HESI Fundamentals Practice Quiz

A client with multiple sclerosis is prescribed Dantrolene (Dantrium) 0.1 grams PO bid for spasticity. Dantrolene is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.)

1

A client is receiving alprazolam (Xanax) 0.75 mg PO bid for anxiety. Alprazolam is available in 0.5 mg scored tablets. How many tablets should the nurse administer? (Enter numeric value only.)

1.5 tablets

Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

1.5 tablets

A client receives a prescription for azithromycin (Zithromax) 500 mg PO x 3 days. Azithromycin is available as 250 mg scored tablets. How many tablets should the nurse administer per dose? (Enter the numerical value only.)

2 tablets

A client with type 2 diabetes is receiving metformin (Glucophage) 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.)

2 tablets

A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is available as 5 mg/5 ml. A measuring device marked in teaspoons is being used. How many teaspoons should the nurse administer?

2 teaspoons 5ml=1 tsp

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A. Avoid any types of sprays, powders, and perfumes. B. Wearing a mask while cleaning will not help to avoid allergens. C. Purchase any type of clothing, but be sure it is washed before wearing it. D. Pollen count is related to hay fever, not to allergens.

A. Avoid any types of sprays, powders, and perfumes.

_________ Docusate sodium (Colace) 0.3 grams is prescribed for a client who has frequent constipation. Each capsule contains 100 mg. How many capsules should the nurse administer?

3 capsules

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How many tablets should the nurse plan to administer? A. 1/2 tablet. B. 1 tablet. C. 1 1/2 tablets. D. 2 tablets.

C. 1 1/2 tablets.

A male client with obesity discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. "Be sure to have a complete physical examination before beginning your planned exercise program." B. "Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more." C. "Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class." D. "Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation." Submit

A. "Be sure to have a complete physical examination before beginning your planned exercise program."

A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? A. "It is important that you continue your medication while learning to meditate." B. "Spiritual meditation requires a time commitment of 15 to 20 minutes daily." C. "Obtain your healthcare provider's permission before starting meditation." D. "Complementary therapy and western medicine can be effective for you."

A. "It is important that you continue your medication while learning to meditate."

A client's spouse is learning passive range-of-motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement? A. Acknowledge that the spouse is supporting the arm correctly. B. Encourage the spouse to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct the spouse to grip directly over the joint for better motion.

A. Acknowledge that the spouse is supporting the arm correctly.

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe.

A. Assist the ambulating client back to the bed.

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.

A. Chocolate pudding.

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? A. Client. B. Healthcare provider. C. A family member. D. Previous medical records

A. Client

A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action should the nurse take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CKD.

A. Commend the client for selecting a high biologic value protein.

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

A. Determine the etiology of the problem.

A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities.

A. Give an around-the-clock schedule for administration of analgesics.

The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A. Inherited familial health disorders. B. Chronic health problems. C. Reason for seeking health care. D. Undetected disorders.

A. Inherited familial health disorders.

An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.

A. Inquire about the source and type of pain.

During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A. Listen and show interest as the client expresses these feelings. B. Reinforce that this behavior means they were not true friends. C. Ask the healthcare provider for a psychiatric consult. D. Continue with the assessment and tell the client not to worry.

A. Listen and show interest as the client expresses these feelings.

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse.

A. Loosen the right wrist restraint.

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? A. The client voluntarily signed the form. B. The client fully understands the procedure. C. The client agrees with the procedure to be done. D. The client authorizes continued treatment.

A. The client voluntarily signed the form.

A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? A. "What is your daily calorie consumption?" B. "What vitamin and mineral supplements do you take?" C. "Do you feel that you are overweight?" D. "Will a clear liquid diet be okay after surgery?"

B. "What vitamin and mineral supplements do you take?"

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch, and before dinner. D. With breakfast, with lunch, and with dinner.

B. 8 am, 4pm, and midnight.

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.

B. A decreased flow rate could result in the formation of a thrombosis.

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer.

B. A lactating woman nursing her 3-day-old infant.

On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? A. Assault. B. Battery. C. Malpractice. D. False imprisonment.

B. Battery.

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed.

B. Blood transfusions are forbidden.

The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering.

B. Continue asking the mother questions about the child.

The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the elderly is accurate? A. Bewilderment is to be expected, and progresses with age. B. Disorientation often follows relocation to new surroundings. C. Uncertainty is a result of irreversible brain pathology. D. Being perplexed can be prevented with adequate sleep.

B. Disorientation often follows relocation to new surroundings.

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, which action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water.

B. Flush the tube with water.

An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). What is the best position for the client for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.

B. Fowler's

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.

B. Instruct the client that the stoma will become smaller when the initial swelling diminishes.

The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.

B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

B. Note which actions were not implemented.

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors.

B. Nutritional history.

An older client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions.

B. Place a pillow between your knees while lying in bed to prevent hip dislocation.

The nurse observes an unlicensed assistive personnel (UAP) checking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. Which action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure.

B. Reassess the client's blood pressure using a larger cuff.

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.

