Exit HESI practice questions

74. Client is receiving a prescription for delteparin sodium 15,000 international units IU subcutaneously the drugs dispense as 25,000 how many ML should the nurse administer? (Enter numeric value only) if rounding is required round to the nearest tenth

0.6

121. The healthcare provider prescribes or placebo instead of paying medication what intervention should the nurse implement? a. The client that the provider prescribed a placebo instead of pain medication b. discuss ethical concerns about placebo use with the health care provider c. Administer the placebo as prescribed when the client complaints of pain d. tell the charge nurse about the prescribed placebo every fuse to administer it

CORRECT ANSWER NOT HIGHLIGH

119. A client present the clinic with large draining ulcer on both lower legs that are characteristics of kyphosis sarcoma lesions the client is accompanied by two family members what action should the nurse take? a. Send family to the waiting area while the client's history is taken b. Complete a head-to-toe assessment to identify all the signs of HIV c. Ask the family member to wear gloves when touching the client d. Obtain a blood sample to determine if the client is HIV positive

CORRECT ANSWER NOT HIGHLIGHTED

101. The nurse is performing an admission assessment of a client with generalized malaise and nonspecific symptoms of not feeling well. Which finding is most important for the nurse report to the health care provider? a. The muscles of the neck are symmetrical b. Thyroid gland that is not visible or palpable c. the trachea is to the right of the suprasternal notch d. The small, discrete, moveable Lymph Lobe

CORRECT ANSWER WAS NOT HIGHLIGHTED

102. Where conducting a funduscopic examination the nurse should assets which area of the right now to detect increased intracranial pressure?

CORRECT ANSWER WAS NOT HIGHLIGHTED

103. When assessing a client with acute asthma the nurse is most likely to obtain which finding?

CORRECT ANSWER WAS NOT HIGHLIGHTED

104. Following a gunshot wound an adult client has hemoglobin level of 4 the nurse prepares to administer a unit of blood for an emergency transfusion the client has AB negative blood type, and the blood bank sends a unit of type A RH negative reporting that there is no type AB negative blood currently available which intervention should the nurse implement? a. Obtain additional consent for administration of type A negative blood b. Recheck the clients blood type and RH factor c. Transfer type A negative blood undo type AB negative is available d. Administer normal saline solution until type a be negative is available

CORRECT ANSWER WAS NOT HIGHLIGHTED

110. The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grow. Which response provides the best explanation? a. Severe motor dysfunction determines the extent of successful habilitation b. Continued development of the brain lesion determines the child's outcome c. CP is one of the most common permanent physical disability in children d. Brain damage with CP is not progressive but those have a variable course

CORRECT ANSWER WAS NOT HIGHLIGHTED

93. The nurse is caring for a client who arrives to the emergency department with reports of expensive dizziness and difficulty walking to the bathroom the nurse observes right sided weakness and sluggish in a education of speech after obtaining vital signs the nurse should implement which intervention? a. Initiate bilateral intermittent sequential pneumatic compression device b. administer aspirin to prevent further clot formation and play glad clumping c. Place an indwelling catheter and measure streets intake and output d. Notify the stroke team to assist with acute assessment and management

THIS ONE WAS NOT HIGHLIGHTED

62. 6 weeks after the birth of a child with Trisomy 21, the parents return to the prenatal clinic for a follow up visit they have spoken with a genetic counselor but are still unsure about the risks of having another child with Trisomy 21 the couple brings literature from the counselor with them and ask the nurse to explain it which action should the nurse take? a. Recommend a community support group for parents of children with trisomy 21 b. Determining their reasoning for seeking genetic counseling at this time c. Tell the couple that it is best to call the counselor with their questions d. Review the literature and answer any questions the nurse is able to answer

c. Tell the couple that it is best to call the counselor with their questions

71. While caring for a client who had an exploratory laparotomy yesterday the nurse notes that coffee ground materials is draining from the nasogastric tube which intervention should the nurse implement? a. Verified correct placement of the nasogastric tube b. listen for evidence of diminished bowel sound c. Test nasogastric drainage for the presence of blood d. irrigate the nasal gastric with water until clear

c. Test nasogastric drainage for the presence of blood

100. The nurse is caring for a client with irritable bowel syndrome who presents with diarrhea and cramping abdominal pain which part of physiological mechanism support this client's clinical presentation a. A history of Helicobacter pylori infection b. Nerve degeneration due to chronic gastric reflux c. Tissue swelling do you to an autoimmune response d. A weakening diaphragm with high abdominal pressure

c. Tissue swelling do you to an autoimmune response

68. the client with type 2 diabetes mellitus and hypertension is admitted with Cellulite is of the right leg due to an embedded turn from gardening. The client is receiving an intravenous infusion for antibiotic administration and is on bed rest with the right leg elevated on a pillow which finding is most important for the nurse to monitor? a. dark yellow urine b. sodium 135 mEq/L (135 mmol/L c. WBC 11X 103/pL (11 x 109/L) d. No appetite with nausea

c. WBC 11X 103/pL (11 x 109/L)

67. A client is admitted with an exacerbation of heart failure secondary to COPD. which observations by the nurse require immediate intervention so reduce the likelihood of harm to this client? (Select all that is apply) a. a bedside commode is positioned near the bed b. a saline lock is present in the right forearm c. a full pitcher of water is on the bedside table d. A low sodium diet tray was brought to the room e. DThe client is lying in a supine position in bed

c. a full pitcher of water is on the bedside table e. The client is lying in a supine position in bed

51. The nurse is preparing an older client for discharge following cataract extraction which instruction should be included in the discharge teaching? a. Limit exposure to sunlight during the first two weeks when the cornea is healing b. Irrigated conjunctiva II we've ophthalmic saline prior instilling antibiotic ointment c. avoid straining at stool, bending, a lifting heavy object d. do not read without direct lightning for six weeks

c. avoid straining at stool, bending, a lifting heavy object

99. A client with pancreatitis complaints of severe epigastric pain so the nurse administered prescribed narcotic analgesic 10 minutes later the Client insists on sitting up and leaning forward which intervention should the nurse implement? a. Place bed in a reverse Trendelenburg position b. Raise head of bed until to a 90 degree angle c. position bedside table so the client can lean across it d. encourage rest until the analgesic becomes infected

c. position bedside table so the client can lean across it

149. An adult client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurry speech pattern and an unsteady gait which assessment finding is most important for the nurse to report to the health care provider? a. Weight loss of 10 pounds (4.5 kg) in past month b. Blood alcohol level of 0.09% c. serum Lithium level of 1.6 mEq/L or mmol/L (SI) d. Six hours of sleep in the past three days

c. serum Lithium level of 1.6 mEq/L or mmol/L (SI)

