HESI Study Quests (from Evolve website)

28.A client in an ambulatory clinic describes awaking in the middle of the night with difficulty breathing and shortness of breath related to paroxysmal nocturnal dyspnea. Which underlying condition should the registered nurse (RN) identify in the client's history? A. Chronic bronchitis. B. Gastroesophageal reflux disease (GERD). C. Heart failure (HF). D. Chronic pancreatitis.

ANS: C Paroxysmal nocturnal dyspnea is secondary to fluid overload associated with HF (C). Shortness of breath (SOB) can be experienced with chronic bronchitis (A) at any time of the day, where as acid reflux from GERD (B) can spill over into the trachea and cause SOB. Chronic pancreatitis (D) is painful which can cause splinting and difficult breathing.

29.A female client calls the clinic and talks with the registered nurse (RN) to inquire about a possible reaction after taking amoxicillin for 5 days. She reports having vaginal discomfort, itching, and a white discharge. The RN should discuss which action with the client? A. Discontinue the antibiotic because original symptoms have subsided. B. Continue taking medication until finished until the symptoms subside. C. Consult with healthcare provider about another treatment for this effect. D. Use an over-the-counter (OTC) vaginal wash to flush out the secretions.

ANS: C Superinfections with normal flora yeast may occur during antibiotic therapy. If suspected, the new onset of findings should be reported to the healthcare provider for another prescribed treatment (C). Antibiotics should not be discontinued unless authorized by the healthcare provider (A). Continued use of the antibiotic may worsen the vaginal symptoms (B). Recommending an OTC remedy is not the correct action at this time (D).

18.The registered nurse (RN) is making early morning rounds on a group of clients when a client begins exhibiting symptoms of an acute asthma attack. The RN administers a PRN prescription for a Beta 2 receptor agonist agent. Which client response should the RN expect? (Select all that apply.) A. Tachycardia. B. Increased blood pressure. C. Rapid resolution of wheezing. D. Improved pulse oximetry values. E. Reduce fever airway inflammation.

ANS: C, D (C and D) are correct. Beta 2 receptor agonist agents provide immediate return of airflow and resolve wheezing (C) and improve oxygenation (D). (A and B) are side effects. (E) is not an expect response.

33.The registered nurse (RN) is teaching a client who is newly diagnosed with emphysema how to perform pursed lip breathing. What is the primary reason for teaching the client this method of breathing? A. Decreases respiratory rate. B. Increases O2 saturation throughout the body. C. Conserves energy while ambulating. D. Promotes CO2 elimination.

ANS: D Pursed lip breathing helps eliminate CO2 (D) by increasing positive pressure within the alveoli which makes it easier to expel air from the lungs. (A, B and C) do not explain the reason for using pursed lip breathing.

25.A male client is admitted after falling from his bed. The healthcare provider (HCP) tells the family that he has an incomplete fracture of the humerus. The family ask the RN what this means. Which type of fracture should the RN explain from these findings? A. Straignt fracture line that is also a simple, closed fracture. B. Nondisplaced fracture line that wraps around the bone. C. A complete fracture that also punctures the skin. D. A fracture that bends or splinters part of the bone.

ANS: D An incomplete fracture (D) occurs through part of the thickness of the bone. A linear (A) and a spiral fracture (B) describe the direction of the fracture line. An open fracture (C) is a compound fracture that breaks through the skin.

39.The registered nurse (RN) is caring for an older client who has been bedridden for two weeks. Which assessment findings indicate to the RN that the client is developing a complication related to immobility? A. Decreased pedal pulses. B. Edema in upper extremities. C. Loss of appetite for food. D. Stiffness in right ankle joint.

ANS: D Stiffness in joints is an early sign of contractures and muscle atrophy (D) related to inactivity and immobility. Decreased pedal pulses (A), upper extremity edema (B) and a loss of appetite (C) are not directly related to immobility.

46.Twenty four hours after a client returns from surgical gastric bypass, the registered nurse (RN) observes large amounts of blood in the nasogastric tube (NGT) cannister. Which assessment finding should the RN report as early signs of hypovolemic shock? A. Faint pedal pulses. B. Decrease in blood pressure. C. Lethargy. D. Slow breathing.

