RN EXIT HESI EXAM V5

Penicillin G procaine 240,000 units intramuscularly is prescribed for four-year-old child who has a streptococcal respiratory infection. The medication bio is labeled 1,200,000 units/2 ml. How many ml should the nurse administer?

0.4

The nurse plans to administer a bolus dose of IV Heparin based on the clients weight. The prescribed bolus dose is 100 units/kg. The client weighs 198 pounds. How many units of heparin should the nurse administer?

9000

A client in the third trimester of pregnancy complaints of frequent nasal stuffiness and occasional nosebleeds. Her chest circumference has increased by 5 cm during the pregnancy, and she uses thoracic breathing. Her diaphragm is elevated, and she has an increased costal angle. Which intervention should the nurse implement? A. Ask a nurse with more experience to validate the costal angle finding B. Ask the health care provider to evaluate the client's respiratory status C. Examine the client for signs of tissue and anoxia, such as pallor D. Record the respiratory finding in the client's record as normal

C. Examine the client for signs of tissue and anoxia, such as pallor

A male client being treated for testicular cancer with chemotherapy has a decreased alpha fetoprotein radioimmunoassay (AFP). Which nursing intervention should the nurse implement? A. Advise the client that the treatment is having a beneficial effect B. Instruct the client to obtain prostate specific antigen (PSA) testing C. Inform the client that his chemotherapy dose will probably be increased D. Discuss options for Hospice care with the client and family members

C. Inform the client that his chemotherapy dose will probably be increased

When performing postural drainage on a client with chronic obstructive pulmonary disease, which approach should the nurse use? a. Explain that the client may be placed in five positions b. Instruct the client to breathe shallow and fast c. Obtain arterial blood gases prior to the procedure d. Perform the drainage immediately after meals

a. Explain that the client may be placed in five positions

The home health nurse observes an older client with unilateral weakness place the walker in front of the chair for support while rising to a standing position. Which action should the nurse take? a. Hold the Walker securely to prevent slipping when the client rises b. Applied gait belt to assist the client to rise out of the chair c. Instruct the client to use the arms of the chair for support d. Encourage the client to use the weaker leg with the walker when rising

a. Hold the walker securely to prevent slipping when the client rises

A successful businessman presents to the community Health Center complaining of sleeplessness and anxiety over his financial status. What action should the nurse take to assist the client in diminishing his anxiety? a. Reinforce the reality of his financial situation b. Direct him to drink a glass of red wine at bedtime c. Teach him to limit sugar and caffeine intake d. Encourage him to initiate daily rituals

a. Reinforce the reality of his financial situation

A client is discussing feelings related to a recent loss with a nurse. The nurse remains silent when the client says, "I don't know how I will go on." What is the reason for the nurse's behavior? a. Silence allows the client to reflect on what was said b. The nurse is respecting the client's loss c. The nurse is stating disapproval of the statement d. Silence is reflecting the client sadness

a. Silence allows the client to reflect on what was said

The nurse is evaluating teaching about drug therapy to treat gout. Which statement by the client demonstrates an understanding of the use of allopurinol to treat gout? a. "I need to take the prescribed amount of the drug to get rid of my gout" b. "I need to take this drug every day to keep from having any flare ups" c. "The pain and swelling can be controlled by taking this drug every day" d. "I should I take this drug when I have gout attacks to reduce symptoms"

c. "The pain and swelling can be controlled by taking this drug every day"

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which healthcare measure is most important for the nurse to recommend to these clients? a. Ensure supplemental oxygen and respiratory medications are available at all times b. Use nasal or cough tissues followed by hand washing at all times c. Get annual flu and pneumococcal vaccine polyvalent vaccines d. Avoid large crowded areas during the colder months of the year

d. Avoid large crowded areas during the colder months of the year

A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The health care provider knows the client has a good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. Which action should the nurse take? A. Initiate an Ethics Committee review of the case B. Place a DNR bracelet on the client's arm C. Ensure resuscitation equipment is available D. Ask the family to review options with the client

A. Initiate an Ethics Committee review of the case

A postoperative client has a large amount of serosanguineous drainage on the surgical dressing and the nurse notes that the operative report indicates the client has a Penrose drain near the incision. What intervention should the nurse implement when changing the clients dressing? A. Place sterile gauze dressings under the Penrose drain B. Apply sterile gloves before removing the soiled dressing C. Cover the Penrose drain with a saline moistened gauze D. Wear a face mask or shield during the dressing change