145. Why conducting a mental status exam, the nurse asks the client to interpret the proverb "A stitch in time saves nine" This exercise provides a measure of which parameter? a. Abstract thinking b. Intelligence c. Reality orientation d. Level of paranoia

a. Abstract thinking

75. What is the primary goal when planning nursing care for a client with degenerative joint disease DJD? a. Achieve satisfactory Pain control b. Improve stress management skills c. reduce risk for infection d. Contain adequate rest and sleep

a. Achieve satisfactory Pain control

32. The healthcare providers prescribed sedative for a client with severe hypothyroidism. The nurse plans to contact the provider to review the safety of the prescription for the client and consults first with the charge nurse. The charge nurse notes that the prescription is written legally and completely. How should the charge nurse respond? a. Affirm that nurse plan to review the prescription with the provider b. Advise the nurse to administer the medication as prescribed c. Offer to administer the prescription since the nurse has concern d. Assume responsibility for discussing the concern with the provider

a. Affirm that nurse plan to review the prescription with the provider

140. Client who arrives in the emergency department after a motor vehicle accident tells the nurse the car started to slide, and I just decided to let it go everyone would be better off if I was no longer around. How should the nurse respond? a. Ask the client even the MVC was a suicide attempt b. Determine what is going on in the client life to make him feel depressed c. Assess the client for other symptoms of depression d. Report to the health care provider that the client may need an antidepressant

a. Ask the client even the MVC was a suicide attempt

24. An older adult male who had an abdominal cholecystectomy has become increasingly confused and disoriented over the past 24 hours he is found wandering into another client room and hereturned to his room by the unlicensed assistive personnel (UAP). Which action should the nurse take? (Select all that is apply) a. Assess the client's breath sound and oxygen saturation b. Report mental status change to the health care provider c. review the client's most recent serum electrolyte values d. Assign the UAP to reassess the client's risk for falls e. Apply soft open limb restraint and raise all four bed rails

a. Assess the client's breath sound and oxygen saturation b. Report mental status change to the health care provider c. review the client's most recent serum electrolyte values

108. The nurse assesses a child in 90-90 skeletal traction where should the nurse assess the for signs of compartment syndrome select the location

a. At the tip on the toes

31. A client receives codeine for pain every 4 to 4 hours over 4 days. Which assessment finding should the nurse perform before administering the next dose? a. Auscultate the bowel sounds b. Measure the blood body temperature c. Palpate the ankles for edema d. Observe the skin for bruising

a. Auscultate the bowel sounds

115. An adolescent client with no union of a comminuted fracture of the tibia is admitted with osteomyelitis the healthcare provider collects bone aspirate specimen for culture and sensitivity and applies a cast to the adolescent lower leg. What action should the nurse implement next? a. Begin parenteral antibiotic therapy b. Bivalve the cast for distal compromise c. provide a high calorie high, protein diet d. Administer antiemetic agents

a. Begin parenteral antibiotic therapy

129. A client male with end-stage liver disease has been unresponsive for the past 3 days. His electroencephalography (EEG) reveals no active brain activity. The family wants to continue feeding and donate his viable organs. Which action should the nurse to take? a. Contact regional organ procurement agency b. Explain that the client may not be an organ donor candidate c. Discontinue feedings and fluids per the family's request d. Convene a multidisciplinary care conference

a. Contact regional organ procurement agency

48. An older adult with a terminal illness is receiving Hospice care and is having difficulty coping with feelings related to death and dying. Which intervention should the nurse include in this client's plan of care? (Select all that is apply) a. Encourage family to visit frequently b. Encourage family to bring the client old photographs c. Record the client desire to live d. Instruct client a family to reconsider end of life choices e. Teach client how to use guided imaginary

a. Encourage family to visit frequently e. Teach client how to use guided imaginary

109. The nurse is providing teaching to a school age child with a left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment? a. Ensure no weight bearing on the affected extremity b. Administer topical antibiotic therapy daily c. Schedule ice pack application to the infected area d. Provide passive range of motion

a. Ensure no weight bearing on the affected extremity

49. An Older adult woman is brought to the emergency department by her daughter who reports that her mother has recently become confused. Further assessment indicates that the client has had the flu and has been vomiting for the past two days and she currently takes medications for diabetes hypertension and heart failure which intervention should the nurse implements FIRST? a. Establish client's mental status baseline b. Obtain a capillary blood glucose level c. Insert an indwelling catheter d. List home medication names and dosage

a. Establish client's mental status baseline

132. A male client with a brain tumor is scheduled for a biopsy in the morning during the admission procedure the client has a tonic clonic seizure the last 50 second following the seizure the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been a lot and communicative which action should the nurse take? a. Explain the postictal states that usually follow seizure b. Keep orienting the client to time and space until he is less confused c. Ask the wife to wait outside the room until the nurse can talk with her d. notify the emergency response team of the client seizure

a. Explain the postical states that usually follow seizure

44. When conducting diet teaching for a client who was diagnosed with hypertension which food should the nurse encourage the client to eat (select all that is Apply) a. Fruit with sauce b. Canned soup c. Pickled olives d. Cottage cheese e. Fresh and frozen vegetables without sauce

a. Fruit with sauce c. Pickled olives e. Fresh and frozen vegetables without sauce

105. A middle-aged client diagnosed with Graves' disease ask the nurse about this condition which etiological pathology should the nurse include in the teaching plan about hyperthyroidism? (Select all that apply) a. Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptor b. Weight gain is a common complaint in hyperthyroidism c. Large protruding eyeballs are a signs of hyperthyroid function d. Early treatments include Levothyroxine e. T3 and T4 hormone level increased

a. Graves' disease, an autoimmune condition, affects thyroid stimulating hormone receptor c. Large protruding eyeballs are a signs of hyperthyroid function e. T3 and T4 hormone level increased

107. The nurse is developing the plan of care for a hospitalized child with Von Willebrand's disease. What priority nursing intervention should be included in the child's plan of care? a. Guard against bleeding injuries b. Reduce contact with other children c. Eliminate contact with cold drafts d. Reduce exposure to infection

a. Guard against bleeding injuries

79. The nurse is assisting a client who recently had an upper respiratory infection and now presents to the emergency department with lower extremity numbness and difficulty swallowing based on these finding this clan is a greatest risk for which Pathophysiological condition: a. Guillain Barre syndrome b. Mycoplasma Pneumonia c. Epstein Barr virus d. Cytomegalovirus

a. Guillain Barre syndrome

114. A preschool age child who is being treated for streptococcus pharyngitis return to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxic that are created by the streptococcus bacteria? a. High protracted fever b. White coating on tongue c. Flaky peeling skin d. Red bumps across chest

a. High protracted fever

72. client who is HIV positive receives a prescription for megestrol 400mg daily. Which finding should the nurse identify as a therapeutic response so the prescription? a. Increase appetite b. Produce serum viral load c. No signs of thrombophlebitis d. Healing skin lesion

a. Increase appetite

54. An older adult client is admitted to the stroke unit after recovering from the acute phrase of an ischemic cerebral vascular accident CVA. Which intervention should the nurse include in the plan of care during convalescence and rehabilitation? SATA a. Measure neurological vital signs every four hours b. Play classical music in Rome while client is awake c. Encourage family to participate in the client's care d. Place a bedside commode next to the bed

a. Measure neurological vital signs every four hours c. Encourage family to participate in the client's care d. Place a bedside commode next to the bed