ANS: C Changes in the level of consciousness occur in the early stages of shock which decreases perfusion to the brain which is manifested as lethargy (C). The respiratory rate increases, not (D). (A and B) are late signs of hypovolemic shock due to cardiac compensatory measures.

1.The registered nurse (RN) uses the mini-mental state examination (MMSE) when assessing a client for admission to an assisted living facility. Which finding is the RN assessing when requesting the client to count by 7s? A. Recall of information. B. Orientation to surroundings. C. Attention to details. D. Ability to follow complex commands.

ANS: C Counting by 7s evaulates the ability to do simple calculations and is specific to the client's attention to detail (C). (A, B, and D) are additional parts of the MMSE that evaluate orientation and cognitive function.

42.The registered nurse (RN) is caring for an Asian client who refuses to make eye contact during conversations. How should the RN assess this client's response? A. The client cannot understand the nurse. B. The client is uncomfortable with the nurse. C. The client is treating the nurse with respect. D. The client is purposefully disrespecting the nurse.

ANS: C In some Asian cultures, it is not appropriate to look a person of authority in the eyes, so the client is being respectful by looking down while speaking with the nurse (C). (A, B, and D) does not reflect behaviors common to the Asian culture.

50.The registered nurse (RN) recognizes which client group is at the greatest risk for developing a urinary tract infection (UTI)? (Rank from highest risk to lowest risk.) -Older females. -School-age female. -Older males. -Adolescent males.

ANS: 1. Older females. 2. School-age female. 3. Older males. 4. Adolescent males. Vesicoureteral reflux, neuromuscular conditions, like Parkinson's disease, previous brain attacks, or the use of anticholinergic medications can all cause incomplete bladder emptying which can create bacterial overgrowth. Fecal and urinary incontinence contributes to poor perineal hygiene and bacterial growth. Hypoestrogenism and alkalotic urine are other age-related factors that put older women at the highest risk for UTIs. School age girls (6 to 12 years) are at risk for UTIs due to a higher prevalence to taking baths instead of showers, but these risks can be controlled in this population as well as hypoestrogenism and alkalotic urine. Older men are at risk due to possible obstruction of the bladder due to benign prostatic hypertrophy (BPH). Adolescent males (12 to 19 years) are the lowest at risk for a UTI.

23.The registered nurse (RN) is assisting the healthcare provider (HCP) with the removal of a chest tube. Which intervention has the highest priority and should be anticipated by the RN after the removal of the chest tube? A. Prepare the client for chest x-ray at the bedside. B. Review arterial blood gases after removal. C. Elevate the head of bed to 45 degrees. D. Assist with disassembling the drainage system.

ANS: A A chest x-ray (A) should be performed immediately after the procedure to ensure lung expansion has been maintained after removal of the chest tube. (B) provides additional data after removal of the CT. (C) may assist the client to breath easily, but the priority after chest tube removal is to ensure that the procedure was successful. The entire system, including the chest tube is discarded and not taken apart (D).

7.A client who is uses ipratropium reports having nausea, blurred vision, headaches, and insomnia after using the inhaler. Which action should the registered nurse (RN) implement first? A. Withhold medication and report symptoms and vital signs to healthcare provider. B. Give PRN medication for nausea and vomiting and evaluate client in 30 minutes. C. Reassure client that the ipratropium given will alleviate the symptoms. D. Delay administration of ipratropium until next maintenance medication is scheduled.

ANS: A Headache, nausea, blurred vision and insomnia are symptoms of excessive use of ipratropium, so withholding the medication (A) until the healthcare provider is notified should be initiated to maintain client safety. If the symptoms continue and are not addressed immediately, then (B, C, and D) may place the client in imminent danger.

45.While caring for a client who has esophageal varices, which nursing intervention is most important for the registered nurse (RN) to implement? A. Monitor infusing IV fluids and any replacement blood products. B. Prepare for esophagogastroduodenoscopy (EGD). C. Maintain the client on strict bedrest. D. Insert a nasogastric tube (NGT) for intermittent suction.

ANS: A Maintaining hemodynamic stability in a client with esophageal varicescan precipitatea life-threatening crisis if esophageal varies leak or rupture and can result in hemorrhage. The priority is assessing and monitoring infusions of IV fluids and any replacement blood products (A). The healthcare provider should be present during(B and D) in the event the client's esophageal varies rupture and bleed profusely. Bedrest (C) is not a priority at this time.

