2020-2021 HESI Live Questions

A client has an order for hydromorphone intravenous (IV) push 1 mg every 3 hours. The drug is available as 4 mg/mL. The nurse administers ______mL of hydromorphone for one dose. (Fill in the blank.)

0.25mL

A pediatric client is prescribed digoxin for a congenital heart defect. The maintenance dosage ordered is 50 mcg/kg/day. The child weighs 10 kg. The prescription requires the digoxin to be administered twice daily. The nurse prepares _______mcg of digoxin at each dose.

250mcg

A client is receiving an infusion of dobutamine hydrochloride. The order reads: Infuse dobutamine IV at 5 mcg/kg/min. 500 mg in 250 mL D5W. The client weighs 65 kg. Calculate the flow rate in mL/hour. _______mL/hour

9.75mL/hr

A charge nurse is making assignments for five clients. The nursing team has an RN, a PN, and two UAPs. Which client(s) are appropriate to assign to the RN? (Select all that apply.) A. A client from the previous shift with unstable angina B. A client with a stage 3 pressure ulcer who needs a bed bath C. A client with an enteral feeding absorbing at 30 mL/h D. A cardiotomy client who is day 2 postoperative and who has chest tubes E. A client with quadriplegia for whom urinary catherization is prescribed

A. A client from the previous shift with unstable angina D. A cardiotomy client who is day 2 postoperative and who has chest tubes

The charge nurse is planning client assignments for the shift. The care team includes a registered nurse (RN), a licensed practical nurse (PN), and unlicensed assistive personnel (UAP) on the care team. Which client(s) are appropriate to be assigned to the PN? (Select all that apply.) A. A client scheduled for a STAT CAT x-ray after a fall from a stretcher B. A client receiving IV vancomycin through a peripherally inserted catheter (PICC) line C. A client with sickle cell crisis who was transferred from the ICU to the acute care area and who is receiving hydromorphone via a patient-controlled analgesia (PCA) pump D. A client with a pressure ulcer who was prescribed negative pressure (wound VAC) care E. A postoperative client who has been prescribed 2 units of packed red blood cells

A. A client scheduled for a STAT CAT x-ray after a fall from a stretcher D. A client with a pressure ulcer who was prescribed negative pressure (wound VAC) care

The mental health RN is assigned to five clients. Which clients should have priority assessments? (Place in order of priority.) A. A newly admitted client diagnosed with major depression whose assessment is incomplete B. A client diagnosed with schizophrenia who is having auditory hallucinations of an infant crying C. A client who has a 5-year history of daily consumption of two six-packs of beer D. A client diagnosed with bulimia who is having difficulty attending group E. A client who has been taking benzodiazepines off and on daily for the last 2 years

A. A newly admitted client diagnosed with major depression whose assessment is incomplete C. A client who has a 5-year history of daily consumption of two six-packs of beer E. A client who has been taking benzodiazepines off and on daily for the last 2 years B. A client diagnosed with schizophrenia who is having auditory hallucinations of an infant crying D. A client diagnosed with bulimia who is having difficulty attending group

The nurse is orienting a graduate nurse (GN) caring for a client dependent on a ventilator. Which action by the GN demonstrates understanding of ventilator-associated pneumonia (VAP) care? (Select all that apply.) A. Administers a proton pump inhibitor as prescribed B. Rinses client's oral cavity with chlorhexidine every 2 hours C. Elevates the HOB 60 degrees D. Implements spontaneous breathing trial E. Performs hand hygiene before and after care

A. Administers a proton pump inhibitor as prescribed B. Rinses client's oral cavity with chlorhexidine every 2 hours D. Implements spontaneous breathing trial E. Performs hand hygiene before and after care

The emergency department nurse is assessing a client with a vesicular rash as a result of suspected smallpox exposure. Which transmission precautions should be most appropriate for this client? (Select all that apply.)​ A. Airborne B. Contact C. Aplastic D. Droplet E. Standard

A. Airborne B. Contact D. Droplet E. Standard

The nurse is assigned to receive a client in the emergency department with suspected anthrax exposure predecontamination. Which transmission precautions should be most appropriate for the client? (Select all that apply.) A. Airborne B. Contact C. Aplastic D. Droplet E. Standard

A. Airborne B. Contact D. Droplet E. Standard

Which findings by the nurse indicate an early sign of increased ICP in a client newly diagnosed with a cerebral vascular accident? (Select all that apply.) A. Alteration in the ability to respond to questions B. Alteration in the ability to respond to verbal stimuli C. Consensual response of pupils D. Heart rate 50, blood pressure 192/60 E. Drooping of the mouth on one side

A. Alteration in the ability to respond to questions B. Alteration in the ability to respond to verbal stimuli

A client with a known cardiac history is admitted to the acute care unit with stable angina. At 7:00 a.m., the client had stable vital signs and was on 2 L of oxygen via nasal cannula. At 10:00 a.m., the client reports chest pain of 6 on a scale of 1 to 10, is slightly diaphoretic and pale, has a blood pressure (BP) of 100/52 mm Hg, and has a respiratory rate of 24 breaths/min. Which action should the nurse implement first? A. Apply 4 L of oxygen as ordered. B. ​​Administer a fluid bolus of 0.9 normal saline. C. Administer the prescribed opioid for pain control. D. Obtain a full set of vital signs, including temperature.