B. Reposition the client on her side.

The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person? A. Arms. B. Upper torso. C. Head. D. Feet.

B. Upper torso

During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? A. Place the stethoscope bell at random points on the posterior chest. B. Use the stethoscope bell over the valvular areas of the anterior chest. C. Move the diaphragm of the stethoscope over the left anterior chest. D. Position the diaphragm of the stethoscope at Erb's point on the chest.

B. Use the stethoscope bell over the valvular areas of the anterior chest.

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client's silence? A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." B. "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." C. "It is OK if you don't want to talk about your surgery. I will be available when you are ready." D. "I will ask a woman who has had a mastectomy to come by and share her experiences with you."

C. "It is OK if you don't want to talk about your surgery. I will be available when you are ready."

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol." B. "I need to avoid eating proteins, including red meat." C. "I will limit my intake of beef to 4 ounces per week." D. "My blood level of low density lipoproteins needs to increase."

C. "I will limit my intake of beef to 4 oz per week."

Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met? A. Expresses concern about the meaning and importance of life. B. Remains angry at God for the continuation of the illness. C. Accepts that punishment from God is not related to illness. D. Refuses to participate in religious rituals that have no meaning.

C. Accepts that punishment from God is not related to illness.

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? A. Restatement of responses. B. Open-ended questions. C. Closed-ended questions. D. Problem-seeking responses.

C. Closed ended questions.

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.

C. Degree of flexion and extension of the client's knee joint.

A postoperative client will need to perform daily dressing changes after discharge. Which outcome response best demonstrates the client's readiness to manage wound care after discharge? A. Asking relevant questions regarding the dressing change. B. Stating theability to complete the wound care regimen. C. Demonstrating the wound care procedure correctly. D. Showing all the necessary supplies for wound care.

C. Demonstrating the wound care procedure correctly.

Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

C. Examining a chest x-ray obtained after the tubing was inserted.

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.

C. Frontal lobe.

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? A. Healthcare provider notified of failure to collect specimens for prescribed blood studies. B. Blood specimens not collected because client no longer wants blood tests performed. C. Healthcare provider notified of client's refusal to have blood specimens collected for testing. D. Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified.

C. Healthcare provider notified of client's refusal to have blood specimens collected for testing.

Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.

C. Keep gloved hands above the elbows.

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 mL of warm water and 5 mL of castile soap. C. Reposition in a Sims' position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

C. Reposition in a Sims' position with the client's weight on the anterior ilium.

The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie.

C. Skim milk, turkey salad, roll, vanilla ice cream

An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. The nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.

C. The nurse who transferred the client to the chair when the fall occurred.

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

D. Assess for bladder distention

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? A. The belief is held that the "evil eye" enters the child if anything cold is ingested. B. After surgery the child probably has refused all foods except broth. C. Eating broth strengthens the child's innate energy called "chi." D. "Hot" remedies restore balance after surgery, which is considered a "cold" condition.

D. "Hot" remedies restore balance after surgery, which is considered a "cold" condition.

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. "That means you have derived the maximum benefit, and the heat can be removed." B. "Your blood vessels are becoming dilated and removing the heat from the site." C. "We will increase the temperature 5 degrees when the pad no longer feels warm." D. "The body's receptors adapt over time as they are exposed to heat."

D. "The body's receptors adapt over time as they are exposed to heat."

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

D. Encourage additional oral intake of juices and water.

A client with acute hemorrhagic anemia is to receive four units of packed red blood cells (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs every 15 minutes for the first hour. D. Ensure the accuracy of the blood type match.

D. Ensure the accuracy of the blood type match.

An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position.

D. Gently lift the client when moving into a desired position.

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? A. At the beginning, middle, and end of the shift. B. After client priorities are identified for the development of the nursing care plan. C. At the end of the shift so full attention can be given to the client's needs. D. Immediately after the assessments are completed.

D. Immediately after the assessments are completed.

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. Demonstrates loss of remote memory. B. Exhibits expressive dysphasia. C. Has a diminished attention span. D. Is disoriented to place and time.

D. Is disoriented to place and time.

The unlicensed assistive personnel (UAP) working on a chronic neuro unit asks the nurse to help determine the safest way to transfer an older client with left-sided weakness from the bed to the chair. Which method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

An older resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

D. Notify the healthcare provider of the family's request.

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A. Generalized dry skin. B. Localized dry skin on lower extremities. C. Red flush over entire skin surface. D. Rashes in the axillary, groin, and skin fold regions.

D. Rashes in the axillary, groin, and skin fold regions.

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again.

D. Re-oxygenate the client before attempting to suction again.

A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take? A. Explain that anyone who speaks her language can answer her questions. B. Provide a translator only in an emergency situation. C. Ask a family member or friend of the client to translate. D. Request and document the name of the certified translator.

D. Request and document the name of the certified translator.

A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client? A. Obtain an interpreter to explain the procedure to the client. B. Encourage the client to make her own decision regarding surgery. C. Ask the family members to provide a clarification of the surgeon's explanation to the client. D. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

D. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.

D. Upper arm circumference.