12.The registered nurse (RN) is caring for a client with peptic ulcer disease (PUD). What assessment should the RN identify and document that is consistent with PUD? (Select all that apply). A. Hematemesis. B. Gastric pain on an empty stomach. C. Colic-like pain with fatty food ingestion. D. intolerance of spicy foods. E. Diarrhea and stearrhea.

ANS: A, B, D (A, B and D) correct. Manifestations of PUD include hematemesis (A), gastric pain (B), and spicy food intolerance. (C) is consistent with cholecystitis (D). (E) is not consistent with PUD.

2.The registered nurse (RN) palpates a weak pedal pulse in the client's right foot. Which assessment findings should the RN document that are consistent with diminished peripheral circulation? (Select all that apply.) A. Diminished hair on legs. B. Bruising on extremities. C. Skin cool to touch. D. Capillary refill less than 3 seconds. E. Darkened skin on extremities.

ANS: A, C Diminished hair on the legs (A) and skin that is cool to touch (C) are symptoms of decreased arterial blood flow. (B, D, and E) are not indicators for impaired peripheral circulation.

11.A client is admitted for dehydration, weight loss, and a flat affect. After reviewing the client's history, the registered nurse (RN) discovers that the client's spouse died 2 weeks ago. Which nursing interventions should the RN implement to help the client begin the process of dealing with loss? (Select all that apply.) A. Establish trust by creating an safe atmosphere for sharing. B. Share personal stories about how other clients dealt with grief. C. Help the client identify ways to adapt lifestyle to accommodate loss. D. Assure the client that their grief will last a short period of time. E. Explore ways to assist the client to make new emotional investments.

ANS: A, C, E (A, C, and E) are correct, and these interventions aid the client in maneuvering through the stages of grieving and establishing a foundation to continue life. Assisting the client in finding a support group and sharing stories of other clients can be misconstrued as a violation of HIPPA rights of other clients (B). Each client deals with grief differently, so offering a time line for grieving (D) is not an expected outcome for this client and offers false reassurance.

5.A registered nurse (RN) is performing a mini-mental state examination (MMSE) for a client who is being admitted to an assisted living community. Which communication techniques should the RN implement to decrease anxiety in the client? (Select all that apply.) A. Use simple sentences during the examination. B. Move to another question if the client seems confused. C. Reduce environmental detractors during the examination. D. Allow family to answer for the client to decrease frustration. Ask questions one at a time to decrease confusion.

ANS: A, C, E (A, C, and E) are correct. Communication techniques for clients with cognitive impairments should be simple (A), withoutenvironmental distractions (C), and direct (E). (B) increases anxiety in a client, so it is important to give the client time to answer a question before moving to the next one. (D) is the family's view of the client's mental status and does not give the RN an objective view of the client's cognitive impairment.

4.A client with progressive hearing loss appears distressed when the registered nurse (RN) asks open-ended questions about the client's health history. Which forms of communication should the RN use? (Select all that apply.) A. Face the client so the client can see the RN's mouth. B. Increase one's speech volume when interacting with the client. C. Repeat information to the client if misunderstood. D. Check if the client's hearing aides are working properly. Reduce environmental noise surrounding the client.

ANS: A, D, E (A, D, and E) are correct. A client with hearing loss can develop the ability to read "lips," so facing the client during conversation (A) allows visualization of the lips and directs the sound towards the client. Inspection of the hearing aide device's functionality is a vital step in communication (D). Hearing aides magnify all surrounding noise, so it is imperative to reduce outside environmental noise during the interview process (E). Speaking clearly with enunciation and in a regular tone is easier for a client to understand than increasing the volume of speech (B). If a client shows signs of confusion, rephrasing the question, instead of repeating (C), should be done to decrease client anxiety and facilitate understanding.

31.The registered nurse (RN) is caring for a client with acute pancreatitis and assesses the admission laboratory results. What laboratory value should the RN anticipate being elevated with this diagnosis? A. Triglycerides. B. Amylase. C. Creatinine. D. Uric acid.

ANS: B An elevated amylase level (B) is associated with acute pancreatitis. Elevated triglycerides (A), creatinine (B) and uric acid (D) are not expected with acute pancreatitis.

