HESI VERSION 4

24. A client is receiving an infusion of 500 ml D5W with 25,000 units of heparin at 1,000 units/hour has a partial thromboplastin time (PTT) of 110 seconds. The sliding scale prescription reads: "If the PTT is less than 65 seconds, increase the rate by 200 units/hour; and if the PTT is greater than 95 seconds decrease the rate by 200 units/hour." The nurse should regulate the infusion pump for how many ml/hour? (Enter numeric value only.)

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104. The charge nurse should intervene when what behavior is observed? A. A hospital transporter is reading a client's history and physical while waiting for an elevator. B. A UAP tells a client, "It's hard to quit drinking but Alcoholic Anonymous helped me." C. Two visitors are discussing a hospitalized client's history of drug abuse in the visitor's lounge. D. Two staff members are overheard talking about a cure for AIDS outside a client's room.

A. A hospital transporter is reading a client's history and physical while waiting for an elevator.

77. A client with dementia describes imagined experiences that have no basis in fact, and a nursing diagnosis of "Altered thought processes related to confabulation" is formulated. What main function does confabulation serve for client with dementia? A. Increase self-esteem. B. Decrease anxiety. C. Keep the conversation going. D. Impress others.

B. Decrease anxiety.

131. The nurse is administering an IV medication through a central venous catheter with a heparin loc. Which sequence of medication administration should the nurse follow? A. Saline, heparin, medication, heparin. B. Saline, medication, saline, heparin. C. Medication, heparin, saline, heparin. D. Heparin, medication, heparin, saline

B. Saline, medication, saline, heparin.

137. A child is injured at a sporting event and a nurse attending the event evaluates the child. What is the most accurate method to determine if a fracture has occurred? A. Palpate the injured part. B. Send the child for a radiological exam. C. Observe for decreased range of motion. D. Assess the level of swelling and pain on movement.

B. Send the child for a radiological exam.

28. The nurse is monitoring an infant with pulmonic stenosis. Which finding is most important for the nurse to report to the healthcare provider? A. Clubbing of the fingers. B. Systemic cyanosis. C. Presence of a thrill. D. Polycythemia.

B. Systemic cyanosis.

5. A client misses breakfast because of a two-hour hand washing ritual that is performed daily. What plan is most therapeutic for the nurse to implement? A. Meet with the client daily to discuss motivation for initiating the ritual. B. Wake the client early so the ritual can be completed before breakfast. C. Set limits on amount of time the client is allowed to perform the ritual. D. Socialize with the client during the ritual to demonstrate acceptance

B. Wake the client early so the ritual can be completed before breakfast.

123. When obtaining a health history, a male client tells the nurse that he has become impotent. What part of his health information is likely to be most significant to the sexual dysfunction he is experiencing? The client A. drinks two to three beers on weekend. B. Was diagnosed with diabetes mellitus 10 years ago. < C. Had a vasectomy five years ago. D. Smokes one pack of cigarettes a day.

B. Was diagnosed with diabetes mellitus 10 years ago.

49. The nurse has completed discharge teaching with a client who had perineal surgery one week ago. Which statement by the client indicates that the teaching was effective? A. "I will try to avoid eating fruits and vegetables." B. "I will limit my fluid intake to about a quart a day." C. "I will cleanse the perineum after every bowel movement." D. "I will only use enemas if I do not have a daily bowel movement."

C. "I will cleanse the perineum after every bowel movement."

29. The nurse is planning care for a newborn with bladder exstrophy. During the preoperative period, which intervention should the nurse implement? A. Expose the bladder to room air to promote scar formation. B. Place a dry sterile dressing over the exposed bladder. C. Apply a sterile non-adherent dressing over the bladder. D. Use pre-weighed large diapers for diapering the infant.

C. Apply a sterile non-adherent dressing over the bladder.

35. A "Code Pink" is announced over the hospital intercom system, indicating that a baby has been abducted from the nursery. What action should the charge nurse on a medical surgical unit implement first? A. Assign one UAP to report to the nursery to assist with the search. B. Instruct the nursing staff to check every client's room, bathroom, and treatment room. C. Assign one staff member to stay at each of the emergency exits and stairwell doors. D. Stay alert for further announcements because a code pink primarily affects maternity units.

C. Assign one staff member to stay at each of the emergency exits and stairwell doors.

82. The nurse is preparing to administer a liter of IV solution to a toddler with gastroenteritis who is dehydrated. Which action should the nurse implement to prevent fluid overload? A. Ask another nurse to distract the child while spiking the IV bag. B. Use tubing with secondary ports and a macro-drip chamber. C. Attach a volume-control device below the primary infusion. D. Immobilize the hand with the IV access device to an arm board.

C. Attach a volume-control device below the primary infusion.

151. A 12-year-old male is diagnosed with idiopathic hypopituitarism based on plasma growth hormone studies. Subcutaneous injections of the human growth hormone somatotropin (HGH) are prescribed three times a week. To promote the most natural physiological release of growth hormone, when should the nurse teach the child to administer the injections? A. In the late afternoon. B. Before going to school in the morning. C. Before going to sleep at night. D. Before breakfast.

C. Before going to sleep at night.

54. The nurse plans to frequently monitor the skin color, mucous membranes, and nail beds of a client with acute renal failure (ARF). What is the purpose in carrying out this nursing intervention? A. Identify early signs of infections. B. Identify early signs of dietary deficiencies. C. Detect signs of anemia. D. Assess for signs of jaundice

C. Detect signs of anemia.

110. In assessing a client diagnosed with left-sided heart failure, the nurse observes new findings of jugular vein distention and pedal edema. What action should the nurse implement? A. Position the client in a left lateral Trendelenburg position. B. Advise the client that thrombolytic therapy will be started immediately. C. Notify the healthcare provider of the onset of right-sided failure. D. Prepare to administer an intravenous vasoconstricting agent.

C. Notify the healthcare provider of the onset of right-sided failure.

56. A female client who is being prepared for a hysterosalpingogram (HSG) informs the nurse that she is allergic to shellfish. What action should the nurse implement? A. Administer an antihistamine before the HSG. B. Document the client's allergy. C. Notify the healthcare provider. D. Ensure that a latex-free supply cart is available.

C. Notify the healthcare provider.

46. One hour after receiving the initial dose of doxazosin (Cardura), a male client with benign prostatic hypertrophy complains of a rapid heartbeat and dizziness. He is sitting at the side of the bed finishing his bedtime snack. His radial pulse is 144 beats/minute. What action should the nurse take first? A. Assist the client to a recumbent position. B. Notify the healthcare provider. C. Obtain his blood pressure and apical pulse rate. D. Obtain an electrocardiogram (ECG).

C. Obtain his blood pressure and apical pulse rate.

1. A male client who had a transurethral resection of the prostate (TURP) today has a continuous bladder irrigation (CBI). The client requests pain medication for abdominal pain rated at "9" on a scale of 1 to 10. What action should the nurse take first? A. Administer prescribed PRN analgesic medication. B. Position him on the left side and slow the irrigation rate. C. Palpate his abdomen and check his urinary output. D. Assist him to ambulate to help pass flatus.

C. Palpate his abdomen and check his urinary output.

109. Thirty-six hours after delivery, the nurse assesses a client's fundus just above the umbilicus and displaced to the right of midline. What action should the nurse take first? A. Assess the amount of lochia. B. Catheterize the client and record the amount. C. Palpate the bladder for distention. D. Ask the client when her last bowel movement occurred.

C. Palpate the bladder for distention.

58. A client with hypertension is scheduled to receive a dose of the alpha-beta adrenergic blocking agent carvedilol (Coreg). Which of the client's vital signs warrants notification of the healthcare provider prior to administering the scheduled dose? A. Temperature of 101.4 F. B. Blood pressure of 170/92. C. Pulse rate of 42 beats/minute. D. Respiratory rate of 12 breaths/minute.

