HESI exit study!!
68. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel a. "The nurse is legally responsible for the actions of the AP". b. "An AP can perform tasks outside of his range if he has been trained". c. "An experienced AP can delegate to another AP". d. "An RN evaluates the client needs to determine tasks to delegate"
. d. "An RN evaluates the client needs to determine tasks to delegate"
90. A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Upper extremity hypotension b. Increased intracranial pressure c. Frequent nosebleeds d. weak femoral pulses
. weak femoral pulses
38. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A . Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr
A . Prime IV tubing with 0.9% sodium chloride
8. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. . Confront the client about this behavior. B. Express sympathy for the client's situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them.
A. Confront the client about this behavior.
29. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium.
A. Increased creatine.
2. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count. B. Potassium level. C. Creatine clearance. D. Prealbumin.
A. Platelet count
37. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A.Pregabalin B.Lorazepam C.Colchicin D.Codeine.
A.Pregabalin
4. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) A. Keep objects in the client's room in the same place. B. Ensure there is high-wattage lighting in the client's room. C . Approach the client from the side. D. Allow extra time for the client to perform tasks. E . Touch the client gently to announce presence.
ABD
35. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? A. . Children who have varicella are contagious until vesicles are crusted. B. . Children who have varicella should receive the herpes zoster vaccination. C . Children who have varicella should be placed in droplet precaution. D. Children who have varicella are contagious 4 days before the first vesicle eruption.
A. . Children who have varicella are contagious until vesicles are crusted.
103. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes and a hemoglobin A1C of 6.8%
A. A client who has sinus arrhythmia and is receiving monitoring
34. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A . Place the tip of the thermometer under the center of the infant's axilla. B . Pull the pinna of the infant's ear forward before inserting the probe. B. Insert the probe 3.8 cm (1.5in) into the infant's rectum. C. Insert the t
A . Place the tip of the thermometer under the center of the infant's axilla
60. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? A. (Unable to read) B. (Unable to read) C. A nswer might be lower platelets. D. (Unable to read)
C. A nswer might be lower platelets.
40. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. B roiled skinless chicken breast with brown rice. D. Warm toast with margarine.
C. B roiled skinless chicken breast with brown rice.
82. A Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. "Let's talk about how you can change your response to stress." B. "We should establish our roles in the initial session." C. "Let me show you simple relaxation exercises to manage stress." D. "We should discuss resources to implement in your daily life."
B. "We should establish our roles in the initial session."
61. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client's children to provide interpretation. B. ( Answer was the nurse was going to do the interpretation) C. Offer client's translation services for a nominal fee. D. Evaluate the clients' understanding at regular intervals.
B. ( Answer was the nurse was going to do the interpretation)
33. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states "I will need to limit how much spinach I eat". B. A client who has gout and states, "I can continue to eat anchovies on my pizza." C. A client who has a prescription for spironolactone and states "I will reduce my intake of foods that contain potassium". D. A client who has (Unable to read) and states "I'll plan to take my calcium carbonate with a full glass of water".
B. A client who has gout and states, "I can continue to eat anchovies on my pizza."
69. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in the FHR D. Temperature 37.4C (99.3)
B. FHR baseline 170/min
9. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client's room. B. L imit the client's visitors to 30 min per day. C. Discard the client's linens in a double bag. D. Discard the radioactive source in a biohazard bag
B. Limit the client's visitors to 30 min per day.
3. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? A. Place an ice pack over the cast. B. Palpate the pulse distal to the cast. C. Teach the client to keep the cast clean and dry. D. Position the casted extremity on a pillow.
B. Palpate the pulse distal to the cast.
39. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. P laying with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom.
B. Playing with a large plastic truck.
51. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn't worry about that. B. lets talk about your moms cancer and how things will progress from here. C. tell me how youare feeling about your mom dying. D. Tell her not to worry. She still has plenty of time left. E. you sound like you have questions about your mom dying. Lets talk about it.
BCE
28. A nurse is performing physical therapy for a client who has Parkinson's disease. Which of the following statements by the client indicates the need for a referral to physical therapy? A. "I have been experiencing more tremors in my left arm than before" B. "I noticed that I am having a harder time holding on to my toothbrush" C. " Lately, I feel like my feet are freezing up, as they are stuck to the ground" D. "Sometimes, I feel I am making a chewing motion when I'm not eating"
C. " Lately, I feel like my feet are freezing up, as they are stuck to the ground"
30. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? A. "Did the doctor discuss with you that there was a change in this medication?" B. "I recommend that you take this medication as prescribed" C. "Do you know why this medication is being prescribed to you?" D. " I will call the pharmacist now to check on this medication"
D. " I will call the pharmacist now to check on this medication"
31. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg. B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.