88. A client is receiving a hypotonic solution for bladder irrigation and is at risk for dilutional hyponatremia the nurse should plan to observe for which common signs of hyponatremia? a. Mental status changes b. Brady cardia c. Irregular heartbeats d. Muscle spasms

a. Mental status changes

12. The nurse is caring for a client who develops signs and symptoms of septic shock following a urinary tract infection one week ago. The healthcare provider prescribed a sepsis protocol to be initiated. Which intervention is MOST important for the nurse to include in the plan of care? a. Monitor blood glucose level b. Keep head of bed raised 45, degrees c. Maintain strict intake and output d. Assess warmth of extremities

a. Monitor blood glucose level

142. The nurse notices that of male client is particularly delusion one afternoon he begins to pace the floor and appears to be losing control of himself which intervention is best for the nurse to implement? a. Move the client to a quiet place on the unit b. Encourage the client to use the punching bag c. Suggest to the client that he take a walk d. Use firmness and direct client to sit for a while

a. Move the client to a quiet place on the unit

85. While caring for a client postoperative dressing the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor before reporting this finding to the health care provider the nurse should note which of the clients Laboratory values? a. Neutrophil field count b. Creatinine level c. Serum Albumin d. Serum potassium and sodium levels

a. Neutrophil field count

148. The nurse is caring for a client with the sexually transmitted infections (STI) gonorrhea. The client eve a report of having pelvic inflammatory disease (PID) caused by the infection which response should the nurse provide? a. Notify that person with STI I reported to local health departments b. Encourage the client to verbalize emotions about the diagnosis c. Urge the client to have regular STI's training every two years d. Clarify that all STI's are transmitted through sexual intercourse

a. Notify that person with STI I reported to local health departments

4. Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a suprapubic catheter? a. Observe insertion site b. Palpate flank area c. Assess perineal area d. Measure abdominal girth

a. Observe insertion site

27. A client who was splashed with a chemical has both eyes covered with bandages. When assessing the clients with eating, which intervention should the nurse instruct the unlicensed assistive personnel (UAP) to implement? a. Orients the client to locate to the location of the food on the plate b. Provide with only fingers food c. Feed the client the entire meal d. Ask family to visit during mealtime to assist with feeding

a. Orients the client to locate to the location of the food on the plate

64. a client hospitalized with pleural effusion has a history of heart failure to reduce cardiac workload which intervention should the nurse include in the client's plan of care? a. Provide a bedside commode for toileting b. Teach to sleep in a side lying position c. Assist with ambulation in the hallway d. Encourage active range of motion exercises

a. Provide a bedside commode for toileting

133. A client who is recently diagnosed with type 2 diabetes mellitus DM received a prescription for metformin 50 mg PO twice daily what information should the nurse include and these clients teaching plan? SATA a. Recognize signs and symptoms of hypoglycemia b. Use sliding scale insulin for finger stick glucose elevations c. report persistent polyuria to the health care provider d. take an additional dose for signs of hyperglycemia e. take metformin with the morning and Evelyn meal

a. Recognize signs and symptoms of hypoglycemia c. report persistent polyuria to the health care provider e. take metformin with the morning and Evelyn meal

35. The client with Deep vein thrombosis DVT is receiving a continuous intravenous heparin infusion the clients now has Tarry black diarrhea and reports abdominal pain which action should the nurse implement? (Select all that is apply). a. Review last Partial thromboplastin time results b. Monitors stool for presence of blood c. Auscultate bowel sounds in all quadrants d. Prepare to administer Warfarin e. Assess characteristics of pain

a. Review last Partial thromboplastin time results b. Monitors stool for presence of blood e. Assess characteristics of pain

52. An order male client who was successfully treated for herpes zoster shingles with an anti-viral medication report that he is not experiencing pain on his trunk where the lesions we are located which action should the nurse take? a. Review the medication record to determine when the last analgesic was administered b. Contact health care provider about the need to resume the client's antiviral medication c. Teach the client about the importance of completing the full course of antiviral medications d. Reassure the client that the infection is resolved, and the pain should soon disappear

a. Review the medication record to determine when the last analgesic was administered

83. The nurse on the medical surgical unit is receiving a transfer report from the post-anesthesia care unit PACU nurse for a client who had an exploratory laparotomy the PACU nurse provides the following information 1000mL Norman Saline is infusing at 125mL/hour into the left wrist with 600mL remaining Ondansetron 4mg intravenously every 8 hours is prescribed for nausea the last dose was a minister at 0700 the client is currently describing pain at a level 2 on a 0 to 10 pain scale the client has a prescription for hydromorphone 1000mg intravenously every 2 hours as needed for pain the last dose was administered at 1000 which additional information should the PACU nurse report? a. Soft abdomen absent bowel sounds no bleeding undressing b. History of vomiting at home for three days prior to surgery c. Peripheral pushes peripheral pulses present with full range of motion of both legs d. Declining to take ice chips for complaints of dry mouth

a. Soft abdomen absent bowel sounds no bleeding undressing

96. The nurse is caring for all clients who has been diagnosed with renal calculi which pathological change occur as renal calculi move through the ureter? a. Uric acid increases b. Cystitis c. Polyuria d. Acute Renal Colic

a. Uric acid increases

34. Which information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine so control muscle spasms? a. Use cold and allergy medications only as directed by a health care provider b. Take this medication on an empty stomach c. Avoid using heat or ice to end injury muscles while taking this medication d. Discontinue all nonsteroidal anti-inflammatory medications

a. Use cold and allergy medications only as directed by a health care provider

150. The plan of care for a client who was recently diagnosed with breast cancer includes the nursing problem anxiety related to death secondary to the cancer diagnosis which expected outcome should the nurse identify for this client? a. Verbalize feelings when becoming anxious b. Cries openly when discussing diagnosis c. Describes acceptance of impending death d. Uses this coping mechanism effectively

a. Verbalize feelings when becoming anxious

91. the clam with a history of chronic obstructive pulmonary disease COPD is admitted for pneumonia vital signs include heart rate 122 beats per minute respiratory rate 28 bit per/minute and blood pressure 170 / 90 which assessment finding warrants the nurse warrant the most immediate intervention by the nurse? a. bilateral diffuse wheezing b. yellow expectorated sputum c. Temperature of 100.5 d. Shortness of breath on exertion

a. bilateral diffuse wheezing

113. A 6-year-old child who has surgery yesterday absolutely refuses to use the incentive spirometer which intervention should the nurse implement? a. blow out lights, blow bubbles and encourage child laughing b. Ask the mother to assist when it is time to use the spirometer c. Contract with the child to use spiral matter only after meals d. Allow child to choose when to perform incentive spirometry

a. blow out lights, blow bubbles and encourage child laughing

59. A post term infant is delivered with meconium-stained skin and cord. The newborn is substernal retractions grunting nasal flaring Surfactant is administered which statement should a nurse provide to the family about the purpose of Surfactant? a. it increases long compliance and decreases surface tension b. it increases pulmonary vascular resistance c. it increases pulmonary circulation and decreases blood viscosity d. it increases cerebral blood flow

a. it increases long compliance and decreases surface tension

86. A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant emlerocco (VRE) infection. Which nursing interventions should the nurse include in a plan of care? (Select all that apply) a. monitor the client's white blood cell count b. send wound drainage for culture and sensitivity c. Use standard precaution wear of mask d. Explain the procedure of a low bacterial diet e. Institute contact precaution for staff and visitor.

a. monitor the client's white blood cell count b. send wound drainage for culture and sensitivity e. Institute contact precaution for staff and visitor.