C. Pulse rate of 42 beats/minute.

94. The nurse is developing the plan of care for a client who is returning from surgery after a total colectomy and ileostomy. Which nursing diagnosis has the highest priority for this client during the immediate postoperative period? A. Risk for impaired skin integrity related to fecal drainage. B. Knowledge deficit related to surgical bowel diversion. C. Risk for electrolyte imbalance related to ileostomy. D. Risk for sexual dysfunction related to pelvic nerve injury.

C. Risk for electrolyte imbalance related to ileostomy.

64. At a 2-year-old well-child visit, a toddler's parent tells the nurse that this child, who is the youngest of five, rarely talks spontaneously. Which intervention should the nurse implement? A. Demonstrate games requiring expressive speech. B. Suggest that the parent read aloud to the child at bedtime. C. Schedule an appointment with pediatric audiologist. D. Encourage the parent to enroll in preschool classes

C. Schedule an appointment with pediatric audiologist.

74. A new plaster cast is applied to a client's arm for a fracture of the ulna. Sixty minutes after receiving an analgesic, the client reports pain in the arm and scores the intensity at "10" on a scale of 1 to 10. Which action is most important for the nurse to perform? A. Teach the client to wiggle the fingers. B. Contact provider for a different analgesic. C. Elevate the extremity on two pillows. D. Assess for distal paresthesia.

D. Assess for distal paresthesia.

11. When the nurse auscultates the anterior chest just above the right nipple, moderate pitched breath sounds are heard that are equal on inspiration and expiration. Which statement best describes this finding? A. Bronchial breath sounds that are normal in that location. B. Bronchovesicular breath sounds that are abnormal in that location. C. Bronchial breath sounds that are abnormal in that location. D. Bronchovesicular breath sounds that are normal in that location.

D. Bronchovesicular breath sounds that are normal in that location.

105. A client who had a left above knee amputation (AKA) two days ago has a soft stump dressing in place. To prevent the development of a contracture on the left leg, which intervention should the nurse implement? A. Turn the client to the unaffected side only. B. Elevate the client's left leg on two pillows at all times. C. Instruct the client to push the stump against a soft pillow. D. Position the client prone 3 to 4 times a day.

D. Position the client prone 3 to 4 times a day.

117. A male client with a history of generalized tonic-clonic seizures tells the nurse that he feels like he is about to have a seizure. What should the nurse do first? A. Perform a neurological assessment. B. Give a STAT dose of an anticonvulsant medication. C. Check client's oxygen saturation level. D. Stay with the client and call for assistance.

D. Stay with the client and call for assistance.

89. The nurse is performing an intake interview at a prenatal clinic. Which planned activity described by the client, who is at 6-weeks gestation, should be investigated by the nurse first? A. A scheduled business trip in 3 weeks that includes travel by airplane and train. B. Plans to continue participating in a low-impact aerobics class. C. The 9-year-old sibling will come with the client to the next prenatal visit. D. Supervision of the renovation of an old house the family just purchased.

D. Supervision of the renovation of an old house the family just purchased.

71. The nurse is planning care for a client who is newly diagnosed with type 1 diabetes mellitus (DM). What nursing intervention should the nurse include in this client's plan of care? A. Give an oral hypoglycemic agent per sliding scale. B. Check each voided urine for sugar and ketones. C. Monitor blood glucose levels every 6 hours. D. Teach diabetic information at every opportunity.

D. Teach diabetic information at every opportunity.

3. A client is receiving a standardized solution of heparin 25,000-units/250 ml of normal saline. The healthcare provider prescribes to increase the client's current infusion rate of heparin to 700 units/hour. How many ml/hour should the nurse program the infusion pump? Enter the numerical value only.

Using formula, D/H x Q, 700 units/hour 25,000 units x 25o ml = 7 ml/hour

108. The nursing diagnosis, "High risk for infection" is most relevant for a client with which hematologic problem? A. Agranulocytosis. B. Thrombocytopenia. C. Erythrocytopenia. D. Polycythemia.

A. Agranulocytosis.

128. The nurse is assessing a client who is eight hours post parathyroidectomy. Assessment findings include a negative Trousseau's sign. What action should the nurse implement? A. Document the findings. B. Notify the healthcare provider. C. Obtain a serum calcium level. D. Administer IV calcium chloride

A. Document the findings.

140. Which intervention would the nurse expect to implement to decrease discomfort and muscle spasms for an elderly client with a fractured left hip? A. Prepare the client for application of Buck's traction. B. Remove the foam boot to perform range of motion exercises. C. Prepare the client for application of Dunlop's traction. D. Inspect the pin site at least q8h for signs of infection.

A. Prepare the client for application of Buck's traction.

13. The nurse should encourage males over the age of 45 to obtain which test to screen for prostatic cancer? A. Prostate-specific antigen (PSA). B. Serum testosterone level. C. Alpha-fetoprotein radioimmunoassay (AFP). D. Ultrasound of the scrotum

A. Prostate-specific antigen (PSA).

76. A client is admitted to the Emergency Department with acute abdominal pain and a provisional diagnosis of pancreatitis. The nurse assesses the client and results from laboratory studies are obtained. Which information is most valuable in reporting the client's status to the healthcare provider? A. Severity of nausea and vomiting and serum amylase results. B. Presence of bowel sounds and degree of abdominal pain. C. Serum H. pylori antibody results and urine output amounts. D. Complaints of chronic constipation and serum gastrin levels.

A. Severity of nausea and vomiting and serum amylase results.

92. An infant is receiving gavage feedings via an orogastric tube. At the beginning of the feeding, the infant's heart rate drops to 80 beats/minute. What action should the nurse take? A. Slow the feeding and monitor the infant's response. B. Immediately clamp and remove the orogastric tube. C. Shift the infant's position to the right lateral side. D. Continue feeding since this is a typical response.

A. Slow the feeding and monitor the infant's response.

67. Vaginal exam of a client who is admitted in early labor reveals cervical dilation of 2 cm with 50% effacement and a -3 fetal station. The client tells the nurse that a friend's bag of waters was ruptured by the doctor to make labor progress faster, and she is concerned because her doctor did not rupture the membranes. What response is best for the nurse to provide? A. The baby's cord can prolapse if the fetal head is high in the pelvis. B. Cervical dilatation to 4 cm is needed to rupture the membranes. C. The bag of waters is not ruptured until the birth is imminent. D. Rupturing the bag of waters does not have any effect on labor.

A. The baby's cord can prolapse if the fetal head is high in the pelvis.

115. After administering phenobarbital to an infant with increased intracranial pressure, which response should the nurse expect? A. The infant is sleepy and less irritable. B. Infant take clear liquids without vomiting. C. Increased heart and respiratory rate. D. The infant's urinary output increases.

A. The infant is sleepy and less irritable.

22. The nurse is planning the discharge teaching for a female client who has frequent urinary tract infections. In teaching the client how to prevent urinary tract infections, which recommendation should the nurse include? A. Void immediately after intercourse. B. Sit in a tub of warm water each evening. C. Drink a glass of water upon arising each morning. D. Perform Kegel exercises several times daily.

A. Void immediately after intercourse.

25. The nurse teaching a preconception preparation class is discussing ways to improve dietary folic acid intake. Which evening snack contains the most folic acid? A. Whole grain cereal and milk. B. Hard-boiled egg and juice. C. Vanilla milkshake with protein supplement. D. Toasted white bread with butter.

A. Whole grain cereal and milk.

118. The nurse gives a client the daily dose of a prescription for captopril (Capoten) 12.5 mg PO every AM. Shortly after administering the medication, the healthcare provider instructs the nurse to give another dose to reach the newly prescribed dose of 50 mg PO daily. The medication is available in 12.5 tablets. How many additional tablets should the nurse give? (Enter the numeric value only.)

3

130. The nurse is calculating the one-minute Apgar score for a newborn male infant, and determines that his heart rate is 150 beats/minute, he has a vigorous cry, his muscle tone is good with total flexion, he has quick reflex irritability, and his color is dusky and cyanotic. What Apgar score should the nurse assign to the infant? (Enter the numeric value only.)