D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration.
36. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. A dminister the medication.
D. A dminister the medication.
6. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. Administer 100% humidified oxygen.
D. Administer 100% humidified oxygen.
1. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets 150,000/mm3. C. Aspartate aminotransferase 10 units/L. D. E rythrocyte sedimentation rate 75 mm/hr
D. Erythrocyte sedimentation rate 75 mm/hr
7. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? A. Place food on the left side of the client's mouth when he is ready to eat. B. Provide total care in performing the client's ADLs. C. Maintain the client on bed rest. D. Place the client's left arm on a pillow while he is sitting
D. Place the client's left arm on a pillow while he is sitting
47. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. a. LOC b. Skin turgor d. Bowel sounds
LOC
94. A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? a. Offer the client saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech
a c
26. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? a. "Describe your feelings to me about being pregnant" b. "You should discuss your feelings about being pregnant with your provider" c. "Have you discussed these feelings with your partner?" d. "When did you start having these feelings?"
a. "Describe your feelings to me about being pregnant"
75. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make? a. "Does the doctor know you are eating that?" b. "Why are you eating seaweed soup?" c. "Of course I will heat that up for you" d. "The hospital good is more nutritious"
a. "Does the doctor know you are eating that?"
102. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? a. "Drink 2 liters of warm water per day". b. "Empty your bladder every 6 weeks.". c. "Soak in a warm bath everyday". d. "Take an oral estrogen tablet".
a. "Drink 2 liters of warm water per day".
62. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? a. "I can give you information about respite care if you are interested." b. "You should consider taking a sleeping pill before bed each night" c. "It must be difficult taking care of someone who is terminally ill" d. "You are doing a great job taking care of your mother"
a. "I can give you information about respite care if you are interested."
22. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. "I will let the client know that I am available as the interpreter." b. "I will receive a small fee for interpreting for this client." c. "I am glad I'm available today, but when I'm not, you can use a family member." d. "I will let the client know that an interpreter is unavailable during the night shift."
a. "I will let the client know that I am available as the interpreter."
A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. "You should not do this procedure if you are allergic to iodine" b. "You should not have this procedure if you have a tattoo." c. "The nurse will ask you to wear protective eyewear during this procedure." d. "The nurse will ask you to remove any transdermal patches prior to the procedure."
a. "You should not do this procedure if you are allergic to iodine"
55. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage? a. 7.5% b. 15% c. 8.1% d. 13.3%
a. 7.5%
74. A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? a. A client receives his antibiotics 2hr late b. A client vomits within 20min of taking his morning medications c. A client requests his statin to be administered at 2100 d. A client asks for pain medication 1hr early
a. A client receives his antibiotics 2hr late
44. A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? a. Acts as an advocate for the nursing unit. b. (Unable to read) for the unit c. Priorities staff request over client needs. d. Provides routine client care and documentation
a. Acts as an advocate for the nursing unit.
2. A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below-the knee amputation b. Fractured tibia c. 95% full-thickness body burn d. 10cm (4in) laceration to the forearm
a. Below-the knee amputation
104. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Consume food high in bran fiber b. Increase intake of milk products c. Sweeten foods with fructose corn syrup d. Increase foods high in gluten
a. Consume food high in bran fiber
13. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime b. Stay in bed at least 1 hr if unable to fall asleep c. Take a 1 hr nap during the day c. Previous violent behavior d. Perform exercises prior to bedtime
a. Eat a light snack before bedtime
77. A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? a. Establish a toileting schedule for the client b. Use clothing with buttons and sippers c. Discourage physical activity during the day d. Engage the client in activities that increase sensory stimulation
a. Establish a toileting schedule for the client
18. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing→ may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face→ side effect d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale "Requires immediate action" choose the worst possibility that could lead to. ABC
a. Increase in frequency of swallowing→ may indicate bleeding
81. A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following a. Inject air into the NPH insulin vial. b. (Unable to read) c. Withdraw the prescribed dose of regular insulin d. Withdraw the prescribed dose of NPH insulin
a. Inject air into the NPH insulin vial.
63. A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's glucose. The nurse should identify this finding as an adverse effect of which of the following medications a. Methylprednisolone. b. Ondansetron. c. Guaifenesin. d. Amoxicillin
a. Methylprednisolone.
12. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level
a. Place the cap from the solution sterile side up on clean surface
72. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? a. Place the tip of the thermometer under the center of the infant's axilla. b. Pull the pinna of the infant's ear forward before inserting the probe. c. Insert the probe 3.8 cm (1.5in) into the infant's rectum. d. Insert the thermometer in front of the infant's tongue.
a. Place the tip of the thermometer under the center of the infant's axilla
57. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? a. avoid hot tub while wearing the patch b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance.
a. avoid hot tub while wearing the patch
54. A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? a. clarify the source of referral b. Your partner can be a great source of support for you at this time c. Is there a reason you don't want your partner to know about your procedure? d. The provider will be tactful when talking to your partner
a. clarify the source of referral
49. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include? a. document clients condition every 15 mins b. Attach the restraints to the beds side rails c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours
a. document clients condition every 15 mins
88. A nurse is caring for a client who is experiencing mild anxiety. Which of the following findings should the nurse expect? a. heightened perceptual field b. Rapid speech -severe c. Feelings of dread d. Purposeless activity
a. heightened perceptual field
6. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. you may breastfeed unless your nipples are cracked.. b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics.
a. you may breastfeed unless your nipples are cracked..
25. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? a. "I will soak in the tub rather and showering" b. "I will wear loose clothing around my ICD" c. "I will stop using my microwave oven at home because of my ICD" d. "I can hold my cellphone on the same side of my body as the ICD"
b. "I will wear loose clothing around my ICD"
15. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. "Can you tell me who visited you today?" b. "What high school did you graduate from c. "Can you list your current medications?" d. "What did you have for breakfast yesterday?"
b. "What high school did you graduate from
3. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. "I will take sucralfate with meals three times per day" b. "i will avoid food and beverages that contain caffeine" c. "I will decrease my daily protein intake to 15 grams per day" d. "I will use ibuprofen as needed to control abdominal pain"
b. "i will avoid food and beverages that contain caffeine"
66. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include? a. Critical pathways have unlimited timeframe for completion b. (Unable to read) decrease health care costs. c. (Unable to read) critical pathway if variances (Unable to read) d. (Unable to read) are used to create the critical pathway.
b. (Unable to read) decrease health care costs
4. A nurse is caring for a client who has arteriovenous fistula which of the following findings should the nurse report? a. Thrill upon palpation. b. Absence of a bruit. c. Distended blood vessels d. Swishing sound upon auscultation.
b. Absence of a bruit
43. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? a. Remove the client's restraint every 4hr b. Document the client's condition every 15 min c. Attach the restrain to the bed's side rails d. Request a PRN restrain prescription for clients who are aggressive
b. Document the client's condition every 15 min
19. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child's cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom
b. Monitor the child's cardiac status
95. A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? a. Assess effectiveness of antiemetic medication b. Perform chest compressions during cardiac resuscitation c. Perform a dressing change for a new amputeed. Apply a transdermal nicotine patch
b. Perform chest compressions during cardiac resuscitation
1. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? a. Administer ondansetron. b. Place the client in a warm shower. c. Apply fundal pressure during contractions. d. Assist the client to a supine position.
b. Place the client in a warm shower.
10. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV
b. Prepare an IV bolus of dextrose 5% in water
23. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year- old. Which of the following actions should the nurse take? a. (Unable to read) b. Tell the child they will feel discomfort during the catheter insertion. c. Use a mummy restraint to hold the child during the catheter insertion. d. Require the parents to leave the room during the procedure.
b. Tell the child they will feel discomfort during the catheter insertion.
78. The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contradiction to the use of oral contraceptives? a. Hyperthyroidism. b. Thrombophlebitis. c. Diverticulosis. d. Hypocalcemia.
b. Thrombophlebitis.
98. A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Asthma b. hypertension c. Fibromyalgia d. Fibrocystic breast condition
b. hypertension
56. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? a. Perform fundal massage (massage if fundus is boggy) b. pour water from a squeeze bottle over the clients perianal area c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client's perineal area.( warm)
b. pour water from a squeeze bottle over the clients perianal area
59. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? a. Avocados b. whole grain bread c. Pepperoni pizza d. Smoked salmon
b. whole grain bread
64. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? a. "You should take folic acid to decrease the risk of transmitting infections to your baby" b. "You should consume a maximum of 300 micrograms of folic acid every day". c. "You can increase your dietary intake of folic acid by eating cereals and citrus fruits". d. "You can expect your urine to appear red-tingled while taking folic acid supplements".
c. "You can increase your dietary intake of folic acid by eating cereals and citrus fruits"
65. A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority? a. Social relationship with peers. b. Plans for attending school while pregnant. c. (Unable to read) (Picked this one) Medicaid? d. Understanding of infant care.
c. (Unable to read) (Picked this one) Medicaid?