A. Apply 4 L of oxygen as ordered.

The nurse reviews the medication record of a 2-month- old and notes that the infant was given a scheduled dose of digoxin with a documented apical pulse of 76 beats/min. Which action should the nurse take first? A. Assess the current apical pulse rate B. Observe for the onset of diarrhea C. Complete an adverse occurrence report D. Determine the serum potassium level

A. Assess the current apical pulse rate **3rd party data; assess**

The nurse is caring for a client in shock of unknown etiology and observes the rhythm on the right on the monitor. Which is the nurse's priority intervention? *Rhythm shows ventricular tachycardia* A. Check for a carotid pulse. B. Defibrillate the patient with 360 joules of energy. C. Administer an intravenous saline bolus. D. Give two breaths via Ambu® bag.

A. Check for a carotid pulse.

Which vaccines should the nurse expect to be prescribed for a 2-month-old brought into the pediatrician's office for a well-baby checkup? (Select all that apply.) A. DTaP B. Hep B C. Hep C D. HIB E. IPV F. PCV

A. DTaP B. Hep B D. HIB E. IPV F. PCV

A parent is preparing a 5-year-old child for kindergarten. The child has not received any immunizations. Which vaccines should be given to this child? (Select all that apply.) A. DTaP B. Inactivated polio virus (IVP) C. Varicella D. Pneumococcal conjugate vaccine (PCV) E. Trivalent inactivated influenza vaccine (TIV)

A. DTaP B. Inactivated polio virus (IVP) C. Varicella

A 68-year-old client who is diagnosed with Alzheimer's disease is admitted to the nursing home by the nurse. The client does not recognize spouse or children and forgets how to eat and dress. What is the nurse's priority intervention for the newly admitted client? A. Establish a daily routine and schedule B. Encourage involvement in structured activities C. Discuss strategies to coordinate care D. Stress the importance of self-nurturing

A. Establish a daily routine and schedule

A child with hydrocephalus is 1 day postoperative for revision of a ventriculoatrial shunt. Which finding is most important for the nurse to assess first? A. Increased blood pressure B. Increased temperature C. Increased serum glucose D. Increased hematocrit

A. Increased blood pressure **shunts can occlude suddenly increasing ICP**

he nurse is conducting an osteoporosis screening clinic at a health fair. Which information should the nurse provide to individuals who are at risk for osteoporosis? (Select all that apply.) A. Limit alcohol and stop smoking B. Suggest supplementing the diet with vitamin E C. Promote regular weight-bearing exercise D. Implement a home safety plan to prevent falls E. Propose a regular sleep pattern of 8 hours nightly

A. Limit alcohol and stop smoking C. Promote regular weight-bearing exercise D. Implement a home safety plan to prevent falls

The nurse is planning a class on stroke prevention for clients with hypertension. Which information reflects accurate prevention measures that the clients can undertake? (Select all that apply.) A. Limit salt intake to 1500mg/day or less B. Eliminate tobacco products C. Initiate a program of walking 1 mile per day D. Achieve body mass index (BMI) of 26.2 E. Schedule routine health assessments bianually

A. Limit salt intake to 1500mg/day or less B. Eliminate tobacco products C. Initiate a program of walking 1 mile per day

​A child admitted with sickle cell crisis is anemic and has painful joints and a fever of 101° F. Which priority intervention should the nurse include in the plan of care for this child? A. Maintain oral fluids for hydration B. Apply cold packs to painful joints C. Administer aspirin daily for pain and fever D. Perform range-of-motion exercises to decrease joint pain

A. Maintain oral fluids for hydration **HOP: Hydration; O2; Pain**

The nurse is caring for a client who is 24 hours postprocedure for a hemicolectomy with a temporary colostomy placement. The nurses assesses the client's stoma, which is dry and dark blue. Which action should the nurse take based on this finding? A. Notify the healthcare provider of the finding. B. Document the finding in the client record. C. Replace the pouch system over the stoma. D. Place petrolatum gauze dressing on the stoma.

A. Notify the healthcare provider of the finding.

A postmenopausal client with a BMI of 19 has come to the clinic for an annual examination. Which information is most important for the nurse to prepare for this high-risk client? A. Osteoporosis B. Obesity C. Anorexia D. Breast cancer

A. Osteoporosis

During the initial phase, a group member, who has a master's degree, states, "My educational background makes it easier for me to help the other group members." Which action should the nurse take to assure effective group functioning? A. Reiterating the purpose of the support group sessions B. Asking the group to identify various stressful problems C. Obtaining ideas from the members about strategies for stressful situations D. Terminating the meeting and evaluate the situation

A. Reiterating the purpose of the support group sessions

A 3-week-old infant with pyloric stenosis has severe vomiting. Which signs of dehydration should the nurse anticipate in the infant? (Select all that apply.) A. Sunken fontanel B. Increased urine output C. High serum hematocrit level D. Cracked lips E. Thirst

A. Sunken fontanel C. High serum hematocrit level D. Cracked lips E. Thirst

A practical nurse (PN) is assigned to care for an 82-year-old client who had a total right hip replacement with cement 2 days ago. Which observation(s) should the PN immediately report to the RN? (Select all that apply.) A. The client complains of incisional pain, rating it an 8 on a scale of 0 to 10. B. The client has had a change in orientation to person but not to time orplace. C. Swelling and redness have developed in the client's lower left leg. D. The LPN emptied 15 mL of bloody drainage from the Jackson-Pratt drain. E. The client's last set of vital signs was temperature 37.9°C (100.2°F), pulse 87, respirations 12, blood pressure 108/74, and O2 saturation 93%.