30. A client is admitted for an exacerbation of heart failure and is being treated with the diuretics for fluid volume excess. In planning nursing care which intervention should the nurse include? (SATA) a. weigh the client daily in the morning b. Monitor PTT, PT and INR lab values c. Teach the clients how to restrict dietary sodium d. Observe for evidence of hypokalemia e. Encourage or fluid intake of 3000 mL/day

a. weigh the client daily in the morning c. Teach the clients how to restrict dietary sodium d. Observe for evidence of hypokalemia

126. Following a house fire, an adult male is admitted to the emergency department with partial and full thickness burns. He used blanket to cover his head and face, but his skin is burned on the dorsal surfaces of both arms and hands and his anterior legs, Using the Rule of Nines to assess the extent of the client's burns, what percentage of burned body surface area should the nurse document? a. 50% b. 36% c. 9% d. 27%

b. 36%

152. At 11:30 the nurse assumes care of an adult client with diabetes mellitus who was admitted with an infected foot ulcer after reviewing a client electronic health record, which priority nursing action should the nurse implement? (Click on each chat top 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. Obtain antibiotic pick and through level b. Administer insulin per sliding scale c. Assess appearance a foot wound d. Initiate hourly urine output measurements

b. Administer insulin per sliding scale

116. After receiving a change of shift reports for clients on a medical surgical unit which activity should the nurse delegates YouTube to the practical nurse PN? a. Initiate teaching for client care after discharge b. Administer medications by piggyback infusion c. Evaluate and update plan of care for clients d. Receive a postoperative client and conduct the assessment

b. Administer medications by piggyback infusion

20. A client is unable to void following a procedure so the nurse obtains a prescription to perform a straight catheterization after inserting the catheter the nurse ask that the client has an immediate output of 500 mL of clear yellow urine which action should the nurse implement a. Remove the catheter and replace with an indwelling catheter b. Allow the bladder to empty completely or up to 1000 mL and mayor of urine c. Remove the catheter and pop it the client's bladder for residual distention d. Clamp the catheter for 30 minutes and then resume draining

b. Allow the bladder to empty completely or up to 1000 mL and mayor of urine

55. The nurse is triaging victims of an explosion from our housing area outside of town. The nurse should issue the black disaster tag to which client? a. A client who is at 40 weeks gestation and having contractions b. An older client with a head injury fixed pupils and absent vital sign c. A pre-teen child who has a bleeding lower left leg laceration d. A middle age with chest pain, dyspnea and diaphoresis

b. An older client with a head injury fixed pupils and absent vital sign

36. Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis? a. Immobilization of affected joints b. Application of heat and cold therapy c. Avoidance of foods containing purine d. Prevention through nutrition and exercise

b. Application of heat and cold therapy

130. Teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client states into the distance and appears to be concentrating on ??? other than the lesson the nurse is presenting. Which action should the nurse take? a. Gently touch the client then continue with the teaching b. Ask the client what he is thinking about at this time c. Leave the client alone so that he can grieve his illness d. Remind the client that a rescue inhaler might save his life

b. Ask the client what he is thinking about at this time

135. The client provides three positive responses two items on the CAGE (cut down, annoying, Guilty Eye-opener) questionnaire which interpretation should the nurse provide the client? a. All responses to the see a GE questionnaire must be positive to suggest alcohol dependence b. At least two positive responses I strongly suggestive of alcohol dependence c. The CAGE questionnaire is the two used to identify general substance abuse d. One positive response indicates the client should seek help with alcohol addiction

b. At least two positive responses I strongly suggestive of alcohol dependence

143. A mother brings her 2 month or infant to the clinic for the well-baby appointment the nurse obtains a history and conducts a physical assessment which finding requires the most immediate intervention? a. A positive Ortolani maneuver b. Bilateral retinal hemorrhages c. History of poor feeding and vomiting d. Mother describes baby as irritable

b. Bilateral retinal hemorrhages

154. A newly admitted client vomits into an emesis basin as seen in the picture. The nurse should consult with the health care provider before administering which of this prescribed medication? (Select all that apply) a. Nitroglycerin, an antianginal, to be given transdermally b. Clopidogrel, an antiplatelet agent, by mouth c. Ibuprofen, a non-steroid anti-inflammatory drug (NSAID) d. Enoxaparin a low-molecular weight heparin, subcutaneously, by mouth e. Furosemide, a loop diuretic, intravenously

b. Clopidogrel, an antiplatelet agent, by mouth d. Enoxaparin a low-molecular weight heparin, subcutaneously, by mouth

97. The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medication through the line the client reports tenderness when the nurse touches the arm above the site which finding should the nurse expect which will require immediate intervention? a. Circumferential skin irritation b. Cool sensation about the site c. Red streak tracking the vein d. A sluggish Blood return

b. Cool sensation about the site

111. When assessing a 6 month or infant the nurse determined that the anterior Fontana is bulgy in which situation with the with this finding be Most significant? a. Straining on stool b. Crying c. Vomiting d. Sitting Upright

b. Crying

144. A Client diagnosed with schizophrenia is prescribed the atypical antipsychotic Clozapine which intervention should the nurse included in the discharge teaching? a. Instruct the client to keep a record of daily Clozapine serum blood level b. Discuss the importance of checking the white blood count weekly c. Explain the importance of not eating cheese or drinking any wine d. Encourage the client to take the blood pressure twice a day

b. Discuss the importance of checking the white blood count weekly

131. A client who is obese reports severe pain and is unable to bear weight in the right ankle after making dietary changes 3 weeks ago for weight loss. The client's medical history includes hypertension, gouty arthritis, and cholecystitis. Which instruction should the nurse include in the discharge teaching? a. Avoid the consumption of wine, beer and coffee b. Encourage active range of motion to limit stiffness c. Use electric heating pads when pain is at its worst d. Substitute natural fruit juice for carbonated drinks

b. Encourage active range of motion to limit stiffness

69. A client is being treated for syndrome of inappropriate antidiuretic hormone SIADH on examination the client has a weight gain of 4.4 pounds (2kg) in 24 hours an elevated blood pressure which intervention should the nurse implement first? a. Measure ankle circumference b. Ensure client takes a diuretic every morning c. Monitor daily sodium intake d. Obtain serum creatinine levels daily

b. Ensure client takes a diuretic every morning

14. A client who is admitted to the intensive care unit (ICU) with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which Intervention should the nurse implement FIRST? a. Reorient often b. Evaluate swallow or Swollen Throat for S/SX c. Range of Motion d. Patch one eye

b. Evaluate swallow or Swollen Throat for S/SX

147. The nurse is interacting with a client who is diagnosed with postpartum depression which findings should the nurse document as objective signs of depression? a. Avoid eye contact b. Expresses suicidal thoughts c. Reports feeling sad d. Interact with a flat affect e. Have a disheveled appearance

b. Expresses suicidal thoughts c. Reports feeling sad

146. A woman with an anxiety disorder called her Obstetricians' office and tells the nurse of increase anxiety since the normal vagina delivery of her son three weeks ago since she's breastfeeding, she stopped taking her anti-anxiety medications, but thinks she may need to start taking them again because of her increased anxiety what response is best for the nurse to provide this woman? a. Encourage her to use stress relieving alternatives such as deep breathing exercises b. Inform her that some anti-anxiety medications are safe to take while breastfeeding c. Explain that anxiety is a normal response to the mother of a three-week-old d. Describe the transmission of drugs to the infant through breast milk

b. Inform her that some anti-anxiety medications are safe to take while breastfeeding

