulthood between the ages of approximately 19 and 40. The major conflict at this stage of life centers on forming intimate, loving relationships with other people.

A patient's chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute? A. Decreased HR B. Paresthesias C. Muscle weakness of the extremities D. Migraines

D. Migraines -Migraines are not a symptom of hyperkalemia. Symptoms of hyperkalemia, when present, are nonspecific and predominantly related to muscular or cardiac function. Option A: Occasionally, a cardiac examination may reveal extrasystoles,

A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium d. Platelet count

c. Serum potassium- diuretic that retains potassium= hyperkalemic risk