A. The client complains of incisional pain, rating it an 8 on a scale of 0 to 10. B. The client has had a change in orientation to person but not to time orplace. C. Swelling and redness have developed in the client's lower left leg. E. The client's last set of vital signs was temperature 37.9°C (100.2°F), pulse 87, respirations 12, blood pressure 108/74, and O2 saturation 93%.

The unlicensed assistive personnel (UAP) reports to the staff nurse that a client who had surgery 4 hours ago has had a decrease in blood pressure (BP), from 150/80 to 110/70, in the past hour. The nurse advises the UAP to check the client's dressing for excess drainage and report the findings to the nurse. Which factor is most important to consider when assessing the legal ramifications of this situation? A. The parameters of the state's or province's nurse practice B. The need to complete an adverse occurrence report C. Hospital protocol regarding the frequency of vital sign assessment every hour postoperatively D. The healthcare provider's prescription for changing the postoperative dressing

A. The parameters of the state's or province's nurse practice

A client who is at 36 weeks' gestation is placed in the lithotomy position when she suddenly complains of feeling breathless and light-headed and shows marked pallor. Which action should the nurse take first? A. Turn the client to a lateral position B. Place the client in Trendelenburg position C. Obtain vital signs and pulse oximetry reading D. Initiate distraction techniques

A. Turn the client to a lateral position

A client with pneumonia has impending respiratory failure. Which set of ABG values demonstrate acute respiratory failure? ​ A. pH-7.30 PCO2-52 PO2-56 HCO3-26 B. pH-7.35 PCO2-44 PO2-86 HCO3-28 C. pH-7.35 PCO2-62 PO2-66 HCO3-31 D. pH-7.30 PCO2-39 PO2-88 HCO3-22

A. pH-7.30 PCO2-52 PO2-56 HCO3-26

The nurse is providing safety education to a client diagnosed with Parkinson disease who is prescribed carbidopa-levodopa. The nurse knows that safety education has been effective when the client verbalizes which statement? (Select all that apply.) A. "I will take the medication at bedtime." B. "I will apply sunscreen before I walk outdoors." C. "It's OK for me to eat tuna on whole wheat toast and a banana." D. "I will take the medication on an empty stomach early in the morning." E. "I will remember to keep hydrated and monitor urine output."

B. "I will apply sunscreen before I walk outdoors." E. "I will remember to keep hydrated and monitor urine output."

Four clients arrive in the emergency department after an explosion. In which order should they be assessed? All options must be used. A. A 70-year-old who is complaining of a pain level of 8/10 from a hand burn B. A 35-year-old with partial and full-thickness burns to the anterior and posterior chest C. A 25-year-old with a superficial burn to the right anterior arm and lateral chest D. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion

B. A 35-year-old with partial and full-thickness burns to the anterior and posterior chest D. A 42-year-old with a partial-thickness burn to the anterior lower extremity and confusion A. A 70-year-old who is complaining of a pain level of 8/10 from a hand burn C. A 25-year-old with a superficial burn to the right anterior arm and lateral chest

A client with burn injuries has lost a significant amount of body fluid. An IV of lactated Ringer's solution is infusing at 200 mL/hour, and the client's urine output for the past 8 hours is 400 mL. Which sign or symptom is the top priority in early distributive shock? A. A change in BP from 118/60 to 102/68 B. A change in level of consciousness from awake to restless C. A decrease in O2 saturation from 98% to 93% D. A decrease in urine output over 8 hours from 400 to 240 mL

B. A change in level of consciousness from awake to restless

The nurse is caring for a client with Guillain-Barré syndrome. Which information should the nurse report to the primary healthcare provider? A. Ascending numbness from the feet to the knees B. A decrease in cognitive status C. Blurred vision and sensation changes D. A persistent unilateral headache

B. A decrease in cognitive status

A 72-year-old client returned from surgery 6 hours ago. The client received hydromorphone 2 mg IV 30 minutes ago for pain rating 8/10. The family member requests her father be checked immediately. On arrival to the room, the nurse finds the client difficult to arouse, with a respiration rate of 6. Which is the priority nursing action? A. Elevate the head of the bed. B. Administer naloxone 0.4 mg IV. C. Assess breath sounds. D. Check vital signs and pulse oximetry.

B. Administer naloxone 0.4 mg IV.

The newly licensed nurse overhears two nurses talking in the elevator about a client who will lose her leg because of negligence of the staff. Which action by the newly licensed nurse should be implemented first? A.Monitor the nurses closely for further occurrences. B. Advise them to cease their communication. C. Inform the nurse manager of the conversation. D. Submit an occurrence or variance report.