13. A client with the history of adrenal insufficiency is admitted to the intensive care unit with an acute adrenal crisis. The client is complaining of nausea and joint pain. Vital signs are: temperature 102 F (38.9 C), heart rate 138 beats/Min, BP 80/60 mmHg. Which intervention should the nurse implement FIRST? a. Cover client with cooling blanket b. Infuse intravenous fluid bolus c. Obtain an analgesic prescription d. Administer PRN oral antipyretic

b. Infuse intravenous fluid bolus

46. The client who has emphysema and recently experienced a stroke received a prescription for a metered-dose inhaler with a spacer device. The client asked the nurse if using the spacer is necessary what information should the nurse provide? a. It allows the medication to slowly enter the lungs b. It increases the effectiveness of the medication c. It prevents mouth infection went on inhaler is used d. It allows time to inhale the entire dispense dose

b. It increases the effectiveness of the medication

125. The nurse is auscultating the client heart sound which description should the nurse use to document this sound please listen to the audio a. S1 S2 S3 b. Murmur c. Pericardial friction rub d. S1 S2

b. Murmur

9. A client is admitted to the intensive care unit (ICU) with spinal cord injury (SCI) following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care? a. Nurse Care manager b. Neurology unit supervisor c. Adult nurse practitioner d. Risk management nurse

b. Neurology unit supervisor

61. The nurse finds a client at 33 weeks gestation in cardiac arrest. Which adaptation to cardiopulmonary resuscitation CPR should the nurse implement? a. Give continuous compression with a ventilation ratio at 20:3 b. Position of firm wedge to support pelvis and thorax at 30-degree tilt c. Apply less compression force to reduce aspiration d. Apply oxygen by mask after opening the airway

b. Position of firm wedge to support pelvis and thorax at 30-degree tilt

123. The nurse provides teaching about a scheduled procedure to a male client who was admitted for diagnostic testing to determine the extent of metastasis of his cancer an hour later the client asks the nurse for information about the scheduled procedure what action should the nurse implement? a. Reassure the client that what are the outcome he'll be able to cope with the results b. Repeat the client's teaching and leave written instructions for the client c. Remind the client of the instructions that were provided an hour ago d. Encourage the client to take deep breaths and to avoid thinking negative thoughts

b. Repeat the client's teaching and leave written instructions for the client

118. A client with Neisseria meningitidis calls the nurses station to report severe headache and vomiting. The unlicensed assistive personnel UAP approaches the room to provide an emphasis basin and is stopped by the nurse which action should the nurse take? a. Reminder UAP to apply fitted respirator mask before entering the client's room b. Review the name for the UAP to wear a face mask while in close contact with the client c. Instruct the UAP to notify the nurse for any changes in the client services d. Assign the UAP to provide care for another client and assume full care of the client

b. Review the name for the UAP to wear a face mask while in close contact with the client

65. two hours after abdominal repair a client remains sedated and mechanically ventilated in the post anesthesia care unit PACU which assessment finding warrants immediate intervention by the nurse? a. Pupils that have a sludgy reaction to light b. Systolic blood pressure less than 90 mmHg c. Palpable regular pause rate of 58 beats/minute d. No spontaneous respirations while ventilated

b. Systolic blood pressure less than 90 mmHg

141. An unlicensed assistive personnel UAP informs the nurse who is giving medication that a female client is crying the. The Client was just informed that she has a malignant tumor. Which action should the nurse implement first? a. Ask other nurse to finish giving medication and attend to the client immediately b. Tell the client that the nurse will be back to talk to her after medication is given c. Provide the client with a PRN undo anxiety medication and allow privacy for her to grieve d. instructor UAP to notify the client spiritual advisor for her needs for counseling

b. Tell the client that the nurse will be back to talk to her after medication is given

5. An older adult client with a history of type 2 diabetes mellitus is seen in the community health clinic for an annual physical examination. Which nursing actions should be included in assessing for long-term complication of diabetes? (SATA) a. Obtain urine specimen to assess for albumin b. Test lower extremities for changes in sensation c. Obtain venous sample for liver enzymes d. Palpate pedal pulses and foot temperature e. Auscultate for adventitious breath sounds

b. Test lower extremities for changes in sensation d. Palpate pedal pulses and foot temperature

153. The nurse Observes an Unlicensed assistive personnel began to provide oral care to an unresponsive client who is a risk for aspiration as seen in the picture which instructions should the nurse provide the UAP? (Select all the apply) a. Apply lubricant on the toothette b. Turn the client's head to the side c. Elevate the head of bed to semi fowlers d. Remove the gloved finger from the mouth e. flex the client's neck towards

b. Turn the client's head to the side c. Elevate the head of bed to semi fowlers

76. Which environmental factor is most significant when planning care for a client with osteomalacial? a. Stimulating sounds and activities b. adequate sunlight c. Cool moist air d. Quiet calm surrounding

b. adequate sunlight

87. the client subjective data include data includes dysuria, urgency, and urinary frequency what action should the nurse implement Next? a. pop it the suprapubic region b. collect a clean catch specimen c. inquire how about recent sexual activities d. Instruct to wipe from front talk back

b. collect a clean catch specimen

78. A male client is admitted for the removal of an internal fixation device that was inserted for a fracture ankle during the client admission history he tells the nurse that he recently received vancomycin for MRSA. Which action should the nurse take? (Select all that is apply) a. home health care provider for linezolid b. continue to monitor the client for signs of an infection c. place the client on contact transmission precaution d. Obtain a spectrum specimen for culture and sensitivity e. Collect multiple site screening culture for MRSA

b. continue to monitor the client for signs of an infection c. place the client on contact transmission precaution

89. An 18 year old female client is seen other health department for treatment of condylomata acuminata perineal warts caused by the human papillomavirus (HPV). Which intervention should the nurse implement? a. recommend the use of latex condoms to prevent HPV transmission b. reinforce the importance of annuals pap smear c. tell the client that the vaccine for HPV is not indicated d. inform the client that what do not return following cryotherapy

b. reinforce the importance of annuals pap smear

98. A male client with heart failure becomes short of breath anxious and has audible wheezing with pink frothy sputum. the nurse set the client upright and provides oxygen nasal cannula the nurse receives a prescription to administer a one-time dose of morphine sulfate intravenously what action should the nurse take? a. Consult with the charge nurse regarding the morphine prescription b. Review the need for the prescription with the health care provider c. Administer dose of morphine sulfate as prescribed d. withhold the morphine until the client dyspnea resolved

c. Administer dose of morphine sulfate as prescribed

122. The nurse enters a client's room to administer oral medication and finds an on unlicensed assistive personnel UAP providing personal care to the client whose condition has obviously deteriorated the client is lying in a supine position and is weak pale and diaphoretic what is the priority nursing action? a. Explain to the UAP that changes in the client's condition should be reported immediately b. Ask the UAP to position the client so the oral medication can be administered c. Advise the UAP to stop providing care so the nurse can assess the client's condition d. Determine why the UAP did not notify the nurse of the change in the patient's condition

c. Advise the UAP to stop providing care so the nurse can assess the client's condition