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44. The healthcare provider prescribes meperidine (Demerol) 25 mg IV every 3 hours for an older, postoperative client. The nurse prepares the prescribed dose from a cartridge labeled "meperidine 75 mg/ml" and dilutes the medication with 5 ml of normal saline for IV administration. How many ml is the total volume of diluted medication? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

5.3

112. A client has an AV graft for hemodialysis in the left forearm and an infiltrated IV in the right arm. After discontinuing the IV, where should the next IV be started? A. Right arm proximal to the former IV. B. Use AV graft for IV access. C. Left arm proximal to the graft. D. Left arm distal to the graft.

A. Right arm proximal to the former IV.

48. The nurse is preparing a disaster plan for a community. When planning for a potential bioterrorism attack, which disease should be considered? A. Shigellosis. B. West Nile virus. C. Pertussis. D. Tularemia.

D. Tularemia.

111. Identify the location of the tragus on the outer auricle. (Click the chosen location. To change, click on a new location.)

SEE THE PICTURE

83. While assessing a 6-year-old, the nurse notices several elevated 1 to 3 mm white spots on the child's buccal mucosa. What other signs should the nurse expect this child to exhibit? A. Irregular red macular rash in the perianal area. B. Red blotchy macular rash on the face and neck. C. Pruritic vesicular skin eruptions on trunk. D. Honey-colored crusted exudate from ruptured skin vesicles.

B. Red blotchy macular rash on the face and neck.

149. The nurse observes a client standing with the use of crutches and notes that the client's arms are fully extended and the tops of the crutches are securely pressed in the client's axillae. Which intervention should the nurse initiate first? A. Demonstrate the prescribed gait to the client. B. Reduce the length of the client's crutches. C. Make sure that the rubber tips are in place on the crutches. D. Instruct the client in the use of the tripod position.

B. Reduce the length of the client's crutches.

141. In performing the admission assessment for a client experiencing complications of long-term Parkinson's disease, which question by the nurse provides the best information about disease progression? A. "Have you experienced any stiffness in your neck or shoulder?" B. "Do you notice any jerky type movements of your arms?" C. "Have you ever been frozen to a spot and unable to move?" D. "Do you have any problems with your hands shaking?"

C. "Have you ever been frozen to a spot and unable to move?"

16. Which nursing intervention has the highest priority when completing discharge teaching for a client with Helicobacter pylori (H. pylori) induced peptic ulcer diseases (PUD)? A. Refer the client to a counselor for information on stress reduction and relaxation. B. Encourage the client to eat regularly scheduled meals to help prevent the pain. C. Instruct the client to take all the antibiotics, proton pump inhibitors, and Pepto-Bismol. D. Teach the importance of taking the Carafate medication immediately before meals.

C. Instruct the client to take all the antibiotics, proton pump inhibitors, and Pepto-Bismol.

38. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What medication can the nurse expect the healthcare provider to prescribe? A. Nitrofurantoin (Macrodantin) orally. B. Erythropoietin (Epogen) intravenously. C. Kayexalate retention enema. D. Azathioprine (Imuran) orally.

C. Kayexalate retention enema.

107. When irrigating an occluded nasogastric tube, what action should the nurse include? A. Check the stomach for the amount of residual volume. B. Clamp the tube after instilling the normal saline. C. Measure the amount of fluid instilled and returned. D. Lubricate the tip of the syringe before insertion.

C. Measure the amount of fluid instilled and returned.

32. The emergency department notifies the charge nurse at 3:00 a.m. of the transfer of a client who is being admitted because of multiple lacerations that are a result of self-destructive behavior. Agency policy states that this client should be admitted to a safe room with window locks, but the only safe room on the unit is currently occupied by a postoperative client. What action should the nurse take? A. Admit the client to a regular room and provide intensive monitoring. B. Have the client remain in the emergency department until morning. C. Move the postoperative client to another room. D. Decline the client because a safe room is unavailable.

C. Move the postoperative client to another room.

114. A 10-year-old boy reports that the words on his teacher's power point presentations are blurry even though he sits in the front row of the classroom. Based on this description, the school nurse should suspect which problem? A. Exotropia. B. Farsightedness. C. Myopia. D. Hyperopia.

C. Myopia.

154. A client who is receiving chemotherapy for lung cancer with brain metastasis is scheduled for cranial radiation therapy (RT) today. The nurse should provide which information about the procedure to the client? A. Radiation precautions are implemented to limit exposure for everyone who enters the client's room. B. A high dose beam of radiation may cause a brief tingling sensation but will not cause pain. C. Skin markings and head positioning devices are used to ensure that only the tumor site is radiated. D. A radioisotope is implanted into the tumor that limits chemotherapy side effects for up to 30 days.

C. Skin markings and head positioning devices are used to ensure that only the tumor site is radiated.

88. A nurse is concerned about the type of legal consequences that can result from breaching client confidentiality. What source states the legal requirements nurses must follow to protect client confidentiality in a nurse-patient relationship? A. Amendments to the Federal Constitution. B. Patient's Bill of Rights Acts. C. State Nurse Practice Acts. D. ANA Code of Ethics for Nurses.

C. State Nurse Practice Acts.

21. The parents of a 4-week-old male infant report that he eats well but vomits after each feeding. Which assessment finding should the nurse expect him to exhibit if the baby is receiving inadequate nutrition? A. Tachypnea. B. Hypoactive bowel sounds. C. Sunken fontanels. D. Absent Moro reflex.

C. Sunken fontanels.

4. A client is receiving the intravenous adrenergic agonist dobutamine (Dobutrex). In evaluating the client's reaction to the medication, which assessment finding indicates to the nurse that the medication is effective? A. The client denies chest pain or discomfort. B. The client had 160 ml urine output in 8 hours. C. The client's blood pressure is 110/70 mmHg. D. The client's posterior tibial pulses are 1+.

C. The client's blood pressure is 110/70 mmHg.

40. A client has produced the first of a series of sputum samples for cytology. What action should the nurse implement? A. Ensure the client remains NPO until all the samples are collected. B. Discard the initial sample and document the time it was obtained. C. Transport the sputum container to the laboratory in a biohazard bag. D. Document the time the client last ate or drank on the laboratory slip.

C. Transport the sputum container to the laboratory in a biohazard bag.

152. When planning care for a group of clients on a medical unit, which task can the nurse delegate to the unlicensed assistive personnel (UAP)? A. Complete a Braden Scale to predict pressure ulcer risk. B. Prepare a schedule for positioning a bedfast client. C. Use a mechanical lift to transfer a client to the chair. D. Determine if a client has learned how to use a walker

C. Use a mechanical lift to transfer a client to the chair.

23. When administering an antibiotic that causes photosensitivity, which instruction is important for the nurse to provide the client? A. Have hearing checked periodically. B. Be sure to drink plenty of fluids after activity. C. Wear long-sleeved clothing outdoors. D. Get up slowly to avoid dizziness.

C. Wear long-sleeved clothing outdoors.

72. The nurse is evaluating preoperative teaching. What statement by the client indicates an understanding of the need to remain NPO prior to surgery? A. "My intestines need to be empty during surgery." B. "Less fluid will collect in my lungs." C. "I will be less likely to vomit after surgery." D. "There's less chance I will vomit during surgery."

D. "There's less chance I will vomit during surgery."

116. The healthcare provider prescribes etanercept (Enbrel) 50 mg subcutaneously weekly for a client with rheumatoid arthritis. The nurse should evaluate the effectiveness of this medication within what time frame? A. Once every 6 months. B. Daily for one week. C. Every 4 months for one year. D. 2 to 4 weeks.

D. 2 to 4 weeks.

31. The nurse is assessing a 48-year-old client with Guillain-Barre syndrome. What symptom is this client most likely to exhibit? A. Pill rolling movement of the fingers. B. Difficulty keeping eyelids open. C. Pain on one side of the face. D. Decreased mobility of the legs.