B. Advise them to cease their communication. (Communication questions always ask "who is a part of the conversation"...not the nurse manager)

The nurse admits a client with suspected early DIC. Which symptoms may indicate early organ ischemia? (Select all that apply.) A. Slight gingival bleeding B. Alterations in mental status C. Petechial hemorrhage to chest D. Slight decrease in urine output E. Bluish discoloration of fingertips

B. Alterations in mental status D. Slight decrease in urine output E. Bluish discoloration of fingertips *EARLY: Clotting; LATE: Bleeding*

A client who is 1 day postoperative after a left pneumonectomy is lying on his right side with the head of bed (HOB) elevated 10 degrees. The nurse assesses his respiratory rate at 32 breaths/min. What action should the nurse take first? A. Elevate the HOB. B. Assist the client into the supine position. C. Measure the client's O2 saturation. D. Administer intravenous (IV) PRN morphine.

B. Assist the client into the supine position. *Remove pressure off of R lung to improve gas exchange*

The complete blood count (CBC) results for a client receiving chemotherapy are hemoglobin 85 mmol/L (8.5 g/dL); hematocrit, 32%; WBC count, 6.5 × 109/L (6500 cells/mm3). Which meal choice is best for this client? A. Grilled chicken, rice, fresh fruit salad, milk B. Broiled steak, whole wheat rolls, spinach salad, coffee C. Smoked ham, mashed potatoes, applesauce, iced tea D. Tuna noodle casserole, garden salad, lemonade

B. Broiled steak, whole wheat rolls, spinach salad, coffee **Red meat**

The nurse finds a client slumped in a chair. Place the nurse's actions in order of priority from first to last for this client. A. Activate the code team and obtain defibrillator. B. Determine unresponsiveness. C. Assess the cardiac rhythm using the "quick-look" paddles. D. Assess for a carotid pulse. E. Open airway and give two rescue breaths by bag-valve mask. F. Move the client to a flat position in bed or on the floor. G. Begin compressions.

B. Determine unresponsiveness. A. Activate the code team and obtain defibrillator D. Assess for a carotid pulse. F. Move the client to a flat position in bed or on the floor. G. Begin compressions. E. Open airway and give two rescue breaths by bag-valve mask. C. Assess the cardiac rhythm using the "quick-look" paddles.

The healthcare provider prescribes the anticonvulsant phenytoin for an adolescent with a seizure disorder. The nurse should instruct the client to notify the healthcare provider if which condition develops? A. Dry mouth B. Dizziness C. Sore throat D. Gingival hyperplasia

B. Dizziness

A client is admitted with a 2-day history of cough, fever, and fatigue. The medical history is positive for type I diabetes and recent upper respiratory infection (URI). Vital signs are heart rate 109 beats per minute, blood pressure 102/58 mm Hg, respiratory rate 24 breaths/min, temperature 104°F (40°C), and SpO2 92% on 2 L oxygen via nasal cannula. Which prescription has the highest priority in this client's care? A. Initiate large-bore IV access. B. Draw two sets of blood cultures. C. Administer the ordered IV antibiotics. D. Draw serum lactate and glucose levels.

B. Draw two sets of blood cultures.

A client with a history of uterine fibroids had a cesarean delivery 12 hours earlier and delivered healthy twins. At shift change, the nurse assesses the client and notes shortness of breath, cool extremities, and oozing of blood from the incision site. Based on the client's presentation, which nursing action has the highest priority? A. Assess the client's temperature. B. Notify the healthcare provider. C. Clean the blood from the incision site. D. Draw labs for PT, PTT, CBC, and fibrinogen.​​

B. Notify the healthcare provider.

A client who is 72 hours post cesarean section is preparing to go home. She complains to the nurse that she can't get the baby's diaper on right. Which action should the nurse take? A. Demonstrate how to diaper the baby correctly B. Observe the client diapering the baby while offering praise and hints C. Call the social worker for long-term follow-up D. Reassure the client that she knows how to take care of her baby

B. Observe the client diapering the baby while offering praise and hints

While receiving IV antibiotics for sepsis, a 2-month-old infant is crying inconsolably, despite the parent's presence. The nurse recognizes that the infant is exhibiting symptoms related to which likely condition? A. Allergic reaction to antibiotics B. Pain related to IV infiltration C. Separation anxiety from parent D. Hunger and thirst

B. Pain related to IV infiltration

The nurse is caring for a 2-year-old child suspected of having croup. Which early sign of respiratory distress requires the nurse's immediate attention? A. Cyanosis B. Restlessness C. Crying D. Barking cough

B. Restlessness

The nurse observes an older client with glaucoma administer eye drops by tilting back the head, instilling each drop close to the inner canthus, and keeping the eye closed for 15 seconds. Which action should the nurse take first? A. Ask the client whether another family member is available to administer the drops B. Review the correct steps of the procedure with the client C. Administer the eye drops correctly in the other eye to demonstrate the technique D. Discuss the importance of correct eye drop administration for persons with glaucoma

B. Review the correct steps of the procedure with the client **inner canthus drains in 4 areas and does not go into the patient's eye**

After the change of shift report, the nurse reviews assignments. Which client should the nurse assess first? A. The elderly client receiving palliative care for heart failure who complains of constipation and nervousness B. The adult client who is 48 hours postoperative for a colectomy and who is reported to be having nausea and vomiting C. The middle-aged client with chronic renal failure whose urinary catheter has been draining 95 mL for 8 hours D. The client who is 2 days postoperative for a thoracotomy and who has chest tubes, is on oxygen at 3 L/min, and has a respiratory rate of 12 breaths/min

B. The adult client who is 48 hours postoperative for a colectomy and who is reported to be having nausea and vomiting

An awake, alert client with impending pulmonary edema is brought to the emergency department. The client provides the nurse with a copy of a living will that states that "no invasive" medical procedures should be used to "keep her alive." The healthcare team is questioning whether the client should be intubated. Which information should guide the team's decision? A. The living will removes the obligation to the client in any medical decision-making B. The client is awake and alert, which makes the living will irrelevant and nonbinding. C. Lifesaving measures do not have to be explained to the client because of the signed living will. D. The family should be contacted to determine who has durable power of attorney for health care for the client.