33. The nurse enters the room of a client with Parkinson's disease who is taking Carbidopa-Levodopa. The client is arising slowly from the chair why the unlicensed assistive personnel stand next to the chair. What action should the nurse take? a. Offer a PRN analgesic to reduce painful movements b. Tell the UAP to assist the client in moving more quickly c. Affirm that the client should arise slowly from the chair d. Demonstrate how to help the client move more efficiently

c. Affirm that the client should arise slowly from the chair

43. The nurse brings an oral medication prescribed to be given daily to a male client who tells the nurse that he will take his medication later. Which action should the nurse implement? a. Leave the medication on the bedside table with a fresh glass of water b. Inform the client that his medication is scheduled to be taken now c. Agreed upon a time to return the client's room with the medication d. Notes the clients not compliance with medications in the nurse's notes

c. Agreed upon a time to return the client's room with the medication

22. In planning care for a client with early-stage Alzheimer's disease, the nurse established the nursing problem of risk for injury related to impaired judgement. Which intervention is MOST important for the nurse to include in this client's plan of care? a. How far the client frequent reassurance that he/she will be safe b. Engaged the client in regularly scheduled activities during the day c. Arrange the client's environment so the client can move about freely d. Assign a UAP to provide the client with total personal care

c. Arrange the client's environment so the client can move about freely

23. In planning care for a client with early stage or Alzheimer's disease that the nurse establishes the nursing problem of risk for injury related to impaired judgement which intervention is MOST important for the nurse to include in the pitch in the clients plan of care a. Offer the client frequent reassurance that he/she will be safe b. engage the client in regularly scheduled activities during the day c. Arrange the client's environment so the client can move about freely d. Assign a UAP to provide the client with total personal care

c. Arrange the client's environment so the client can move about freely

155. A series of stool guaiac tests to prescribed for a client receiving anticoagulant therapy. While obtaining the first specimen, the nurse observes that the client's stool is clay colored. Which action should the nurse take? a. Report stool's appearance to the healthcare provider b. Implement contact isolation precautions c. Assess for signs of bleeding from other orifices d. Increase the frequency of guaiac testing

c. Assess for signs of bleeding from other orifices

56. What nursing intervention is particularly indicated for the second stage of Labor? a. Monitoring effects of oxytocin ministration to help achieve cervical dilation b. Assessing the fetal heart rate and pattern for signs of fetal distress c. Assisting the client to push effectively so the explosion of the fetus can be achieved d. Providing pain medication to increase the client's tolerance of Labor pains

c. Assisting the client to push effectively so the explosion of the fetus can be achieved

90. the nurse is caring for a client with chronic obstructive pulmonary disease COPD who uses oxygen at 2L/minutes per nasal cannula continuously the nurse oxide that the client is having increased shortness of breath with respiration at 23 beats/minute which action should the nurse implement FIRST a. Notify the health care provider about the clients destress b. Access the delivery mechanism to the oxygen tank tubing and canula c. Auscultate the client's bilateral lung sounds and oxygen saturation d. Determine if the client is experiencing any anxiety

c. Auscultate the client's bilateral lung sounds and oxygen saturation

60. A postpartum client who is breast feeding develops breast engorgement. What is the best recommendation for the nurse to provide this client? a. Take a prescribed analgesic and expose breast to air b. Place warm packs on both of the breast c. Avoid stimulation of the breast and wear a tight bra d. Express a small amount of breast milk by hand

c. Avoid stimulation of the breast and wear a tight bra

A client presents to the emergency department (ED) with complaints abdominal pain. The nurse observes the client's right cheek and eye bruised and suspects possible domestic violence. Which approach is best the nurse to use when interviewing the client? a. Share personal values to put the at ease b. Ask questions in a vague, non-specific format c. Begin with questions that are less sensitive in nature d. Get the most difficult questions over with fist

c. Begin with questions that are less sensitive in nature

95. An older client is admitted with pneumonia and the health care provider prescribed penicillin G potassium intravenously which assessment finding increases the risk of adverse reaction in this client? a. Spam culture result at streptococcus pneumoniae b. Previous treatment with penicillin for pneumonia c. Documented allergy to sulfa drugs d. Daily use of spironolactone for hypertension

c. Documented allergy to sulfa drugs

29. To prevent infection by autocontamination during the acute phase of recovery from multiple burns which intervention is most important for the nurse to Implement? a. word sharing equipment between multiple clients b. Implement protective isolation c. Dress each wound separately d. Used gown, mask and gloves with dressing change

c. Dress each wound separately

138. The nurse notes that a client with depression has been more withdrawn and more noncommunicative during the past two weeks which intervention is most important to include in the updated plan of care for these clients? a. Encourage the client to participate in Group activities b. Schedule a daily conference with the social worker c. Encourage the client a non-threatening conversation d. Encourage the client's family to visit more often

c. Encourage the client a non-threatening conversation

26. A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight has increasingly peripheral edema and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to Implement? a. Evaluate patency of the AV graft for assumptions of hemodialysis b. Recommend the use of support stockings to enhance venous return c. Ensure the client receives frequent small meals containing complete proteins d. Instruct the client to continue to follow the prescribed rigid flow with restrictions and amounts

c. Ensure the client receives frequent small meals containing complete proteins

40. School age child with chronic renal failure receive a prescription from the health care provider for Losartan. Which action should the nurse implement prior to administer the medication? a. Access strength range of motion b. Determine the time of the last meal c. Evaluate the ability to swallow medication d. Examine the color of the sclera

c. Evaluate the ability to swallow medication

70. A male client with cirrhosis and severe ascites, who is scheduled for a paracentesis tells the nurse that he is in pain and feels short of breath so he wants to reschedule the procedure how should the nurse respond? a. Advise the client that the procedure will help diagnosis the cause of his symptoms b. Encourage the client to verbalize his fears about the outcome of the procedure c. Explain to the client that the paracentesis will provide relief from his discomfort d. Offer to notify the healthcare provider of his desire to reschedule the procedure

c. Explain to the client that the paracentesis will provide relief from his discomfort

57. A client in labor begins bleeding profusely from the vagina which findings should the nurse report to the health care provider? a. Pain in lower quadrant and oliguria b. Sharp fundal pain and uterine tenderness c. Increase in pulse and fetal rate reactivity d. Mild discomfort and elevated blood pressure

c. Increase in pulse and fetal rate reactivity

A client who received an open reduction and internal fixation (ORIF) of the right femur after experiencing a fall home experiences a sudden onset of increasing confusion and agitation. When reporting to the healthcare using SBAR communication, which information should the nurse provide FIRST a. Currently prescribed medication b. Client's healthcare power of attorney c. Increasing confusion of the client d. Fall at home as reason for admission

c. Increasing confusion of the client

82. A client with cancer develops tumor lysis syndrome following chemotherapy which nursing action has the highest priority in responding to the symptoms of this syndrome? a. Encourage the client to verbalize anxiety and grief b. Instruct the client to take energetic on a regular schedule c. Maintain intravenous therapy d. Identify potential sources of infection

c. Maintain intravenous therapy

117. A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquid. The client is pain free. Which intervention should the nurse include in the client's plan of care? a. Administer daily vitamin supplements b. Encourage positive accolades for dietary adherence c. Maintain the client on our NPO status d. Ask if the client is over hydrating to feel satiated

c. Maintain the client on our NPO status

11. The nurse is caring for a client admitted a spontaneous pneumothorax. Which actions should the nurse include in this client's plan of care? a. Give bronchodilator by endotracheal route b. Schedule client for hyperbaric oxygen therapy (HBOT) c. Monitor bubbling of chest unit water-seal chamber d. Administer antibiotics via long-line IV catheter

c. Monitor bubbling of chest unit water-seal chamber

94. An adult male is brought to the emergency department by ambulance following a motorcycle accident he was not wearing a helmet and he presents with periorbital bruising and bloody drainage from both eyes which assessment my finding warrants immediate intervention by the nurse? a. Diminished bilateral breast sounds b. Rib pain with deep inspiration c. Nausea with projectile vomiting d. Rebound abdominal tenderness Sheep

c. Nausea with projectile vomiting

38. Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea? a. Sausage, poached eggs, and milk b. Granola, Strawberries, and Tea c. Oatmeal banana and herbal tea d. Butter whole wheat toast and coffee

c. Oatmeal banana and herbal tea

8. The nurse is discussing mitigation at a disaster preparedness committee meeting. Which activity should the nurse suggest to enhance mitigation? a. Discuss some ways to ensure safety in the home during a disaster b. Design requirement for an incident Command Center c. Provide a community disaster preparedness meeting d. Participate as an active member of the local American Red Cross