D. Decreased mobility of the legs.

124. The mother of a hospitalized 2-year-old boy asks the nurse if her child is ready to be toilet trained. Which response is best for the nurse to provide? A. "Yes, most children are ready when they are 15-months old." B. "We have potty chairs here. Would you like to start working with him on it now?" C. "He will train quicker and more easily if you wait until he is in a familiar environment." D. "Does he let you know just before or after he soils his diaper?"

"Does he let you know just before or after he soils his diaper?"

102. While reporting a client's blood glucose results to the nurse, the LPN states that the glucometer was not calibrated prior to use because the report given by the night shift ran late. What action is most important for the nurse to perform. A. Advise the LPN of the implications involved by not calibrating the glucometer. B. Complete a variance report describing the inaccurate blood glucose measurements. C. Discuss the need for a more efficient shift report with the night charge nurse. D. Ask the supervisor to schedule an in-service training on the correct use of glucometers.

A. Advise the LPN of the implications involved by not calibrating the glucometer.

93. A 40-year-old client with Type 1 diabetes developed chronic kidney disease (CKD) 6 months ago. Because of secondary complications often associated with this illness, the nurse plans to carefully assess for signs of what condition? A. Anemia. B. Kidney stones. C. Rheumatoid arthritis. D. Bacterial endocarditis

A. Anemia.

142. An 18-year-old female client with primary dysmenorrhea does not want to take any medication to relieve the symptoms, and asks the nurse which herbal supplement is likely to help alleviate the pain she is experiencing. What herbal supplement is likely to be most helpful for this young woman? B. Ginseng. C. Yarrow. D. Ginger.

A. Chamomile.

2. The mental health nurse takes several adolescent clients to the inpatient schoolroom. The teacher asks the nurse to stay and help one of the male clients who has attention-deficit hyperactivity disorder with his spelling assignment. Which goal is reasonable for this client to attain during this one-hour class? A. Completes at least one page of spelling. B. Follows directions the first time they are given. C. Sits quietly with peers and completes assignment. D. Shares his problems with others in the class.

A. Completes at least one page of spelling.

53. An adult male client presents to the psychiatric clinic accompanied by his mother who is concerned that her child is going to jail because he broke into a jewelry store. The nurse conducts an intake assessment and determines that the son is using marijuana daily. What information should the nurse provide this mother? A. Describe the consequences of enabling behaviors. B. Suggest to the mother that she allow her son to go to jail. C. Refer the son to a drug treatment program immediately. D. Tell the mother to discourage her son's marijuana use.

A. Describe the consequences of enabling behaviors.

52. A 25 year-old male client with testicular carcinoma is scheduled for a unilateral orchiectomy tomorrow. During the preoperative preparation, he tells the nurse that he is concerned that his scrotum will not look normal after the surgery, even though he knows that a testicular prosthesis will be inserted during surgery. What immediate response is best for the nurse to provide? A. Explain that the prosthesis feels and looks natural in the scrotum. B. Refer the client to a support group for young adults with cancer. C. Reassure the client that no one will know just by looking at him. D. Arrange for a recipient of testicular prosthesis to visit the client.

A. Explain that the prosthesis feels and looks natural in the scrotum.

138. The nurse working in a health clinic is assessing clients' needs for a hepatitis A vaccine. Which client has the greatest risk for contracting Hepatitis A? A. Female client who regularly consumes raw oysters. B. An adolescent client who reports illicit IV drug use. C. An elderly client with a large daily alcohol consumption. D. Male client who has received multiple blood transfusions.

A. Female client who regularly consumes raw oysters

47. When preparing the client for a thoracentesis, it is essential for the nurse to take which action? A. Have the client lie in the prone position. B. Determine if chest x-rays have been completed. C. Encourage the client to cough during the procedure. D. Ask the client to void prior to the procedure.

A. Have the client lie in the prone position.

158. A toddler with hemophilia is being discharged from the hospital. Which teaching should the nurse include in the discharge instructions to this child's mother? A. Place padding on the corners of all furniture. B. Give the child only one baby aspirin for pain relief. C. Ensure that dental hygiene is done frequently. D. Do not allow the child run inside the house.

A. Place padding on the corners of all furniture.

39. The nurse finds a client at 33-weeks gestation in cardiac arrest. What adaptation to cardiopulmonary resuscitation (CPR) should the nurse implement? A. Position a hip wedge for lateral uterine displacement. B. Adjust the ventilation-to-compression ratio to 3:20. C. Apply less compression force to reduce aspiration. D. Apply oxygen mask after opening the airway.

A. Position a hip wedge for lateral uterine displacement.

2. The charge nurse observes a male healthcare provider viewing his sister's record on the computer monitor. What action should the nurse take? A. Remind the healthcare provider that only the treatment team should view the client's records. B. Tell the healthcare provider to maintain confidentiality of the contents in his sister's record. C. Allow the healthcare provider to continue viewing the client's medical record. D. Ask the client if she gave her brother permission to view her record.

A. Remind the healthcare provider that only the treatment team should view the client's records.

127. A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine (Clozaril) is prescribed. Which intervention should the nurse include in the client's plan of care? A. Report findings from the client's weekly white blood cell (WBC) counts to the healthcare provider. B. Inform UAPs that the client will likely complain of a sore throat and fever. C. Offer this medication the client with food to decrease the possibility of gastric upset. D. Place the client in reverse isolation for the first two weeks of treatment with this medication

A. Report findings from the client's weekly white blood cell (WBC) counts to the healthcare provider.

98. During breath sound auscultation of a client who is being mechanically ventilated, the nurse hears coarse, snoring sounds over the upper anterior chest with clear breath sounds over the other lung fields. What intervention should the nurse implement at this time? A. Suction the client's endotracheal tube. B. Notify respiratory therapy immediately. C. Continue to assess the client frequently. D. Begin manual resuscitation with ambu bag.

A. Suction the client's endotracheal tube.

155. While inserting an indwelling catheter for a female client, the nurse observes that the catheter is in the vagina. In what order should the nurse perform these actions? (Arrange from first on top to last on the bottom.) 5 - Inflate the indwelling catheter's balloon with sterile water. 1 - Leave the catheter in the vagina. 2 - Obtain a new catheterization kit. 4 - Insert the catheter and observe for a urinary return. 3 - Use forceps and cotton balls to cleanse the urethral meatus. 6 - Remove the wrongly placed catheter.

ARRANGE IN ORDER

129. The nurse is preparing a Native-American client for surgery in one hour. The client states, "I want to have my medicine man called before surgery." How should the nurse respond? A. "Tell me how you believe that your medicine man will be able to help you." B. "I will be happy to assist you in contacting your medicine man right away." C. "The hospital chaplain is available and can meet with you before surgery." D. "Your medicine man is too far away to visit before your scheduled surgery."

B. "I will be happy to assist you in contacting your medicine man right away."

51. Which equipment should the nurse use to administer iron to an infant with iron deficiency anemia? A. Rectal suppository. B. Medicine dropper. C. Medicine cup. D. IV pump.

B. Medicine dropper.

90. A young adult male client is admitted to the psychiatric unit because of a drug overdose. Which nursing intervention is most important when planning prioritized care for this client during the initial drug withdrawal period? A. Limit visitors who might bring the client drugs. B. Monitor the client's physical response to withdrawal. C. Plan activities to increase the client's self-esteem. D. Help the client gain insight into his behavior.

B. Monitor the client's physical response to withdrawal.

15. The nurse is caring for a laboring client whose membranes ruptured 24 hours prior to admission. Based on the laboring client's record and the current fetal monitor reading, which action should the nurse implement? (Click on each chart for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) A. Stop the oxytocin infusion. B. Prepare for Cesarean delivery. C. Assess the vital signs. D. Apply oxygen 10 L/mask.

B. Prepare for Cesarean delivery.

9. An unresponsive female victim of a motor vehicle collision is brought to the emergency department where it is determined that immediate surgery is required to save her life. The client is accompanied by a close friend, but no family members are available. Which intervention should the nurse implement? A. Obtain an emergency court order for life-saving surgery for the client. B. Prepare the client for surgery without a signed informed consent. C. Ask the woman's friend if the client has an advanced directive. D. Monitor the client until a family member can be located.