B. The client is awake and alert, which makes the living will irrelevant and nonbinding.

A client with gestational diabetes asks the nurse to explain the reason her baby is at risk for macrosomia. Which explanation should the nurse offer? A. The placenta receives decreased maternal blood flow during pregnancy because of vascular constriction. B. The fetus secretes insulin in response to maternal hyperglycemia, causing weight gain and growth. C. Infants of diabetic mothers are postmature, which allows the fetus extra time to grow. D. Rapid fetal growth contributes to congenital anomalies, which are more common in infants of diabetic mothers.

B. The fetus secretes insulin in response to maternal hyperglycemia, causing weight gain and growth.

The nurse is precepting a nurse orientee who's caring for a client with a chest tube. The client is 12 hours postoperative from a left partial pneumonectomy. Which assessment will the nurse advise the orientee to immediately report to the healthcare provider? (Select all that apply.)​ A. Pain level of 6 out of 10 on the left side B. Tracheal deviation toward the right side C. Drainage from the chest tube of 50 mL in the last hour D. Oxygen saturation of 90% on 2 L/min E. Vigorous bubbling in the suction chamber

B. Tracheal deviation toward the right side D. Oxygen saturation of 90% on 2 L/min E. Vigorous bubbling in the suction chamber

A woman who is in labor becomes nauseated, starts hiccupping, and tells her partner to leave her alone. The partner asks the nurse what he did to make this happen. Which response should the nurse provide? A. "In active labor, it is quite common for women to react this way. It's nothing you did." B. "I don't know what you did, but stop, because she is quite sensitive right now." C. "I'll come and examine her. This reaction is common during the transition phase of labor." D. "Early labor can be very frustrating. I'm sure she doesn't mean to take it out on you."

C. "I'll come and examine her. This reaction is common during the transition phase of labor."

The nurse is reinforcing teaching for a school-age child and the child's parent regarding the administration of inhaled beclomethasone dipropionate and albuterol for the treatment of asthma. Which statement by the parent indicates that teaching has been effective? A. "I'll keep the inhalers in the refrigerator." ​B. "My child only needs to use inhalers when the peak flow numbers are in the red."​ C. "My child will take the bronchodilator first, then the corticosteroid." D. "My child will take the corticosteroid first, wait a few minutes, and then take the bronchodilator."

C. "My child will take the bronchodilator first, then the corticosteroid."

The nurse is reinforcing discharge teaching for parents of a 4-year-old with cystic fibrosis. Which statement by the parents demonstrates understanding of the teaching presented? A. "We will discourage our child from playing outdoors." B. "We will use pancreatic enzymes only if needed." C. "We will thoroughly wash our child's hands after toileting." D. "We will schedule a physical therapist evaluation."

C. "We will thoroughly wash our child's hands after toileting."

A client's suspected pregnancy is confirmed. The client tells the nurse that she had three previous pregnancies where she delivered one infant at 39 weeks, twins at 34 weeks, and another infant at 35 weeks. Using the GTPAL notation, how should the nurse record the client's gravidity and parity? A. 3-0-3-0-3 B. 3-1-1-1-3 C. 4-1-2-0-4 D. 4-2-1-0-3

C. 4-1-2-0-4

Which client should be assigned to a graduate nurse orienting to the neurological unit? A. A client with a head injury who has a Glasgow Coma Scale of 6 B. A client who developed autonomic dysreflexia after t6 spinal cord injury C. A client with multiple sclerosis who needs the first dose of interferon D. A client diagnosed with Guillian-Barre syndrome

C. A client with multiple sclerosis who needs the first dose of interferon

The nurse and the unlicensed assistive personnel (UAP) take a group of mental health clients to a baseball game. During the game, a client reports shortness of breath and dizziness. Which intervention should the nurse implement first? A. Have the UAP escort the client back to the unit. B. Request that the client describes current feelings. C. Accompany the client to a quiet area. D. Ask the client if anything untoward occurred.

C. Accompany the client to a quiet area.

Which action by the unlicensed assistive personnel (UAP) requires immediate follow-up by the nurse? A. Positioning a client who is 12 hours post above-the-knee amputation (AKA) with the residual limb elevated B. Assisting a client with ambulation while the client uses a cane on the unaffected side C. Accompanying a client who has lupus erythematosus to sit outside in the sun during a break D. Helping a client with rheumatoid arthritis to the bathroom after the client takes celecoxib (Celebrex)

C. Accompanying a client who has lupus erythematosus to sit outside in the sun during a break (sun triggers lupus)

The nurse is planning to teach client strategies for coping with anxiety. The nurse finds the client engaged in compulsive handwashing. What action should the nurse take next? A. While the client is hand washing, introduce alternatives to hand washing. B. Ask the client to immediately stop hand washing; then begin teaching. C. Allow client to complete hand washing; then begin teaching. D. Ask client to describe events that precipitated the handwashing.