c. Provide a community disaster preparedness meeting

139. A client is admitted to the mental health unit for feelings of depression secondary 2 or positive HIV report to provide a safe milieu for this client which action should the nurse take? a. Take the clients cellular telephone and provide a telephone in the room b. Ensure that prescribed medications are kept in a safe place in the room c. Remove soft drinks cans from the nurse's desk and patient's lounge d. Replace paper trash bags we plastic biohazard bags

c. Remove soft drinks cans from the nurse's desk and patient's lounge

63. The nurse is preparing a four-day old infant with a serum bilirubin level of 19 mg/dL (325 micromol/L) for discharge from the hospital when teaching the parents about home phototherapy which instruction should the nurse include in the discharge teaching plan? a. Cover with a receiving blanket b. Feed the infant every four hours c. Reposition the infant every two hours d. Perform diaper changes under the light

c. Reposition the infant every two hours

124. The nurse is preparing to send a client to that cardiac catheterization lab for elective cardioversion which intervention should the nurse implement before the client leaves the medical unit? a. Confirm monitor reading in synchronous mode b. document that the client has remained NPO c. Secure cardioversion pads on the client's chest d. Notify the rapid response team of the transfer

c. Secure cardioversion pads on the client's chest

106. A 6-month-old infant is admitted to the hospital with diarrhea the parent is feeding the infant a bottle of tap water and tells the nurse that the baby has taken 3 ounces bottles of water in the last four hours which laboratory finding is most important for the nurse to monitor a. Creatine clearance b. White blood cell count c. Serum potassium d. Serum sodium levels

c. Serum potassium

53. An older client is admitted with flu volume deficit and dehydration which assessment finding is the best indicator for hydration that the nurse should report to the health care provider? a. Systolic blood pressure decreases 10 points when standing b. The client denies being thirsty c. Skin tenting occurs when the client's forearm is pinched d. Urine specific gravity is 1.040

c. Skin tenting occurs when the client's forearm is pinched

137. A male client on the psychiatric unit is making sexual advances towards a female nurse which action should this nurse implement first? a. Request an immediate team meeting to discuss the inappropriate behavior b. Discuss with the client why he is making sexual advances towards the nurse c. Tell the client in a matter-of-fact manner to stop the sexual advances d. Document as specifically as possible the client's behavior in the nurses' notes

c. Tell the client in a matter-of-fact manner to stop the sexual advances

136. The client who is a veteran comes to the emergency department appearing tense, anxious, and having difficulty concentrating on the questions the nurse is asking during the health history which client statement is most important for the nurse to document? a. "I can't forgive myself for leaving my body behind" b. "I'm having a lot of trouble sleeping most nights" c. "I worry I will get fired because I call in sick so often" d. "I can't seem to shake out of these helpless feelings"

d. "I can't seem to shake out of these helpless feelings"

58. In determining the one-minute Apgar score of a neonate the nurse assesses a heart rate of 120 beats per minute and 44 respiratory beat per minutes the new baby has a flaccid muscle tone with slight flexion and slight resistance to straightening, a loud cry with stimulation and acrocyanosis color what is the current Apgar score for this neonate? a. 9 b. 10 c. 7 d. 8

d. 8

128. The client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which intervention should the provide to address the client's problem? a. Ask for a consultation with a psychologist b. Contact a hospice nurse for an evaluation c. Form an interdisciplinary team for evaluation d. Arrange an appointment with pain specialist

d. Arrange an appointment with pain specialist

81. The client which cancer is admitted to the oncology unit and tells the nurse that he is in the hospital for palliative care measures, the nurse notes that the client admission prescription include radiation therapy what action should the nurse implement a. Explain that palliative care measures can be provided at home b. Notify the radiation department to withhold the treatments for now c. Determine if the client wishes to cancel further radiation treatment d. Ask the client about his expected goals for this hospitalization

d. Ask the client about his expected goals for this hospitalization

3. A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states that it still takes at least two hours to fall asleep at night. Which action should the nurse implement? a. Determine the amount of weight the client has lost since increasing activity b. Encourage the client to exercise every day to eliminate bedtime wakefulness c. Advise the client that lifestyle changes often take several weeks to be effective d. Ask the client for a description of the exercise schedule that is being followed

d. Ask the client for a description of the exercise schedule that is being followed

80. Seven months after a foot injury an adult woman is diagnosed with neuropathic pain the client describes the pain as severe and burning and is unable to put weight on her foot she asks the nurse when the pain we finally go away how should the nurse respond? a. Explain that healing from injury can take many months b. Complete an assessment of the client functional ability c. Encourage the client to verbalize her fears about the pain d. Assist the client in developing goal of managing the pain

d. Assist the client in developing goal of managing the pain

6. The home health nurse is assessing a male client who has started peritoneal dialysis (PD) 5 days ago. Which assessment finding warrants immediate intervention by the nurse? a. Anorexia and poor intake of adequate dietary protein b. Arteriovenous (AV) graft surgical site pulsations c. Fingerstick blood glucose 12o mg/Dl (6.66 mmol/L) post exchange d. Cloudy dialysate output and rebound abdominal pain

d. Cloudy dialysate output and rebound abdominal pain

151. In performing an inspection of a client's fingernails, the nurse observes a suspected abnormality of the nails shape and characters the client has a history of chronic bronchitis which finding should the nurse confirm? a. Anonychia b. Onycholysis c. Koilonychias d. Clubbing

d. Clubbing

37. Which information is most important to include in the teaching plan for a client with who is discharged after a thyroidectomy for Graves' disease? a. Meticulous I care with artificial tears should be used daily b. The need to use more blankets at night or extra clothing should be reported c. A high fiber diet with Alec adequate fluid intake should be followed d. Daily hormone replacement will be needed for the rest of the client's life

d. Daily hormone replacement will be needed for the rest of the client's life

127. The nurse observes the practical nurse (PN) has positioned the client safety on the right arm behind the head for a scheduled echocardiogram. Which action should the nurse implement? a. Acknowledge that the PN has positioned the client safety and correctly b. Arrange for Unlicensed assistive personnel to assist the PN during the procedure c. Assume care of the client and assign the PN to the care of a different client d. Demonstrate to the PN how to position the client more effectively for the procedure

d. Demonstrate to the PN how to position the client more effectively for the procedure

39. The nurse is preparing to administer 1.6 mL of medication intramuscularly to a 4-month-old infant. Which action should the nurse include? a. Use a quick dark-like motion to inject into the dorsogluteal site b. Administer into the deltoid muscle why the parents hold the infant securely c. Select a 22 gauge 1 1/2 inches 3.8 cm needle for the intramuscular injection d. Divide the medication into two injections with volume under 1 mL

d. Divide the medication into two injections with volume under 1 mL

28. The nurse walked into a client's room and noticed bright red on the sheets and on the floor but IV pole which action should the nurse take FIRST? a. Apply direct pressure on the client IV site b. Notify the health care provider that the client appears to be bleeding c. Clean up the spill blood to reduce infection transmission d. Identify the source and amount of bleeding

d. Identify the source and amount of bleeding

7. What action should the school nurse implement to provide secondary prevention for school aged children? a. Prepare a presentation on how to prevent the spread of lice b. Collaborate with a science teacher to prepare a health lesson c. Observe a person with type 1 Diabetes self-administer a dose of insulin d. Initiate a hearing and vision screening program for first graders