A. Place sterile gauze dressings under the Penrose drain

A client in labor states, "I think my water just broke!" The nurse notes that the umbilical cord is on the perineum. What action should the nurse perform first? A. Place the client in Trendelenburg B. Administer oxygen via face mask C. Notify the operating room team D. Administer a fluid bolus of 500 mL

A. Place the client in Trendelenburg

A client who was recently diagnosed with anorexia nervosa collapses at an outpatient clinic. While taking the blood pressure, the client begins to demonstrate cloudy consciousness, stupor, and has slurred speech. The nurse obtains a blood glucose 50 mg/dL, heart rate of 116 beats/minute, and blood pressure of 88/50 mmHg. Which intervention is most important for the nurse to implement? A. Position client with head flat and feet elevated B. Suggest obtaining a medical alert bracelet to be always worn C. Encourage the client to eat low carbohydrate and high protein meals D. Reinforced the need to continue the outpatient clinic therapy

A. Position client with head flat and feet elevated

A terminally ill male hospice client who is at home is showing decreased awareness of his surroundings. His appetite is poor, and he often uses oral intake of solids and liquids. For the past several days he has been unable to get out of bed. Which action should the hospice nurse implement? A. Ask family to remain nearby, but in another room B. Encourage family to speak often with the client C. Teach family how to assist the client to a wheelchair D. Instruct family to offer client only soft bland foods

C. Teach family how to assist the client to a wheelchair

The nurse is planning care for a 16 year old, who has juvenile idiopathic arthritis. The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Exercise in a swimming pool b. Splint affected joints during activity c. Perform passive range of motion exercises twice daily d. Begin a training program lifting weights and running

a. Exercise in a swimming pool

The nurse is reviewing the laboratory values for a client with acute pancreatitis who reports that the abdominal pain is not as severe as it was on admission. Which laboratory test should the nurse review to evaluate the client's clinical recovery? a. Lipase b. Creatinine c. Bilirubin d. Glucose

a. Lipase

A client with cancer complains of fever, chills, malaise, and headache following administration of a colony stimulating factor. Which nursing intervention is most beneficial in helping to reduce the flu like symptoms? a. Monitor lab values for an increase in WBCs b. Administer anti emetics before, during, and after therapy c. Administer acetaminophen Q4H d. Monitor vital signs Q4H for 24 hours

a. Monitor lab values for an increase in wbcs ?

A female client is admitted to the hospital with a diagnosis of right lower quadrant (RLQ) abdominal pain in a possible ectopic pregnancy. She tells the nurse that her pain is gone, but she is now experiencing a generalized abdominal aching. Her blood pressure has decreased in her pulse has increased over the past two hours. While waiting for the health care provider to arrive, which intravenous solution is best for the nurse to initiate? a. Normal saline at 20 ml/hr b. Lactated ringer's at 150 ml/hr c. D5W/ 0.45 NS at 125 ml/hr d. Dextrose 10% at 83 ml/hr

a. Normal saline at 20 ml/hr

A mother of a one-month-old infant calls the clinic to report that the back of her infant's head is flat. How should the nurse respond? a. Position the infant on the stomach occasionally when awake and active b. Turn the infant on the left side braced against the crib when sleeping c. Prop the infant in a sitting position with a cushion when not sleeping d. Place a small pillow under the infants head while lying on the back

a. Position the infant on the stomach occasionally when awake and active

A woman was admitted yesterday afternoon with severe abdominal pain. Her pregnancy tests and ultrasounds were negative, so an exploratory laparotomy was completed during the night. When coffee ground material is observed in the drainage from the nasal gastric tube, which intervention should the nurse implement? a. Verify correct placement of the nasogastric tube b. Perform gastroccult test on the nasogastric drainage c. Listen for evidence of diminished bowel sounds d. Irrigate the nasogastric tube with water until clear

a. Verify correct placement of the nasogastric tube

The nurse is caring for an adolescent client with an intestinal obstruction who presents with severe, colicky pain, nausea, vomiting, and abdominal distention. Which pathophysiologic mechanism supports the client's clinical presentation? a. An incompetent lower esophageal sphincter b. A weakened diaphragm with high abdominal pressure c. Intestinal scar tissue buildup from a chronic condition d. History of having Helicobacter pylori infection

b. A weakened diaphragm with high abdominal pressure

The nurse assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites and a client with cirrhosis? a. Hypoalbuminemia that results in a decreased colloidal oncotic pressure b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubes c. Decreased renin angiotensin response related to an increase in renal blood flow d. Decrease portacaval pressure with greater collateral circulation

b. Hyperaldosteronism causing an increased sodium reabsorption in renal tubes ?