B. Prepare the client for surgery without a signed informed consent.

85. A female client diagnosed with major depression was admitted to the psychiatric unit yesterday. Today she refuses to take a bath, dress, or eat, and wants to sleep during the day. Which intervention has the highest priority for this client? A. Request a meeting with the family to discuss her behavior. B. Provide and maintain a safe, structured daily routine. C. Administer the prescribed intramuscular antidepressant medication. D. Assess the client's ability to communicate with the staff.

B. Provide and maintain a safe, structured daily routine.

153. To administer a saline enema to a client, the nurse inserts the enema tubing 3 inches into the client's rectum, and elevates the saline container 6 inches above the client's body. After the nurse opens the clamp, the saline solution does not infuse. What is the best action for the nurse to take? A. Instruct the client to take several slow, deep breaths. B. Raise the saline container 6 more inches above the body. C. Insert the tubing an additional 3 inches into the rectum. D. Remove the tubing and check the client for fecal impaction.

B. Raise the saline container 6 more inches above the body.

30. After positioning a client on the side to administer a rectal suppository, the nurse observes that the client has been incontinent of a large amount of liquid stool, which has soaked through a gauze pad covering a stage three-pressure ulcer. What action should the nurse take first? A. Administer the rectal suppository. B. Replace the soiled dressing. C. Assess the client's bowel sounds. D. Check the client for an impaction.

B. Replace the soiled dressing.

159. The nurse is preparing a male client for a bilateral adrenalectomy. Which explanation should the nurse include in this client's preoperative teaching? A. It will be necessary to take desmopressin acetate (DDAVP) for the rest of his life. B. Replacement therapy with corticosteroids will be needed for the rest of his life. C. It will be necessary to take the prednisone for at least 6 weeks after surgery. D. The surgery should relieve symptoms, so that no medication will be needed after the adrenal glands are removed.

B. Replacement therapy with corticosteroids will be needed for the rest of his life.

134. To assess a client with meningitis for meningeal irritation, how should the nurse position the client's head? A. The neck and head are twisted toward the shoulder. B. The head and neck are flexed toward the chest. C. The ear is flexed downward toward the shoulder. D. The head and neck are extended toward the back.

B. The head and neck are flexed toward the chest.

96. A client diagnosed with schizophrenia looks frightened and tells the nurse, "I keep hearing the voices telling me to hurt somebody. Don't you hear them?" Which response is best for the nurse to provide? A. "If you keep taking your medication the voices will go away." B. "The voices are not real. They are part of your illness." C. "I don't hear the voices, but you seem very frightened." D. "Just ignore the voices and pretend they are not there."

C. "I don't hear the voices, but you seem very frightened."

100. An adult woman and her live-in boyfriend are seen in the Emergency Department following a motor vehicle collision. Based on which finding should the nurse assess further for the possibility of domestic violence? A. The woman is demanding and argumentative with staff. B. The couple is vague about how the collision occurred. C. Several old bruises appear on the woman's chest and neck. D. Her live-in boyfriend seems unconcerned about her condition.

C. Several old bruises appear on the woman's chest and neck.

144. The nurse is conducting a routine assessment of a 24-hour-old, African-American infant who was delivered vaginally. At birth the infant's weight was 5 pounds 5 ounces, heart rate was 150 beats/minute, respiratory rate was 88 breaths/minute, and the axillary temperature was 97.7 F. Which finding requires further assessment? A. Respiratory rate of 59 breaths/minute. B. Edema present along the sagittal suture. C. Weight loss of 10 ounces since birth. D. 2 cm bluish purple area on the scrotum.

C. Weight loss of 10 ounces since birth.

119. A client is receiving an intermittent infusion of erythromycin lactobionate for injection, USP (Erythrocin Lactobionate) 1 gram in 250 ml of normal saline over two hours. The nurse should program the infusion pump to deliver how many ml/hour? (Enter numeric value only.)

12

87. A school-aged child with otitis media receives a prescription for azithromycin (Zithromax) 300 mg once, then 150 mg daily for 4 days. The medication is available in a solution containing 200 mg/5 ml. How many ml should the nurse administer on the first day of the treatment regimen? (Enter numeric value only. If rounding is necessary, round to the nearest tenth.)

7.5

157. A client at 40-weeks gestation is admitted in active labor, and laboratory findings indicate that she is HIV positive. What actions should the nurse plan to perform? (Select all that apply.) A. Administer zidovudine (AZT) intravenously. B. Establish enteric isolation. C. Place her in a negative pressure room. D. Notify the pediatrician that the mother is HIV positive. < E. Promote bonding by encouraging breastfeeding. F. Use universal precautions. <

A. Administer zidovudine (AZT) intravenously D. Notify the pediatrician that the mother is HIV positive. F. Use universal precautions.

126. The nurse is evaluating teaching about short-acting insulin coverage to a client newly diagnosed with Type 1 diabetes. Which statement by the client indicates an understanding of short acting insulin coverage? A. "After taking my regular insulin, I need to eat a meal soon to prevent a hypoglycemic episode." B. "I can eat whatever I want, just as long s I check my blood sugar and cover it appropriately." C. "When meeting a friend for lunch, it is OK to take my coverage at home before driving to the restaurant." D. "I need to check my sugar also at bedtime, and then give my coverage before going to sleep."

A. "After taking my regular insulin, I need to eat a meal soon to prevent a hypoglycemic episode."

97. A client newly diagnosed with Type 1 diabetes received 28 units of Humulin N at 0700. The nurse is making rounds at 1330. Which client statement requires the most immediate follow-up intervention by the nurse? A. "I let my wife eat my lunch since I wasn't hungry." B. "I get so nervous when I have to give my shot." C. "I didn't sleep well last night. I am going to take a nap." D. "I get dizzy when I get up out of the bed too fast."

A. "I let my wife eat my lunch since I wasn't hungry."

84. In evaluating teaching of a client about wearing a Holter monitor, which statement made by the client would indicate to the nurse that the client understands the procedure? A. "I must record any symptoms occurring with my activity." B. "I am not looking forward to staying in bed for 24 hours." C. "I really am dreading the frequent blood drawing." D. "I know that I shouldn't get close to my microwave oven."

A. "I must record any symptoms occurring with my activity."

43. Which statement by the mother of a male toddler with croup indicates to the nurse that the teaching was effective? A. "I need to take him to the nearest ER immediately if he starts having trouble swallowing." B. "The cough makes him sound sicker than he is. I don't need to worry." C. "I can give him baby aspirin for the fever and cough." D. "Using a steam vaporizer at night in his room will help ease the cough."

A. "I need to take him to the nearest ER immediately if he starts having trouble swallowing."

57. Returning to the office after seeing a homebound client, the home health care nurse has many telephone messages from the assigned caseload. Which telephone message should the nurse return first? A. A young adult who was discharged from the hospital yesterday and is not feeling well. B. An older adult with Type 2 diabetes who complains of intense itching of both feet. C. An adult client with a peripheral saline lock with redness at the insertion site. D. A middle-aged client with a sigmoid colostomy who has irritation around the stoma.

A. A young adult who was discharged from the hospital yesterday and is not feeling well.

12. A client is seen in the clinic with an acute episode of acute gastritis. Which nursing diagnosis has the highest priority? A. Acute pain related to inflammation. B. Nausea related to gastric irritation. C. Knowledge deficit related to diet. D. Potential for injury related to bleeding.

A. Acute pain related to inflammation.

146. A client with angina experiences chest pain after completing morning care. What action should the nurse take first? A. Administer a nitroglycerin tablet. B. Place a pulse oximetry probe to index finger. C. Give an 81 mg Aspirin tablet. D. Monitor for premature ventricular contractions.