C. Allow client to complete hand washing; then begin teaching. **Allow them to finish whatever they are doing to improve safety w/you and patient to not increase their anxiety levels**

A client has not had a bowel movement in 2 days and reports this information to the nurse. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the HCP and request a prescription for a stool softener. C. Assess the client's medical record to determine his normal bowel pattern. D.Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.

C. Assess the client's medical record to determine his normal bowel pattern.

What nursing action has the highest priority when admitting a client to a psychiatric unit on an involuntary basis?​ A. Reassure the client that this admission is only for alimited amount of time. B. Offer the client and family the opportunity to share their feelings about the admission. C. Determine the behaviors that resulted in the need foradmission. D. Advise the client about the legal rights of all hospitalized clients.

C. Determine the behaviors that resulted in the need foradmission. **SAFETY**

The nurse is preparing for change of shift. Which action by the nurse is characteristic of ineffective handoff communication? A. The nurse states to the nurse coming on duty: "The client is anxious about pain after surgery. Review the information I provided about how to use an incentive spirometer." B. The nurse refers to the electronic medical record (EMR) to review the client's medication administration record. C. During rounds, the nurse talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client. D. Before giving report, the nurse performs rounds on assigned clients so that there is less likelihood of interruption during handoff.

C. During rounds, the nurse talks about the problem the UAP created by not performing a fingerstick blood glucose test on the client.

The nurse is caring for a child who had a tonsillectomy 2 hours ago. Which sign or symptom most likely relates to a complication? A. Apical rate 90 beats/min B. Blood pressure 96/50 C. Frequent swallowing D. Nasal congestion

C. Frequent swallowing **bleeding complication within 24 hours or again 5-10 days**

n completing a client's perioperative routine, the nurse finds that the consent form has not been signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take? A. Witness the client's signature on the consent form. B. Answer the client's questions about the surgery C. Inform the HCP that the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthetic is administered.

C. Inform the HCP that the client has questions about the surgery.

A client diagnosed with borderline personality disorder returns after a weekend pass with lacerations to both wrists. The client complains about how the nurse is performing the dressing change. The nurse's response should be presented in which manner? A. Disinterested B. Concerned C. Matter-of-fact D. Empathetic

C. Matter-of-fact

A client diagnosed with a history of bulimia is admitted to the mental health unit. What intervention is most important for the nurse to include in the initial treatment plan? A. Observe the client after meals for purging. B. Assess daily weight and vital signs. C. Monitor serum potassium and calcium. D. Provide a structured environment at mealtime.

C. Monitor serum potassium and calcium.

The nurse is assessing a client who is scheduled for surgical fixation of a compound fracture of the right ulna. Which finding should the nurse report to the healthcare provider? A. Ecchymosis around the fracture site B. Crepitus at the fracture site C. Paresthesia distal to the fracture site D. Diminished range of motion of the right arm

C. Paresthesia distal to the fracture site *Look for the 5 P's*

he charge nurse is making assignments for each of four staff members, including a registered nurse (RN), a licensed practical nurse (PN), and two unlicensed assistive personnel (UAPs). Which task is best to assign to the PN? A. Maintain a 24-hour urine collection. B. Wean a client from a mechanical ventilator. C. Perform sterile wound irrigation. D. Obtain scheduled vital signs.

C. Perform sterile wound irrigation.

The nurse is caring for a 16-year-old client with Down syndrome who has a mental age of 5. Which priority nursing action should be included in this client's plan of care? A. Monitoring for hearing loss B. Monitoring I&O C. Providing a dependable routine D. Providing small puzzles

C. Providing a dependable routine

A client who has chronic obstructive pulmonary disease (COPD) is resting in a semi-Fowler's position with oxygen at 2 L/min per nasal cannula. The client develops dyspnea. Which action should the nurse take first? A. Call the HCP. B. Obtain a bedside pulse oximeter. C. Raise the head of the bed higher. D. Assess the client's vital signs.

C. Raise the head of the bed higher.

A client recovering from ARDS is awake and alert but has residual fatigue and generalized weakness. The client's current vital signs are heart rate 83 beats per minute, blood pressure 104/64 mm Hg, respiratory rate 25 breaths/min, SpO2 is 92% on 2 L/min oxygen via nasal cannula. Which vital sign finding should the unlicensed assistive personnel (UAP) immediately report to the nurse? A. Heart rate of 83 beats per minute B. Blood pressure of 104/64 mm Hg C. Respiratory rate of 25 breaths/minute D. SpO2 92% of 2L/min O2 via nasal cannula

C. Respiratory rate of 25 breaths/minute

Which laboratory result for a preoperative client should prompt the nurse to contact the healthcare provider? A. Platelet count: 151 × 109/L (151,000/mm3) B. White blood cell (WBC) count: 85 × 109/L (8500/mm3) C. Serum potassium level: 2.8 mEq/L (mmol/L) D. Urine specific gravity: 1.031

C. Serum potassium level: 2.8 mEq/L (mmol/L)

The nurse is teaching an 86-year-old client who has glaucoma and bilateral hearing loss. Which intervention should the nurse implement? A. Maintain constant eye contact B. Stand on the side unaffected by glaucoma C. Speak in a lower tone of voice D. Keep the environment dimly lit

C. Speak in a lower tone of voice (Glacoma: do not position to the side. Stand directly in front of the patient. To the side, they are unable to see you.)