21.The registered nurse (RN) is administering haloperidol 0.5 mg IM PRN to a client for the first time. What side effects should the RN assess the client for during the initial dose? A. Bradykinesia. B. Dystonia. C. Somatization. D. Akathisia.

ANS: B Dystonia (B) can be a sudden adverse reaction to this psychotropic medication which should be discontinued to resolve dystonia, and the healthcare provider notified immediately. Bradykinesia (A), slow movements and slowed responses, and akathisia (D), the inability to sit still or to sill down, are side effects of haloperidol, but do not require immediate treatment. Somatization (C) is not a side effect but a psychological condition that is treated with cognitive therapy.

8.While reviewing the client's electronic medical record (EMR), the registered nurse (RN) assesses a client who is at risk for a possible interaction with an over-the-counter (OTC) decongestant. Which client health history should the RN report to the healthcare provider concerning the OTC medication? (Select all that apply). A. Type I diabetes mellitus (DM). B. Closed angle glaucoma. C. Chronic hypertension. D. Rheumatoid arthritis. E. Crohn's disease.

ANS: B, C (B and C) are correct. OTC decongestants can increase intraocular pressure and should be avoided in clients with closed angle glaucoma (B). Decongestants can increasing heart rate and elevate blood pressure which can impact the client's management of chronic hypertension (C). Although the healthcare provider should be informed of all medications taken, (A, D, and E) are not directly affected by a decongestant.

6.A Muslim male client refuses to let the female registered nurse (RN) listen to his breath sounds during the examination. How should the RN respond? A. Explain how the nursing skill will be performed before proceeding. B. Examine client with an additional healthcare provider for support. C. Request a male nurse or healthcare provider to perform the exam. D. Avoid any skills that involve touching the client during the exam.

ANS: C Modesty is an important value in the Muslim community, and Muslims are reluctant to expose any part of their body to healthcare members. Muslim clients are accustomed to examination by "same sex" healthcare providers, so (C) is the best solution for the client. (A and B) will not alleviate the issue for the Muslim client. (D) does not allow a thorough exam of the client.

47.The registered nurse (RN) is developing the plan of care for a client who is admitted for alcohol detoxification. Which goal should be most important for the RN to primarily focus the client's care? A. The client maintains optimal nutritional status. B. The client will remain alert and oriented. C. The client will remain free from injury. D. The client will remain alcohol free during hospitalization.

ANS: C The client is at highest risk for injury due to altered cognitive and sensory disturbances as well as tremors during withdrawal. Remaining free from injury (C) is the most important goal for the acute phase of alcohol withdrawal. (A, B and D) are important goals to obtain during the client's stay but not the priority during the acute phase of withdrawal from alcohol.

37.The registered nurse (RN) is caring for a client with aplastic anemia who is hospitalized for weight loss and generalized weakness. Laboratory values show a white blood count (WBC) of 2,500/mm3 and a platelet countof 160,000/mm3. Which intervention is the primary focus in the client's plan of care for the RN to implement? A. Assist with frequent ambulation. B. Encourage visitors to visit. C. Maintain strict protective precautions. D. Avoid peripheral injections.

ANS: C The client should be under strict protective transmission precautions (C) because the WBC values are low, and the client is at high risk for infection. Assisting the client with ambulation (A) should be limited to the protective environment.Encouraging visitors to visit (B) expose the client to possible infection and should includevisitors to follow the plan of care that includes protective transmission precautions. The client's platelet count is within normal limit (D), avoiding peripheral injections are not needed at this time.

24.The registered nurse (RN) is caring for a client who has a closed head injury from a motor vehicle collision. Which finding should the RN assess the client for the risk of diabetes insipidus (DI)? A. High fever. B. Low blood pressure. C. Muscle rigidity. D. Polydipsia.

ANS: D A characteristic finding of DI is excretion of large quantities of urine (5 to 20L/day), and most clients compensate for fluid loss by drinking large amounts of water (polydipsia) (D). (A) is indicative of an infection, not DI. (B) can be characteristic of hypovolemia, but not an initial finding of DI. Muscle rigidity (C) can be a serious manifestation of a closed head injury that requires immediate action, but is not related to DI.