A. Administer a nitroglycerin tablet.

50. A male client tells the nurse that he has experienced acid reflux for several years. The nurse recognizes that this client has an increased risk for what problem? A. Cancer. B. Cardiac disease. C. Abdominal aneurysm. D. Lymphadenopathy.

A. Cancer.

17. A client had a total hip replacement two days ago. She has never been in the hospital before. She has just called for the bedpan. How should the nurse place the pan under this client? A. Ask her to roll to the unoperated side and slide the bedpan under her, then roll back onto the pan. B. Ask her to roll to the operated side and slide the bedpan under her, then roll her back onto the pan. C. Ask her to flex her knees, spread her legs, and lift her buttocks with the flat part of her feet, then push the bedpan under her from the front. D. Ask her to grab her over bed trapeze, push both heels into the mattress, and raise her buttocks off the bed so the bedpan can be slipped under her.

A. Ask her to roll to the unoperated side and slide the bedpan under her, then roll back onto the pan.

63. The nurse is working with an unlicensed assistive personnel (UAP) to prepare a client who had hip replacement surgery for transfer to the rehabilitation unit. A practical nurse (PN) enters the room and reports that a client with pneumonia has become confused and combative. What action should the nurse implement? A. Ask the UAP to continue packing the belongings of the surgical client while the two nurses return to the room of the combative client. B. Continue to prepare the surgical client for the transfer and instruct the PN to apply restraints to the combative client. C. Assign the UAP to stay with the combative client until the two nurses have transferred the surgical client to the rehabilitation unit. D. Assess the combative client after asking the PN to help the UAP prepare the surgical client for transfer to the rehabilitation unit.

A. Ask the UAP to continue packing the belongings of the surgical client while the two nurses return to the room of the combative client.

99. At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond? A. Ask the woman if she also performs monthly breast self-exams. B. Advise the woman that mammograms are only needed every two years at her age. C. Encourage the woman to explore her fears about breast cancer. D. Comment the woman for adhering to the recommended cancer detection guidelines.

A. Ask the woman if she also performs monthly breast self-exams.

19. On the third day of hospitalization for depression, a male client tells the nurse that he is feeling much better and reports that he believes the antidepressant therapy is working. He participates in all scheduled activities and agrees to take on additional ward assignments. What nursing action is most important for the nurse to implement at this time? A. Assign an attendant to monitor the client's whereabouts at all times. B. Praise the client's willingness to take on additional duties. C. Encourage the client to share his positive attitude with other clients. D. Monitor the client's behavior and intake during meals to determine appetite

A. Assign an attendant to monitor the client's whereabouts at all times.

6. Which discharge instruction should the nurse provide a client with heart failure who is taking digoxin (Lanoxin)? A. Avoid concurrent use of herbal products. B. Take Lanoxin with high-fiber foods. C. Restrict fluid intake to equal urine output. D. Check blood glucose level weekly.

A. Avoid concurrent use of herbal products.

135. A client diagnosed with severe acute diverticulitis is being admitted to the medical unit. Which prescription should the nurse question? A. Bisacodyl (Dulcolax) rectally PRN for constipation. B. Meperidine (Demerol) ICP PRN for pain. C. Cefoxitin (Mefoxin) IVPB q8h. D. 5% dextrose with 0.45 NS at 125 ml an hour.

A. Bisacodyl (Dulcolax) rectally PRN for constipation.

60. After sitting outside, an elderly male who is attending an adult daycare center develops uticaria and a macular rash with raised wheals over most of his trunk. He is slightly dyspneic, and is furiously scratching the rash with both hands. What action should the nurse take first? A. Call 911 to transport the client to an emergency center. B. Assess the vital signs q15 minutes for one hour. C. Ask the client if there were any fire ants on the patio. D. Cover the hives with a topical antihistamine cream.

A. Call 911 to transport the client to an emergency center.

10. A confused and combative male client was placed in bilateral wrist restraints to keep him from pulling out a nasogastric tube. The client developed severe abrasions on both wrists. On the morning that the abrasions were found, the client's record contained nursing documentation stating that skin and circulation checks were conducted every 6 to 8 hours. How should the nurse-manager respond to this situation? A. Meet with the client's nurse to determine why adequate assessment was not performed. B. Reassure the staff that skin damage can occur even when the standard of care is met. C. Provide an in-service on the documentation needed for clients with altered skin integrity. D. Instruct the staff about the correct protocol for the application of bilateral wrist restraints.

A. Meet with the client's nurse to determine why adequate assessment was not performed.

86. A client with chronic controlled atrial fibrillation develops symptoms of a pulmonary embolus. What intervention has the highest priority? A. Monitor oxygen saturation via pulse oximeter. B. Evaluate the client's most recent INR result. C. Determine if the client converted to a sinus rhythm. D. Administer PRN IV morphine to control anxiety.

A. Monitor oxygen saturation via pulse oximeter.

45. Which assessment finding indicates to the nurse that resolution of a client's subcutaneous emphysema has occurred? A. No crepitus palpated at site. B. Client denies pain or tenderness at site. C. No lymph node enlargement. D. No redness or inflammation noted.

A. No crepitus palpated at site.

14. A male client tells the nurse that he does not want to receive a blood transfusion that was prescribed to treat internal hemorrhaging. What action should the nurse implement? A. Notify the prescribing healthcare provider of the client's refusal to receive the blood transfusion. B. Notify the hospital's attorney of the client's wishes and the need to exercise life-saving measures. C. Check the client's medical record to see if he signed a legal informed consent form. D. Explain the treatment options available to him if he refuses the prescribed blood transfusion.

A. Notify the prescribing healthcare provider of the client's refusal to receive the blood transfusion.

120. A one-day-old neonate is awaiting surgical correction of a myelomeningocele. During the preoperative period, what is the priority nursing intervention? A. Observe for CNS infection related to sac trauma. B. Position supine to protect the sac from urine and feces. C. Maintain the neonate on a pressure-reducing surface. D. Minimize the neonate's exposure to latex products.

A. Observe for CNS infection related to sac trauma.

145. Following the vaginal delivery of a 10-pound infant, the nurse assesses a new mother's vaginal bleeding and finds that she has saturated two pads in 30 minutes and has a boggy uterus. What action should the nurse take first? A. Perform fundal massage until firm. B. Have the client empty her bladder. C. Determine the client's blood pressure. D. Increase oxytocin (Pitocin) IV rate.

A. Perform fundal massage until firm.

101. The nurse knows the client with a mechanical valve replacement understands the discharge teaching when the client makes which statement? A. "I should notify my healthcare provider if I hear a clicking sound near my heart." B. "I will need to take antibiotics before any type of invasive dental work." C. "I will not have to take any more heart medication since I have a new valve." D. "I will need to have this valve replaced in about 10 years."

B. "I will need to take antibiotics before any type of invasive dental work."

125. A nurse agrees to work a double shift because of a staffing shortage, but requests that another nurse be assigned to care for a demanding client. What response is best for the charge nurse to make? A. "I'm sorry, but you know I cannot allow you to choose your assignments." B. "I'll assign the client to another nurse, but your help may be needed." C. "I would appreciate you reconsidering since you are always so good with difficult clients." D. "You'll probably need to keep the same assignment so that continuity of care can be provided."

B. "I'll assign the client to another nurse, but your help may be needed."

18. A male client diagnosed with hypertension has a nursing goal of, "The client will be able to verbalize ways to decrease blood pressure." What statement by the client indicates that this outcome has been met? A. "I should have my blood pressure checked monthly to make sure it is within normal limits." B. "If I lose weight, quit smoking, and exercise regularly I may not have to take any medication." C. "I should increase my fluid intake and decrease my fiber intake." D. "If I take my medication every day, I won't have to worry about my blood pressure."

B. "If I lose weight, quit smoking, and exercise regularly I may not have to take any medication."

103. A female client is instructed to do Kegel exercises. What statement identifies to the nurse that the client understands how to perform these exercises? A. "I need to tighten my stomach muscles while sitting and standing, hold for 10 seconds, and repeat 5 times." B. "When I urinate, I should tighten those muscles and stop the flow of urine for 10 seconds and repeat this 5 to 10 times." C. "I need to press the small of my back against a chair and hold for 5 seconds, repeating this 10 times." D. While lying on my back, I need to do modified sit-ups at least twice a day."