Which assignment should the nurse delegate to a UAP in an acute care setting? ​A. Checking blood glucose hourly for a client with acontinuous insulin drip​ B. Giving PO medications left at the bedside for the client to take after eating C. Taking vital signs for an older client with left humeral and left tibial fractures D. Replacing a client's pressure ulcer dressing that hasbeen soiled by incontinence

C. Taking vital signs for an older client with left humeral and left tibial fractures

A client, who is HIV positive, asks why it is necessary to have a viral load study performed every 3 to 4 months. Which information should the nurse provide? A. To determine the progression of the disease B. To evaluate the enzyme-linked immunosorbent assay (ELISA) C. To monitor the effectiveness of the treatment D. To track the effectiveness of the vaccine

C. To monitor the effectiveness of the treatment

An adult client is admitted to the inpatient mental health unit with a diagnosis of severe depression. As the client begins to recover, the client develops rapport with the nurse. After being discharged from the hospital, the client and the nurse happen to meet in the coffee shop. The client asks the nurse if they can schedule future meetings at the coffee shop. Which response by the nurse is most therapeutic? A. "I'll contact the nurse supervisor about this plan." B. "Let's not plan to meet; however, we may inadvertently see each other here." C. "It's not appropriate for me to discuss therapy with you when I'm off duty." D. "A social relationship with a former client is not appropriate."

D. "A social relationship with a former client is not appropriate."

A client at 33 weeks' gestation who has been diagnosed with pregnancy-induced hypertension (PIH) is admitted to the labor and delivery area. The client expresses concern for the health of her baby. Which response should the nurse make? A. "You have the best doctor on the staff, so don't worry about a thing." B. "Your anxiety is contributing to your condition and may be the reason for your admission." C. "This is a minor problem that is easily controlled, and everything will be all right." D. "As I assess you and your baby, I will explain the plan for your care and answer your questions."

D. "As I assess you and your baby, I will explain the plan for your care and answer your questions."

The nurse enters the room of a preoperative client to obtain the client's signature on the surgical consent form. Which question is most important for the nurse to ask the client?​ A. "When did the surgeon explain the procedure to you?"B. "Is any member of your family going to be here during your surgery?" C. "Have you been instructed in postoperative activities and restrictions?" D. "Have you received any preoperative pain medication?"

D. "Have you received any preoperative pain medication?"

Which situation warrants a variance (incident) report by the nurse? A. A client refuses to take prescribed medication. B. A client's status improves before completion of the course of medication. C. A client has an allergic reaction to a prescribedmedication. D. A client received medication prescribed for another client.

D. A client received medication prescribed for another client.

The nurse is assessing clients at the site of a community disaster. Using the color-code system for triage, which client should the nurse tag with a red code? A. A client with a large head injury that is bleeding, an open chest wound, cyanotic skin, no capillary refill, and agonal respirations B. A client with bruising and swelling of the right forearm, assorted lacerations to the face and neck, dry skin, normal capillary refill, and a respiratory rate of 18 C. A client with scratches and scrapes to the head and face who is limping and helping other clients at the scene D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiratory rate 32, who is moaning

D. A client with an open wound to the abdomen, and a deformed right femur, pulse 125, delayed capillary refill, respiratory rate 32, who is moaning

A pregnant client tells the nurse that she drinks only one glass of wine a day. Which information should the nurse provide the client about the effects of drinking alcohol during pregnancy? A. Alcohol causes vasoconstriction and decreases placental perfusion. B. Alcohol decreases the lecithin:sphingomyelin (L:S) ratio, contributing to lung immaturity. C. Alcohol causes vasodilation and increased fluid overload for the fetus. D. Alcohol during pregnancy places the fetus at risk for fetal alcohol spectrum disorders.

D. Alcohol during pregnancy places the fetus at risk for fetal alcohol spectrum disorders.

A client at 15 weeks' gestation is admitted for an inevitable abortion. Thirty minutes after returning from surgery, her vital signs are stable. Which intervention has the highest priority? A. Ask the client if she would like to talk about losing her baby. B. Place cold cabbage leaves on the client's breasts to decrease breast engorgement. C. Send a referral to the grief counselor for at-home follow-up. D. Confirm the client's Rh and Coombs' status and administer RhoGAM if indicate

D. Confirm the client's Rh and Coombs' status and administer RhoGAM if indicate

​​The nurse palpates a crackling sensation around the insertion site of a chest tube in a client who has had thoracic surgery. Which action should the nurse take? A. Return the client to surgery. B. Prepare for insertion of a larger chest tube. C. Increase the water-seal suction pressure. D. Continue to monitor the insertion site.

D. Continue to monitor the insertion site.

A school-age child with nephrotic syndrome is seen at the clinic 2 days after discharge from the hospital. Which assessment is most important for the nurse to perform after discharge? A. Pain B. Capillary refill C. Urine ketones D. Daily weight

D. Daily weight

A client with a history of alcohol abuse is admitted to the medical unit for gastrointestinal bleeding and pancreatitis. The admission data include BP 156/96 mm Hg, pulse 92 beats/min, and temperature 37.3° C (99.2° F). Which intervention is most important for the nurse to implement? A. Provide a quiet, low-stimulus environment B. Initiate seizure precautions C. Administer as-needed (PRN) lorazepam (Ativan) as prescribed D. Determine the time and quantity of the client's last alcohol intake

D. Determine the time and quantity of the client's last alcohol intake

Which nursing action has the highest priority for an infant immediately after birth? A. Place the infant's head in the "sniff" position and give oxygen via face mask. B. Perform a bedside glucose test and feed the infant glucose water as needed. C. Assess the heart rate and perform chest compressions if rate is <60 beats/min. D. Dry the infant and place him or her under a radiant warmer or skin to skin with the mother.