30.An infant with heart failure receives a prescription, digoxin 35 mcg PO. The registered nurse (RN) calcuates the desired dose for administration using the available concentration of digoxin labeled, 0.05 mg/mL. How many millilitersshould the registered nurse (RN) prepare for administration? (Enter the numerical value only. If rounding is required round to the nearest tenth.)

ANS: 0.7 Desired dose, 35 mcg converts to 0.035 mg because the equivalent is 1 mg = 1,000 mcg Using the formula, D/H x A = 0.035 mg / 0.05 mg x 1 mL = 0.7 ml

19.The registered nurse (RN) is interviewing a female client who states she has a persistent productive cough during the winter caused by bronchitis. Which additional finding should the RN assess for bronchitis? A. Phlegm production and wheezing. B. Smoking history. C. Hemoptysis. D. Night sweats.

ANS: A A chronic seasonal cough related to bronchitis is likely accompanied withphlegm production and wheezing (A). Although smoking can contribute to a chronic cough, the typical seasonal cough is an inflammatory reaction to seasonal changes (B). Hemoptysis (C) or a "new" cough or changes in a persistent chronic cough is likely related to lung cancer (C). Night sweats (D) is a trend in fever that is often seen with tuberculosis.

43.The registered nurse (RN) is caring for a client who developed oliguria and was diagnosed with sepsis and dehydration 48 hours ago. Which assessment finding indicates to the RN that the client is stabilizing? A. Urine output of 40 mL/hour. B. Apical pulse 100 and blood pressure 76/42. C. Urine specific gravity 1.001. D. Tented skin on dorsal surface of hands.

ANS: A A decrease in urinary output is a sign of dehydration. When the urine output returns to a normal range, 40 mL/hour (A), the client's kidneys are perfusing adequately and indicates the client's status is stablizing. A blood pressure of 76/42 (B) and tented skin (D) are consistent with dehydration and possible hypovolemia, however the client's urine output is improving. Specific gravity of 1.001 is indicated of the kidney's ability to concentrate urine adequately.

22.The registered nurse (RN) reviews the new prescription, phenelzine, a monoamine oxidase inhibitor (MAOI), for a client on the psychiatric unit with depression. Which information is most important for the RN to assess? A. Consumptiion of any alcohol or tyramine-rich foods. B. Complaints of nausea or vomiting. C. Therapeutic serum drug levels. D. Blood pressure and pulse prior to taking each dose.

ANS: A All alcohol (A) and any foods that contain tyramine should be avoided while taking an MAO inhibitor, which interact to cause a hypertensive crisis. (B and C) should be discussed, but are not as important as (A). Although assessing blood pressure and pulse may be indicated, it is not necessary prior to taking each dose (D).

13.The registered nurse (RN) is caring for a client with a newly placed nasogastric tube (NGT). Once the placement of the NG tube is verified by x-ray, which technique should the RN use as a reliable method to ensure the NGT is not displaced? A. Check pH of aspirated stomach contents obtained from the NGT. B. Auscultate over the epigastrium while injecting air into the NGT. C. Disconnect and place the end of NGT in water to see if bubbles appear. D. Listen for hyperactive bowel sounds in all four quadrants of abdomen.

ANS: A Checking the pH of the aspirate (A) is the best method to validate that the NGT is not displaced and should reveal an acidic pH of 1.5 to 3.5 due to presence of gastric acid. (B, C and D) are not reliable methods to ensure the NGT placement in the stomach.

49.The registered nurse (RN) places an ice pack on a middle school student who comes to the school clinic complaining of a sprained ankle. Which therapeutic response should the RN anticipate? A. Reduced pain and minimized brusing. B. Lowering of body core temperature. C. Increased circulation around injury. D. Reabsorption of edema at injury.

ANS: A Cold applications produce a topical anesthetic effect to reduce pain as well as constricts blood vessels to minimize bruising (A). Local ice over an injured area will not lower the core temperature (B). The cold pack causes vasoconstriction which reduces circulation, not (C), to traumatized tissue and limits further edema around the injury (D), but not byreabsorption of edematous fluid.

34.The registered nurse (RN) is caring for a client with tuberculosis (TB) who is taking a combination drug regimen. The client complains about taking "so many pills." What information should the RN provide to the client about the prescribed treatement? A. The development of resistant strains of TB are decreased with a combination of drugs. B. Compliance to the medication regimen is challenging but should be maintained. C. Side effects are minimized with the use of a single medication but is less effective. D. The treatment time is decreased from 6 months to 3 months with this standard regimen.