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. Which action should the nurse take first? a. Determine the client's vital signs b. Monitor urinary output hourly c. Notify the surgeon immediately d. Assess the client's level of pain

b. Monitor urinary output hourly

The nurse is caring for a child newly diagnosed with attention deficit hyperactive disorder (ADHD). The child's mother asked about information of the treatment options. Which information is most helpful for the nurse to provide? a. Emphasize the addictive nature of popular medications b. Offer effective time management strategies c. Explore the combination of medication and behavioral therapies d. Discuss dietary changes such as increasing protein intake

b. Offer effective time management strategies

In observing a client's face, which assessment finding requires the most immediate intervention by the nurse? a. Cornea are jaundiced b. Oral mucosa is cyanotic c. Face is flushed and diaphoretic d. Eyelids are matted and crusted

b. Oral mucosa is cyanotic

A client has a new prescription for the maximum recommended dosage of piperacillin/tazobactam for nosocomial pneumonia. The nurse should report which laboratory finding to the health care provider before administering the prescribed dose? a. Elevated white blood cell count b. Presence of gram-positive bacteria in the sputum c. Decrease creatinine clearance d. Elevated cholesterol and lipoproteins

b. Presence of gram-positive bacteria in the sputum

An older client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan? a. Decreased abdominal girth b. Prothrombin time within normal limits c. Improved level of consciousness d. Clear, dark amber colored urine

b. Prothrombin time within normal limits ?

Following discharge teaching, a client with a duodenal ulcer tells the nurse of plans to eat plenty of dairy products, such as milk, to help coat and protect their ulcer. Which is the best follow up action by the nurse? a. Remind the client that it is also important to switch to decaffeinated coffee and tea b. Review with the client the need to avoid foods that are rich in milk and cream c. Reinforced this teaching by asking the client to list dairy foods that he might select d. Suggest that the client also plan to eat frequent small meals to reduce discomfort

b. Review with the client the need to avoid foods that are rich in milk and cream

Which laboratory value should the nurse review prior to administering the initial dose of a statin medication? a. Serum electrolytes b. Serum liver enzymes c. Capillary blood glucose d. Complete blood count

b. Serum liver enzymes

A client is admitted to the hospital with symptoms consistent with the right hemisphere stroke. Which neurovascular assessment requires immediate intervention by the nurse? a. Orientation to person in place only b. Unequal bilateral hand grip strengths c. Pupillary changes to ipsilateral dilation d. Left sided facial droop and dysphasia

b. Unequal bilateral hand grip strengths

The charge nurse is making assignments on a cardiac unit. Which client is best to assign to a new graduate who is orienting to the unit? A client... a. With pneumonia whose serum potassium level is 6.5 mg/dl b. With atrial fibrillation whose saline lock is infiltrated c. Who is receiving heparin infusion has developed hematuria d. With hypertension whose blood pressure is 230/118

b. With atrial fibrillation whose saline lock is infiltrated

The nurse documents that a male client with schizophrenia is delusional. Which statement by the client confirms this assessment? a. "The fire is burning my skin away right now" b. "The voices are telling me to kill the next person I see" c. "The nurse at night is trying to poison me with pills" d. "The snakes on the wall are going to eat me"

c. "The nurse at night is trying to poison me with pills"

A client is receiving a continuous infusion of normal saline at 125 ml/hr post abdominal surgery. The client is drowsy and complaining of constant abdominal pain and a headache. The urine output is 800 ml over the past 24 hours with a central venous pressure of 15 mmHg. The nurse notes respiratory crackles and bounding central pulses. Vital signs: temperature 101.2 degrees Fahrenheit, heart rate 96 beats/minute, respirations 24 breaths/minute, and blood pressure of 160/90 mmhg. Which intervention should the nurse implement first? a. Review last administration of IV pain medication b. Decrease IV fluids to keep vein open (KVO) rate c. Administer PRN dose of acetaminophen d. Calculate total intake and output for the last 24 hours

c. Administer PRN dose of acetaminophen

The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives a prescription for Clonidine 0.2 milligrams PO taken twice daily. Which action should the nurse take? a. Monitor for signs of bleeding or hemorrhage b. Compare daily electrolyte levels prior to each morning dose c. Advice to sit up slowly from a reclining position d. Administer the medication on an empty stomach