B. "When I urinate, I should tighten those muscles and stop the flow of urine for 10 seconds and repeat this 5 to 10 times."

7. The charge nurse in the Intensive Care Unit (ICU) needs to transfer a client to the medical unit so that a client from the Emergency Room can be admitted to ICU. Which client is best to consider? A. A 38-year-old with a myocardial infarction who is having multifocal premature ventricular contractions. B. A 66-year-old with congestive heart failure who has 2+ pitting edema and is short of breath on exertion. C. A 58-year-old diagnosed with Guillain-Barre syndrome who is having difficulty breathing. D. An 80-year-old with a bleeding peptic ulcer who has a Hgb of 7 g/dl and coffee ground drainage from NG.

B. A 66-year-old with congestive heart failure who has 2+ pitting edema and is short of breath on exertion.

26. An 8-month-old boy who has tetralogy of Fallot experiences periodic "tet spells" with paroxysmal dyspnea. Which nursing intervention is most effective in managing these episodes? A. Administer digoxin and Lasix as prescribed. B. Administer oxygen and place the child in the knee-chest position. C. Place the child in a prone position and administer chloral hydrate. D. Elevate the head of the bed and take the child's vital signs.

B. Administer oxygen and place the child in the knee-chest position.

65. An 82-year-old female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to "speak up" so that she can hear the questions. Which action is best for the nurse to take? A. Over-enunciate word syllables. B. Decrease speaking speed. C. Raise voice volume to a shout. D. Exaggerate nonverbal expressions.

B. Decrease speaking speed.

61. A client with an indwelling urinary catheter has developed hematuria in the last four hours. What action should the nurse implement? A. Assist the client to a right side-lying position in the bed. B. Determine if the client is receiving any anticoagulant medications. C. Withhold further oral fluids until the healthcare provider is notified. D. Remove the client's indwelling urinary catheter immediately.

B. Determine if the client is receiving any anticoagulant medications.

79. While assessing a client who had a laparotomy the previous day, the nurse notices that 300 ml of dark red fluid has drained from the nasogastric tube in the last hour. What action should the nurse take first? A. Monitor urinary output hourly. B. Determine the client's vital signs. C. Assess the client's level of pain. D. Notify the surgeon immediately

B. Determine the client's vital signs.

70. In planning strategies to promote client rest and sleep during the night shift, the nurse should encourage the staff to adhere to which guideline? A. Keep the nurses' station free of excessive debris and clutter. B. Exchange shift report in a private room with the door closed. C. Wear dark colored scrub suits, uniforms, and lab jackets. D. Make sure bright lighting is maintained in the hallways.

B. Exchange shift report in a private room with the door closed.

139. A client with depression remains in bed for most of the day, declines activities, and refuses meals. Which nursing diagnosis has the greatest priority for this client? A. Social isolation. B. Feeding self-care deficit. C. Situational low self-esteem. D. Deficit diversional activity.

B. Feeding self-care deficit.

73. A resident of a long-term care facility falls during the night. After determining the resident has an obvious wrist injury and blunt head trauma, the charge nurse is unable to reach the healthcare provider despite multiple calls to the pager and answering service. Which action should the charge nurse implement? A. Request permission from the family to transport the client to the hospital. B. Refer the situation the Director of Nursing for further action. C. Document the incident and transport the client to the hospital. D. Apply a wrist splint and continue to try contacting the healthcare provider.

C. Document the incident and transport the client to the hospital.

160. When a nurse with a history of drug impairment returns from a drug rehabilitation program, what is the best initial action by the charge nurse? A. Request that the nurse be transferred to another nursing unit. B. Assign another staff person to observe the nurse administering medications. C. Establish a contract with the nurse about role limitations. D. Assign the nurse to clerical responsibilities only.

C. Establish a contract with the nurse about role limitations.

147. A gravida 3, para 2 at 31-weeks gestation is admitted to the hospital with suspected HELLP syndrome. She complains of nausea, vomiting, malaise, and epigastric pain. Her blood pressure is 116/74. What assessment is most important for the nurse to obtain? A. Confirm gestational age with ultrasound. B. Observe for signs of dehydration. C. Evaluate the client for thrombocytopenia. D. Determine urine protein level.

C. Evaluate the client for thrombocytopenia.

121. A female client who has just completed a full chemotherapy cycle for cancer has lost 15 pounds because of anorexia, nausea, and vomiting. Her BMI is 19. The nurse reinforces nutritional concepts during discharge planning. Which dinner menu selection best indicates that the client understands her nutritional needs? A. Vegetarian spaghetti, garlic bread, Caesar salad, apple pie, and iced tea. B. Lean hamburger patty, tomato and lettuce, sugar-free gelatin, cantaloupe, and diet soda. C. Fried chicken breast, sweet potato, spinach, roll and butter, and protein milk shake. D. Grilled chicken breast with no skin, broccoli, fresh fruit, and skin milk.

C. Fried chicken breast, sweet potato, spinach, roll and butter, and protein milk shake.

133. The nurse is caring for a client who is being treated for fever. What nursing intervention is most important to prevent chills? A. Assess client's temperature q4h. B. Offer a cup of hot tea q8h. C. Give prescribed antipyretics around the clock. D. Provide a sponge bath q8h.

C. Give prescribed antipyretics around the clock.

91. What area of the body should be palpated to assess for the presence of Heberden's nodes in the client with osteoarthritis? A. Lower spine. B. Knee and hip joints. C. Face and neck. D. Distal fingers.

D. Distal fingers.

20. A client experiencing intracranial hypertension from a traumatic brain injury is admitted to the trauma unit. How should the nurse position this client? A. Totally prone. B. Right side lying. C. Completely supine. D. Elevated head of bed.

D. Elevated head of bed.

59. A 45-year-old female client who had a hysterectomy one week ago asks the nurse when she will start to experience hot flashes. Before responding to the client's question, what information should the nurse obtain? A. The reason why the hysterectomy was performed. B. The type of birth control used preoperatively. C. The type of hysterectomy that was performed. D. Whether the client's ovaries were also removed.

D. Whether the client's ovaries were also removed.

42. A client is hospitalized for pregnancy-induced hypertension (PIH) and is receiving magnesium sulfate 2 g/hour IV. Which medication should the nurse plan to have immediately available for this client? A. Sodium bicarbonate. B. Atropine. C. Epinephrine. D. Calcium gluconate.

D. Calcium gluconate.

95. Which approach is best for the nurse to use when communicating with a client with amyotrophic lateral sclerosis (ALS)? A. Speak clearly, slowly, and loudly. B. Reorient the client frequently. C. Use visual cues to increase comprehension. D. Demonstrate a positive, caring demeanor.

D. Demonstrate a positive, caring demeanor.

41. In scheduling home visits, which client is best for the home health charge nurse to assign to the licensed practical nurse (LPN)? A. A client who needs the first postoperative dressing change following a skin graft to the lower leg. B. A postoperative client who no longer needs wound care, but has called to report a fever. C. A client with diabetes who has called to report a newly discovered foot ulceration. D. A bedfast client who needs daily irrigation of a stage 4 pressure ulcer.

D. A bedfast client who needs daily irrigation of a stage 4 pressure ulcer.

132. After receiving the change of shift report on the psychiatric unit of a general hospital, which client should the nurse assess first? A. A male client with paranoid schizophrenia who thinks his food is poisoned. B. A 20-year-old client who is trying to telephone the President of the United States. C. A female client who is pacing the hallway and trying to sell her clothes. D. A client with depression who states she is leaving because she feels better.

D. A client with depression who states she is leaving because she feels better.

36. A client who is experiencing paranoid ideation is admitted to the psychiatric unit. During the first 48 hours of treatment, which nursing intervention is best for the nurse to implement? A. Place the client in group activities with other paranoid clients. B. Encourage the client to participate in unit social activities. C. Refer the client to occupational therapy. D. Allow the client to initiate relationships and activities.