ANS: A Combination therapy is necessary to decrease the development of resistant strains of TB (A) and ensure treatment effectiveness. (B, C, and D) are not the rationale for multiple drug protocol for TB.

27.The registered nurse (RN) assesses a client's results for arterial blood gases who has emphysema. Which finding is consistent with respiratory acidosis? A. pH 7.32, pCO2 46 mmHg, HCO3 24 MEq/L. B. pH 7.45 , pCO2 37 mmHg, HCO3 24 mEq/L. C. pH 7.34, pCO2 36 mmHg, HCO3 21 mEq/L. D. pH 7.46, pCO2 35 mmHg, HCO3 28 mEq/L.

ANS: A Normal ABG ranges are pH 7.35 to 7.45; pCO2 35 to 45 mmHg; HCO3 21 to 28 mEq/L, and pO2 80 to 100 mmHg. (A) represents a client with respiratory acidosis which is characterized by: low pH, pCO2 higher than normal, and HCO3 within normal limits. (B) is within normal limits. (C) is an example of a client in metabolic acidosis, and (D) is an example of client in metabolic alkalosis.

17.A female client is recently diagnosed with Sarcoidosis. The client tells the registered nurse (RN) that she does not understand why she has this. When teaching about the occurrence of sarcoidosis, the RN should include that sarcoidosis most commonly occurs with which ethnic group of women? A. African American women. B. Caucasian women. C. Asian women. D. Hispanic women.

ANS: A Sarcoidosis, an autoimmune inflammatory disease affecting multiple organs, has shown presence in relatives due to multiple genes that together to increase the susceptibility of developing the disease, which most commonly occurs in African American women and women of Northern European heritage (A). (B, C, and D) have a lower percentage of women affected by sarcoidosis than African American women.

26.The registered nurse (RN) is assessing common complications related to a client's recent diagnosis, systemic lupus erythematosus (SLE). Which symptom should the RN instruct the client to report immediately? A. Fever related to infection. B. Weight loss and anorexia. C. Depressed mood. D. Break in tissue integrity.

ANS: A Secondary infections are a major concern with SLE clients due to the use of corticosteroids and chemotherapeutic agents, which suppresses the immune system, so reporting fever and infections (A) should be reported immediately. (B, C, and D) can occur from treatment protocols for SLE, but the most immediate risk is infection.

36.The registered nurse (RN) is caring for a young adult who is having an oral glucose tolerance tests (OGTT). Which laboratory result should the RN assess as a normal value for the two hour postprandial result? A. 140 mg/dl. B. 160 mg/dl. C. 180 mg/dl. D. 200 mg/dl.

ANS: A The two hour postprandial level should be less 140 mg/dl for a young adult client (B). (A, C and D) are elevated and are not normal at 2 hours after ingesting the glucose solution.

16.The registered nurse (RN) is teaching a client who is being discharged after treatment of tuberculosis (TB). Which cultural issues should the RN assess when preparing the client for discharge? (Select all that apply.) A. Native language. B. Education level. C. Type of lifestyle. D. Previous medical history. E. Financial resources.

ANS: A, B, C, D (A, B, C and D) are correct. To ensure compliance, language (A), education (B), lifestyle (C), and financial resources (D) should be considered when preparing the client's discharge instructions about continued treatment of TB. (E) does not directly impact compliance with long term treatment of TB.

48.The registered nurse (RN) did not note that a prescription dose was recently changed and did not note the updated medication administration record (MAR). After giving the client the original dose, the RN reports the medication error to the nurse manager. What consequences will the RN experience due to this error in medication administration? A. The incident will be reported to the state's Board of Nursing (BON). B. A medication error report will be completed and risk management will be notified. C. The RN will be suspended from medication administration until the error is investigated. D. The incident will be documented in the RN's personnel file.

ANS: B By reviewing quality of care internally, steps of care can be evaluated and staff can be educated where gaps are identified. The medication report and notification of management (B) is the responsibility of the RN who made the mistake so an internal review of the steps of the occurrence can be completed to determine further risk potentials. The BON does not need to be notified (A) if the error is not repetitive by the RN and if the client's life is not endangered. Suspension (C) is not indicated. Personnel file documentation (D) is based on agency policy about nursing performance of safety guidelines.