d. Initiate a hearing and vision screening program for first graders

25. A male client with a fracture at the right femur has skeletal traction in place within waiting for surgery. When the client tells the nurse that he needs to go to the bathroom which intervention should the nurse implement? a. Release traction so client can use a bedside commode b. Log roll so deposable buels can be placed on the client c. Insert an indwelling urinary catheter d. Maintain traction while client uses a urinal

d. Maintain traction while client uses a urinal

42. The nurse plans to contact the health care provider regarding a client's need for a belt restraint. What information is most important to report the health care provider? a. Any special mattresses on the client's bed b. The presence and location of any pressure ulcers c. Current vital signs and oxygen saturation d. Measure already taking to maintain client safety

d. Measure already taking to maintain client safety

66. An older adult male with heart failure HF develops cardiac tamponade. after the health care provider performs pericardiocentesis. which intervention is most important for the nurse to implement? a. Determine if I Do Not resuscitate Document is in the medical record b. Discuss Hospice with the family as a possible option for the client c. Have IV fluids available for bolus infusion to increase cardiac output d. Monitor for recurrence of tamponade and cardiovascular collapse

d. Monitor for recurrence of tamponade and cardiovascular collapse

77. An Adult client with a broken femur is transferred for the medical surgical unit to await surgical internal fixation after the application of an external fixation device the stabilize the leg an hour after an opioid analgesic was Administered, the client reports muscle spasms and pain at the fraction site while waiting for the client to be transported to surgery which action should the nurse implement? a. Check client most recent electrolyte values b. reduce the weight on the traction device c. administer PRN dose of a muscle relaxant d. Observe for signs of deep vein thrombosis

d. Observe for signs of deep vein thrombosis

50. An older male client arrived at the clinic complaining that his bladder always feels full he complains of weak urine flow, Frequent dribbling after avoiding and increasing nocturia with difficulty initiating his urine strain which action should the nurse implement a. Advise the client to maintain avoiding dairy for one week b. Instruct the effective techniques to cleanse the glands penis c. Obtain a urine specimen for culture and sensitivity d. Palpate the client suprapubic area for distention.

d. Palpate the client suprapubic area for distention.

73. A client with a history asks systemic lupus erythematous receive a prescription for hydroxychloroquine during a follow up visit which intervention should the nurse take next? a. Obtain a complete blood count b. Apply electrocardiogram leads c. Collect a urine specimen d. Perform an ophthalmic exam

d. Perform an ophthalmic exam

84. The nurse places a client in a supine position on the operating table for a domino surgery that is expected to extend beyond two hours which measure is most important for the nurse to provide? a. Use tape to measure the client's extremity in position b. Prevent exposing the clients unnecessarily c. Provide warm blankets and a pillow d. Place protective padding Add all those pressure points

d. Place protective padding Add all those pressure points

134. A male clients report to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now his flush he reports a history of stable angina but denies experiencing any current or recent chest pain which action should the nurse take? a. Advise the client to place one nitroglycerin tablets under his tongue as a precaution b. Instruct the client to increase his intake of oral fluids onto the skin flushing is relieved c. Tell the client to have someone bring him to an emergency department immediately d. Reassure the client that skin flushing is a common side effect of the medication

d. Reassure the client that skin flushing is a common side effect of the medication

45. The charge nurse observes a new nurse preparing to insert an intravenous IV catheter. The new nurse gathers equipment, including an intravenous catheter insertion kit and a 4X4 Gauze dressing to apply over the insertion site. which action should the charge nurse take? a. Obtain a smaller 2X2 gauze dressing to apply over the site b. Remain nearby in the room during the IV insertion procedure c. Offer to demonstrate the IV insertion procedure to the nurse d. Remind the nurse to use a transparent dressing over the site

d. Remind the nurse to use a transparent dressing over the site

47. A client with Atrial fibrillation received a new prescription for dabigatran etexilate. Which instruction it's important for the nurse to emphasize when teaching the client about this medication? a. Monitor your blood pressure regularly b. Check your pause rate every day c. Elevates your feet if swelling occur d. Report unusual bruising and bleeding

d. Report unusual bruising and bleeding

112. A 4-year-old child is brought to the emergency department by appearing after being bitten by a non-venomous snake the child is anxious and fearful with a heart rate of 120 beats/minute my respiratory respiration of 42 beats per minute the nurse anticipates the child developing which acid base imbalance? a. Respiratory acidosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory alkalosis

d. Respiratory alkalosis

15. After successful resuscitation, a client is given propranolol and transferred to Intensive Coronary Care Unit (ICCU). On admission, magnesium sulfate 4 grams IV in 250 mL D5W at one gram/hour. Which assessment findings require immediate intervention by the nurse? a. Dark amber urine draining per indwelling catheter with 40 mL per hour b. Sinus rhythm at 72 beats/minute and peripheral blood pressure of 99/62 mm Hg c. Serum calcium of 9.0 mg/dL (2.2 mmol/L SI) and magnesium of 1.8 mg/dL or Eq/L (0.74 mmol/L S1) d. Respiratory rate of 10 breaths per minute and pulse oximetry of 90%

d. Respiratory rate of 10 breaths per minute and pulse oximetry of 90%

17. A male client with right-sided weakness calls for assistance with ambulating to the bathroom. What action should the nurse implement? a. Give the client a cane to hold in the right hand b. Bring a bedside commode to the client c. Walk directly behind the client to prevent a fall d. Stand on the client's right side as he walks

d. Stand on the client's right side as he walks

18. The nurse observes unlicensed assistive personnel (UAP) who is preparing to provide care for a client who requires contact precautions. The UAP has applied a gown and gloves and secure the tops of the gloves over the gown sleeves what action should the nurse take space a. help the UAP reposition the gown sleeve over the glove edge b. assist the UAP with application of a face mask or shield c. reminder UAP to wash hands frequently while in the room d. confirm that the gown is tight securely at the neck and waist

d. confirm that the gown is tight securely at the neck and waist

92. During orientation a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class as seen in the video after the demonstration the supervising nurse expresses concern that the demonstrated procedure increase in clients risk for which problem? a. impaired gas exchange b. Altered comfort c. any sensitive airway clearance d. infection

d. infection

120. Nurses working on a surgical unit are concerned about a physician's treatment of clients during invasive procedure such as dressing changes and insertion IV lines clients are often crying during the procedure and the physician is usually unconcerned or annoyed by the client's response. To resolve this problem which action should the nurse take? (Arrange from the first action on top to last on the bottom) • Contact hospital chief of medical services • File a formal complaint with the state medical board • document concerns and report them to the charge nurse • Talk to the physician as a group in a non-confrontational manner • Submit a written report to the director of nursing

• Talk to the physician as a group in a non-confrontational manner • document concerns and report them to the charge nurse • Submit a written report to the director of nursing • Contact hospital chief of medical services • File a formal complaint with the state medical board

The nurse using a straight urinary catheter kit to collect a sterile urine specimen from a female client. After positioning and prepping the client, rank the action in the sequence they should be implemented (place the first action at the top with the last action at the bottom) Open the sterile catheter kit close to the client's perineum Place distal end of the catheter in sterile specimen cup and insert catheter into meatus Cleanse the urinary meatus using the solution, swabs, and forceps provided Don sterile gloves and prepare the sterile field

Open the sterile catheter kit close to the client's perineum Don sterile gloves and prepare the sterile field Cleanse the urinary meatus using the solution, swabs, and forceps provided Place distal end of the catheter in sterile specimen cup and insert catheter into meatus