D. Allow the client to initiate relationships and activities.

156. When assessing both lower extremities (BLE) of a client who has chronic venous insufficiency, the nurse identities bilateral stasis dermatitis and an ulcer on the medial surface of the left ankle. To promote effective self-care, which client teaching should the nurse provide? A. Soak feet to soften nails before trimming. B. Keep legs dependent to promote blood flow. C. Medicate inflamed skin areas with an antibiotic ointment. D. Apply compression stockings before ambulation.

D. Apply compression stockings before ambulation.

143. Which assessment intervention should the psychiatric nurse implement when performing a mental status exam? A. Request the client hold out his/her tongue for one minute. B. Have the client close his/her eyes and count slowly to 100. C. Allow the client to discuss what brought him/her to the hospital. D. Ask the client to interpret the proverb, "A stitch in time saves nine."

D. Ask the client to interpret the proverb, "A stitch in time saves nine."

34. A client's arterial blood gases are: pH 7.5, PaO2 94, PaCO2 30, HCO2 24. What action should the nurse take based on these findings? A. Auscultate the client's breath sounds for increased secretions. B. Review the client's electrolytes and intake/output for fluid balance. C. Assess the client for nausea, vomiting, or diarrhea. D. Assess the client for causes of hyperventilation.

D. Assess the client for causes of hyperventilation.

81. The nurse overhears two hospital employees discussing confidential client information in the cafeteria. The nurse decides to intervene, because this situation is a breach of which ethical principle. A. Consistency. B. Autonomy. C. Veracity. D. Fidelity.

D. Fidelity.

122. The nurse is caring for a dyspneic client whose oxygen saturation rate is currently 90%. What position is best for this client? A. Sims' with a pillow under the upper leg. B. Any position that is comfortable. C. Supine with the legs slightly elevated. D. Fowler's with both legs supported.

D. Fowler's with both legs supported.

27. A 21-year-old male client has developed splenomegaly secondary to infection mononucleosis. What factor in the client's history is most important in developing his discharge-teaching plan? A. He regularly eats at fast food restaurants. B. On weekends he usually drinks 1 or 2 beers. C. Lately he has been sleeping 10 to 12 hours every night. D. He works as a furniture mover.

D. He works as a furniture mover.

66. A 79-year-old female client with chronic obstructive pulmonary disease (COPD) asks why she has a round chest. The nurse correctly responds that the typical "barrel-chest" appearance of an emphysema client is caused by which condition? A. Constant coughing. B. Abdominal breathing. C. Upper body exercises to increase lung capacity. D. Hyperinflation of the lungs.

D. Hyperinflation of the lungs.

78. A man who was trapped for 2 days on the roof of his home awaiting rescue during a weather-related disaster spent several weeks in a shelter. During this time, he says he wondered if he was going to die like many of his friends and relatives had. Now, several months later, he reports feeling numb and cannot relate well with others. He sometimes relives the isolation and anxiety associated with the ordeal. Nursing care should be directed toward which outcome? A. Uses time productively when conducting activities of daily living and during social or recreational activities. B. Exhibits a more positive self-evaluation when describing himself. C. Responds to his name when addressed by a member of the treatment team. D. Implements anxiety-control strategies such as progressive relaxation and thought substitution.

D. Implements anxiety-control strategies such as progressive relaxation and thought substitution.

37. Which surveillance clues are specific potential indicators of a bioterrorism attack? (Select all that apply.) A. Geographic clustering of client illnesses. < B. Increased rate of hospital emergency room visits. C. Emergency room understaffing for six consecutive shifts. D. Increased prevalence of cases previously not seen in a geographic area. E. Increased biosafety practice precautions used by emergency room staff. F. Unusual age distribution for a common disease. <

D. Increased prevalence of cases previously not seen in a geographic area.

69. "Social isolation" is identified as a nursing diagnosis for a 16-year-old who is experiencing facial edema. What behavior indicates a positive outcome for this diagnosis? The client A. Is quietly watching television. B. Requests that visitors be restricted. C. Sleeps soundly through the night. D. Is laughing and talking on the phone.

D. Is laughing and talking on the phone.

106. An ACE inhibitor is prescribed for a male client with diabetes whose blood pressure is 120/60 mm Hg. The client asks the nurse why he is receiving the medication when his blood pressure is normal. The nurse's response should be based on what information? A. It lowers insulin resistance at the cellular level in Type 1 diabetics. B. It helps to prevent gastric reflux and gastroparesis associated with diabetes. C. It helps prevent platelet aggregation and plaque formation in diabetics. D. It slows the progression of kidney damage often associated with diabetics.

D. It slows the progression of kidney damage often associated with diabetics.

8. The nurse stops to render aid at the scene of a motor vehicle collision and finds a child about 6 months of age strapped into a car seat in the back seat of the car. After calming the infant with a pacifier, what action should the nurse take? A. Remove the infant from the car seat while stabilizing the neck. B. Assess the infant's ability to move arms and legs. C. Determine if pupils constrict when exposed to light. D. Lift the car seat out of the car with the infant strapped in it.

D. Lift the car seat out of the car with the infant strapped in it.

148. A 60-year-old male client is admitted to the hospital complaining of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. During the admission assessment, which information is most important for the nurse to obtain? A. Medication history for the past two weeks. B. Cardiac assessment of heart sounds. C. A 24-hour recall of dietary intake. D. Neurovascular status of lower extremities.

D. Neurovascular status of lower extremities.

75. Which assessment finding contraindicates removal of staples from a surgical incision? A. Incision edges are well approximated. B. Client complains of incisional itching and discomfort. C. No evisceration present entire length of incision. D. Partial dehiscence noted at incision's distal end.

D. Partial dehiscence noted at incision's distal end.

55. A 7-year-old with Guillain-Barre syndrome is admitted with ascending paralysis to the C-6 level. In developing a plan to prevent disease until the paralysis subsides, which intervention is most important for the nurse to include in the child's plan of care? A. Emotional support and diversional, educational activities. B. Adequate fluid intake and hygienic care for an indwelling catheter. C. Bowel incontinent care and skin care to bony prominences. D. Range of motion and passive exercises of all large muscle groups.

D. Range of motion an passive exercises of all large muscle groups.

150. The parents of a child with cystic fibrosis (CF) ask the nurse about their chances of having another child with CF. Which response is best for the nurse to provide? A. Male children have a greater chance of inheriting the autosomal recessive gene. B. Since this child is affected future children will be carriers and will not be affected. C. 1 in 20 persons in the United States carry the recessive gene for cystic fibrosis. D. There is a 1 in 4 chance that any child of heterozygous parents will be affected.

D. There is a 1 in 4 chance that any child of heterozygous parents will be affected.

68. The nurse plans to administer a 0.5 ml intramuscular injection to an 18-month-old toddler in the vastus lateralis. What is the rationale for choosing this site? A. This injection site is the easiest to expose fully at this age. B. The mother of the child can hold the child most securely when this site is used. C. This injection site has the fewest major blood vessels at this age. D. This is the most developed muscle until the child has been walking longer.

D. This is the most developed muscle until the child has been walking longer.

33. The nurse is caring for a two-day postoperative client. What assessment finding indicates that wound healing is likely? A. Tolerated a full liquid diet on the second postoperative day. B. Ambulated in the hallway 24 hours after surgery. C. Current serum potassium level is 4.9 mEq/L. D. Total serum protein is 5.4 g/dl.

D. Total serum protein is 5.4 g/dl.

136. The nurse notes that a depressed adolescent client's fluoxetine (Prozac) cannot be given because the mother refuses to sign the consent for medication. What should the nurse do? A. Give the medication if the client is willing to take it. B. Obtain two witnesses and ask the client to sign the consent. C. Determine if there is an emergency contact person to notify. D. Wait for the mother to sign the medication consent.

D. Wait for the mother to sign the medication consent.