40.An older client is admitted to the hospital with severe diarrhea. The registered nurse (RN) is completing an assessment and notes the client has dry mucous membranes and poor skin turgor. Which assessment data should the RN gather to determine if the client has a fluid volume deficit? A. Lower extremity edema. B. Orthostatic hypotension. C. Elevated blood pressure. D. Cheyne-Stokes respirations.

ANS: B Orthostatic hypotension (B) can be a sign of fluid volume deficit in an older client who has experienced severe diarrhea. (A and C) are signs of excess fluid volume. Cheyne Stokes respirations (D) is an abnormal breathing pattern often seen in a client who is near death.

14.The registered nurse (RN) is evaluating a client who presents with symptoms of viral gastroenteritis. Which assessment finding should the RN report to the healthcare provider? A. Dry mucous membranes and lips. B. Rebound abdominal tenderness over right lower quadrant. C. Dizziness when client ambulates from a sitting position. D. Poor skin turgor over client's wrist.

ANS: B RLQ rebound abdominal tenderness (B) may be related to acute appendicitis and should be reported to the healthcare provider. (A, C and D) are expected findings associated with gastroenteritis that are not urgent findings or life threatening.

9.The registered nurse (RN) is assessing a client who was discharged home after management of chronic hypertension. Which equipment should the RN instruct the client to use at home? A. Exercise bicycle. B. Sphygmomanometer. C. Blood glucose monitor. D. Weekly medication box.

ANS: B Self-awareness is the best way for a client to manage chronic hypertension, so the client should obtain a sphygmomanometer (B) and learn how to monitor blood pressure daily and maintain a record. Bicycle (B) exercise may be an option for the client as long as it is overseen by the healthcare provider and started slowly. Glucose monitors (C) do not provide information about blood pressure. (D) is a good way to manage daily medication, but daily blood pressure readings provide the best method to evaluate medication effectiveness and compliance.

10.The registered nurse (RN) notifies the spouse of a client who was admitted to hospice with shallow respirations, of a change in the client's condition. Over the past hour, the client's respiratory pattern has changed to a Cheyne Stokes pattern.After receiving this information, the client's spouse begins vacuuming around the bed. Which stage of grief is the spouse displaying during the visit? A. Acceptance. B. Denial. C. Bargaining. D. Depression.

ANS: B The spouse is exhibiting the first stage of denial (B) of Kubler-Ross's grief model by ignoring that the client's death is imminent. (A, C, and D) are stages of grief that are not being displayed by the client's spouse during this observation.

20.A client with chest pain, dizziness, and vomiting for the last 2 hours is admitted for evaluation for Acute Coronary Syndrome (ACS). Which cardiac biomarker should the registered nurse (RN) anticipate to be elevated if the client experienced myocardial damage? A. Creatine Kinase (CK-MB). B. Serum troponin. C. Myoglobin. D. Ischemia modified albumin.

ANS: B Troponin (B) is the most sensitive and specific test for myocardial damage. Troponin elevation is more specific than CK-MB (A). (C) can be elevated when there is skeletal muscle damage. (D) can be elevated nonspecifically and create false positives, so is not a reliable choice.

3.Which action should the registered nurse (RN) implement to complete an assessment for a client while using an interpreter? A. Ask closed-ended questions with the assistance of the interpreter. B. Maintain eye contact with the client while listening to the translation. C. Instruct interpreter to answer questions from interpreter's point of view. D. Protect the client's privacy by asking a limited number of questions.

ANS: B When completing an assessment, the RN should maintain eye contact with the client (B) to gather additional information from the client's nonverbal cues. (A, C, and D) do not use both verbal and nonverbal communication techniques to gather data during an assessment.

38.After a liver biopsy is performed at the bedside, the registered nurse (RN) is assigned the care of the client. Which nursing intervention is most important for the RN to implement? A. Position client on left side with pillow placed under the costal margin. B. Assist the client with voiding immediately after the procedure. C. Evaluate vital signs q10 to 20 minutes for 2 hours after procedure. D. Ambulate client 3 times in first hour with pillow held at abdomen.