D. Dry the infant and place him or her under a radiant warmer or skin to skin with the mother.

The charge nurse confronts a staff nurse whose behavior has been resentful and negative since a change in unit policy was announced. The staff nurse states, "Don't blame me; nobody likes this idea." Which is the charge nurse's priority action?​ A. Confront the other staff members involved in the change of unit policy. B. Call a unit meeting to review the reasons the change was made. C. Develop a written unit policy for the expression of complaints. D. Encourage the nurse to be accountable for her own behavior.

D. Encourage the nurse to be accountable for her own behavior.

A 4-year-old is brought to the clinic with a fever of 103∘ F, sore throat, and moderate respiratory distress caused by a suspected bacterial infection. Which medical diagnosis is a contraindication to obtaining a throat culture in the child? A. Tonsillitis B. Streptococcal infection C. Bronchiolitis D. Epiglottitis

D. Epiglottitis **DO NOT occlude the airway anymore**

The nurse directs the unlicensed assistive personnel (UAP) to play with a 4-year-old child on bed rest. Which activities should the nurse recommend? (Select all that apply.) A. Monopoly board game B. Checkers C. 50-piece puzzle D. Hand puppets E. Coloring book

D. Hand puppets E. Coloring book

A 2-year-old child's blood work is evaluated by the nurse. Considering that the child is prescribed furosemide, captopril, and digoxin for congestive heart failure, which value should the nurse verify with the laboratory? A. Hypocalcemia B. Hypernatremia C. Low hemoglobin D. Hypokalemia

D. Hypokalemia

A female client who is a 5-year breast cancer survivor received confirmation that she has a recurrence of breast cancer. She informs her family that the biopsy was negative. What action should the nurse take? A. Tell the client's family to consult the healthcare provider. B. Ask the client to restate what the healthcare provider told her. C. Encourage the client to inform her family about the results. D. Suggest the client talk to the nurse about her fears.

D. Suggest the client talk to the nurse about her fears.

The charge nurse is assigning rooms for four new clients. Only one private room is available in the oncology unit. Which client should be placed in the private room? A. The client with ovarian cancer who is receiving chemotherapy B. The client with breast cancer who is receiving external beam radiation C. The client with prostate cancer who has just had a transurethral resection D. The client with cervical cancer who is receiving intracavity radiation

D. The client with cervical cancer who is receiving intracavity radiation

A family member of a client who is in a Posey vest restraint (safety reminder device) asks why the restraint was applied. Which response should the nurse make?​ A. The restraint was prescribed by the healthcare provider. B. There is not enough staff to keep the client safe all the time. C. The other clients are upset when the client wanders at night. D. The client's actions place the client at high risk for self-harm.

D. The client's actions place the client at high risk for self-harm.

The nurse observes an adolescent client experiencing a tonic-clonic seizure. Which intervention should the nurse provide first? A. Restrain the client to protect against injury B. Flex the neck to ensure stabilization C. Use a tongue blade to open the airway D. Turn client on side to aid ventilation

D. Turn client on side to aid ventilation

Today's lab report of the lithium level is 1.3 mEq/mL for a client diagnosed with bipolar disorder. Which is the first action the nurse should take? A. Withhold the dose until after breakfast B. Give the client the prescribed dose C. Obtain a prescription to increase the dose D. Withhold the dose and notify the healthcare provider

D. Withhold the dose and notify the healthcare provider

A client in shock develops a mean arterial pressure (MAP) of 60 mm Hg and a heart rate of 110 beats per minute. Which prescribed intervention should the nurse implement first? A. Increase the rate of O2 flow. B. Obtain arterial blood gas results. C. Insert an indwelling urinary catheter. D. ​Increase the rate of intravenous (IV) fluids.

D. ​Increase the rate of intravenous (IV) fluids.

A client who has hyperparathyroidism is scheduled to receive a prescribed dose of oral phosphate. The nurse notes that the client serum calcium is 12.5 mg/dL. What action should the nurse take? A. Hold the phosphate and notify the HCP. B. Review the client's serum parathyroid hormone level. C. Give a PRN dose of intravenous (IV) calcium per protocol. D.Administer the dose of oral phosphate.

D.Administer the dose of oral phosphate.

pH = 7.28​ pCO2 = 35​ HCO3 =18​ ​This client has ________

Metabolic Acidosis

pH = 7.56 pCO2 = 44​ HCO3 =38 This client has ________

Metabolic Alkalosis

pH = 7.43​ pCO2 = 40​ HCO3 =24​ This client has ________

Normal

pH = 7.32​ pCO2 = 50​ HCO3 =25 ​ The client has:__________

Respiratory Acidosis

pH = 7.33​ pCO2 = 50​ HCO3 = 29 This client has ________

Respiratory Acidosis