c. Advice to sit up slowly from a reclining position

Which assessment finding places a client at risk for problems associated with impaired skin integrity? a. Smooth nail texture b. Scattered macula on the face c. Capillary refill 5 seconds d. Absence of skin tenting

c. Capillary refill 5 seconds

A woman is brought to the labor and delivery unit after delivering a term infant and the placenta in the hospital parking lot 10 minutes ago. Which action should the nurse perform first? a. Inspect the perineum for lacerations b. Collect specimen for hemoglobin and hematocrit c. Massage the fundus and give oxytocic agent d. Place the infant to breast for bonding

c. Massage the fundus and give oxytocic agent

After placing a 36-week gestation newborn in and isolette and drying the infant with several blankets, what should the nurse implement next? a. Administer the vitamin K injection b. Remove the wet blankets and linens from the isolette c. Place erythromycin ophthalmic ointment in both eyes d. Open the isolate door to assess the infants' vital signs

c. Place erythromycin ophthalmic ointment in both eyes

Which action should the nurse take first after obtaining a urine specimen for culture and sensitivity from an indwelling urinary catheter? a. Ensure that the drainage bag is attached to the bed frame b. Ensure continued sterility of the specimen container c. Securely fasten the clamp on the drainage bag d. Label the container with the clients identifiers

c. Securely fasten the clamp on the drainage bag ?

The nurse is assessing the mood of the depressed male client. When asked how he feels, the client looks down and states, "I don't know! I just can't think." Which activity should the nurse suggest that this client perform? a. Complete a written self-esteem assessment b. Review the client handbook about unit therapies c. Set daily goals in the community meeting d. Read, "The Depression Recovery Book"

c. Set daily goals in the community meeting

A 7 year old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant? a. Chicken pox b. Mumps c. Sore throat d. Influenza

c. Sore throat

The nurse is educating a client in end stage renal failure who requires dialysis three times a week. Which information is important for the nurse to include about the clients daily diet? a. The intake of protein should be increased to stimulate the kidneys nephrons function b. The intake of protein should be increased due to its loss through the filter membrane c. The protein intake should be decreased to prevent nitrogenous waste buildup d. The intake of protein should be decreased due to the progressively failing function of the kidney

c. The protein intake should be decreased to prevent nitrogenous waste buildup ?

The nurse plans to administer a low dose prescription for dopamine to a client who is in septic shock. Which physiologic parameter should the nurse use to evaluate a therapeutic response to dopamine? a. Pupil response b. Heart sounds c. Urinary output d. Temperature

c. Urinary output

Following a lumbar puncture, the client voices several concerns. Which concern indicates that the nurse that the client is experiencing a complication of the procedure? a. "I Feel sick to my stomach and I'm going to throw up" b. "I'm having pain in my lower back when I move my legs" c. "My throat hurts badly when I swallow and when I talk" d. "I have a headache that gets worse when I sit up"

d. "I have a headache that gets worse when I sit up"

The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski reflex. Which action should the nurse take in response to the finding? a. Ask the client to describe recent alcohol use b. Keep the clients feet elevated when in bed c. Assess the clients muscle strength and tone d. Complete a thorough neurological assessment

d. Complete a thorough neurological assessment

As part of the treatment plan for a client diagnosed with acute pancreatitis, the nurse plans to withhold oral fluids based on which pathophysiological process? a. Removing gastric secretions and to relieve abdominal distention b. Reducing hydrochloric acid secretion c. Restoring and maintaining a positive fluid balance d. Decreasing the formation and secretion of pancreatic enzymes

d. Decreasing the formation and secretion of pancreatic enzymes ?

A client who is admitted with diabetic ketoacidosis is demonstrating Kussmaul breathing and has a severe headache along with nausea. Her arterial blood gases are: ph 7.50; paco2 30 mmhg; HCO3 24 meq/L. Which assessment finding warrants immediate intervention by the nurse? a. Muscle stiffness b. Abdominal pain c. Mental stupor d. Fruity breath

d. Fruity breath

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which instruction is most important for the nurse to provide this client? a. Wear prescription glasses b. Eat a diet high in carotene c. Avoid frequent eye pressure measurements d. Maintain prescribed eyedrop regimen

d. Maintain prescribed eyedrop regimen