ANS: C Vital signs should be checked every 10 to 20 minutes (C) to assess for bleeding after biopsy of the liver, which is highly vascular. The client should be positioned on the right side, not the left (A), with a pillow or sandbag under the costal margin and supporting the biopsy site. Voiding immediately after the procedure (B) is not the highest priority intervention after a liver biopsy. The client should be maintained on bedrest (D) for several hours to decrease the risk of bleeding from the biopsy site.

15.A client is newly diagnosed with diverticulosis. The registered nurse (RN) is assessing the client's basic knowledge about the disease process. Which statement by the client conveys the client's understanding of the etiology of diverticula? A. Over use of laxatives for bowel regularity result in loss of peristaltic tone. B. Inflammation of the colon mucosa cause growths that protrude into the colon lumen. C. Diverticulosis is the result of high fiber diet and sedentary life style. D. Chronic constipation causes weakening of colon wall which result in out-pouching sacs.

ANS: D A client who has chronic constipation (D) often strains to pass constipated stool which increases intestinal pressure that weakens the intestinal walls and causes out-pouching sacs, called diverticula which commonly occur in the sigmoid. Regular use of laxatives (A) can result in the bowel's dependency on laxative to stimulate intestinal motility, but constipation due to lack of fiber in the diet, not (C), is a predisposing factor for formation of diverticula. Growths that protrude into the colon lumen are polyps (B), which are often pre-cancerous lesions.

35.The registered nurse (RN) is caring for an older client who recently experienced a fractured pelvis from a fall. Which assessment finding is most important for the RN to report the healthcare provider? A. Lower back pain. B. Headache of 7 on scale 1 to 10. C. Blood pressure of 140/98. D. Dyspnea.

ANS: D A client with a large bone fracture is at risk for intramedullary fat leaking into the blood stream and becoming embolic. Dyspnea is an indication of fat embolism to the lungs and should be reported to the healthcare provider immediately. (A, B, and C) are expected findings after a fall and do not require immediate notification of the healthcare provider.

44.A client with cirrhosis of the liver asks the registered nurse (RN) to explain how varicose veins can occur in the esophagus. Which statement should the RN provide to teach the client about the physiological etiology? A. The enlarged liver presses on the lower half of the esophagus which weakens blood vessel walls. B. Abnormal vessels form as a result of liver damage that causes chronic low serum protein levels. C. Esophageal swelling and tissue damage causes blood to circulate blood back through the stomach. D. Increased portal pressure causes blood flow through liver to be shunted to the esophageal vessels.

ANS: D Esophageal varices are weakened, dilated, fragile blood vessel walls that result from a cirrhotic and fibrosed liver. Obstructed blood flow through portal vessels to the liver increases portal pressure that causes blood flow through the liver to be shunted to the esophageal vessels resulting in varices (D). (A, B, and C) are not accurate information about the pathophysiological formation of esophageal varices.

41.The registered nurse (RN) is assessing a male client who arrives at the clinic with severe abdominal cramping, pain, tenesmus, and dehydration. The RN discovers that the client has had 14 to 20 loose stools with rectal bleeding. Which condition should the RN ask the client about his medical history? A. Irritable bowel syndrome. B. Diverticulitis. C. Crohn's disease. D. Ulcerative colitis.

ANS: D The RN should ask the client if he has a history of ulcerative colitis (D), which is characterized by these presenting symptoms. Irritable bowel (A) often includes irregular bowel movements with constipation. Diverticulitis (B) is related to constipation, bowel irregularity, and cramping. Crohn's disease (C) can cause constipation or diarrhea, abscess formation, and abdominal cramping, but tenesmus is rare.

32.The registered nurse (RN) is caring for a client who has taken atenolol for 2 years. The healthcare provider recently changed the medication to enalapril to manage the client's blood pressure. Which instruction should the RN provide the client regarding the new medication? A. Take the medication at bedtime. B. Report presence of increased bruising. C. Check pulse before taking medication. D. Rise slowly when getting out of bed or chair.

ANS: D The client's new medication is an angiotensin-converting enzyme (ACE) inhibitor, which has the side effect oforthostatic hypotension. Instructing the client to rise from a chair or bed slowly (D) is indicated to avoid dizziness and falling. (A, B and C) are not indicated when talking an ACE inhibitor.