71. A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse's station? a. A client who has an anxiety disorder and is experiencing moderate anxiety. b. A client who has somatic symptom disorder and reports chronic pain. c. A client who has depressive disorder and reports feeling hopeless. d. A client who has bipolar disorder and impaired social interactions.
c. A client who has depressive disorder and reports feeling hopeless
76. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. Leaving a nasogastric tube clamped after administering oral medication b. Documenting communication with a provider in the progress notes of the client's medical records c. Administering potassium via IV bolus d. Placing a yellow bracelet on a client who is at risk for falls
c. Administering potassium via IV bolus
A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative b. Administering oral fluids to a client who has dysphagia c. Applying a condom catheter for a client who has a spinal cord injury d. Reviewing active range-of-motion exercise with a client who had a stroke
c. Applying a condom catheter for a client who has a spinal cord injury
80. A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? a. Placing a belt restraint on a school-age child who has seizures. b. Securing wrist restraints to the bed rails for an adolescent. c. Applying elbow immobilizers of an infant receiving cleft lip injury d. Keeping the side rails of a toddler's crib elevated.
c. Applying elbow immobilizers of an infant receiving cleft lip injury
73. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? a. Encourage the client to spend time in the day room b. Withdraw the client's TV privileges is the does not attend group therapy c. Encourage the client to take frequent rest periods d. Place the cline in seclusion when he exhibits signs of anxiety
c. Encourage the client to take frequent rest periods
70. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia the following actions is the nurse's priority? a. Consult with a case manager about insurance coverage. b. Counsel caregivers about respite care options. c. Ensure that the client has a referral for physical therapy. d. Refer the client to a local stroke support group.
c. Ensure that the client has a referral for physical therapy
45. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client's plan of care. a. Serum sodium 144 mEq/ b. (Unable to read) c. Hba1c 10 % d. Random serum glucose 190 mg/dl.
c. Hba1c 10 %
14. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home
c. Identify environmental hazards in the home
A nurse is teaching who has chronic pain about avoiding constipation from opioid medications. Which of the following should the nurse include in the teaching? a. Drink 1.5L fluids each day. b. Take mineral oil at bedtime. c. Increase exercise activity d. Decrease insoluble fiber.
c. Increase exercise activity
5. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. C INAHL. C. ProQuest
c. ProQuest
21. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count
c. Serum potassium- diuretic that retains potassium= hyperkalemic risk
67. A nurse is reviewing the medical record of a client who has schizophrenia. Which of the following should the nurse report to the provider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse's notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in the past month. Also reports a sore throat for the past 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. a. Dietary intake b. Heart rate. c. Sore throat. d. Blood pressure.
c. Sore throat.
A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction
c. Use of tobacco decreases the level of athletic ability
52. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) b. A client who is scheduled for colonoscopy and taking sodium phosphate c. a client who received a Mantoux test 48 hours ago and has induration d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin)
c. a client who received a Mantoux test 48 hours ago and has induration
11. A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. history of violent behavior d. A history of being in prison
c. history of violent behavior
1. A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? a. Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) b. Locate financial support to open a shelter for abuse survivors (3rd) c. teach parenting skills to families at risk for abuse d. Connect abuse survivors with legal counsel (3rd)
c. teach parenting skills to families at risk for abuse
96. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? a. The client takes vitamin C daily b. The client has a history of alcohol use disorder c. the client has a history of asthma d. The client takes furosemide twice daily
c. the client has a history of asthma
A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? a. Increased salivation- dry it will cause - anticholinergic effects b. Weight loss c. urinary retention d. Hypertension- orthostatic hypotension it will cause instead
c. urinary retention
79. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, "It's hard not to listen to the voices." Which of the following questions should the nurse ask the client? a. "Do you understand that the voices are not real?" b. "Why do you think the voices are talking to you?" c. "Have you tried going to a private place when this occurs?" d. "What helps you ignore what you are hearing?"
d. "What helps you ignore what you are hearing?"
27. A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? a. Encourage a maximum fluid intake of 1,500 ml per day. b. Increase the amount of refined grains in the client's diet. c. Provide the client with a cold drink prior to defecation. d. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
d. Administer a rectal suppository 30 minutes prior to scheduled defecation times.
32. A nurse in a provider's office is reviewing the laboratory results of a group of clients. Which to report? a. Herpes simplex. b. Human papillomavirus c. Candidiasis d. Chlamydia
d. Chlamydia
16. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7%
d. HbA1c level less than 7%
100. A nurse in a provider's office is reviewing a female client's medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12
d. Vitamin B12
50. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? a. Providing pain management b. Offering emotional support c. Preventing infection d. initiate IV fluid resuscitation
d. initiate IV fluid resuscitation
48. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket → if hypothermia. c. Administer oral acetaminophen d. initiate seizure precuations
d. initiate seizure precuations
17. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client's seizure disorder is no longer under control c. The client is having adverse effects due to combination antimicrobial therapy d. the client is showing evidence of phenytoin toxicity
d. the client is showing evidence of phenytoin toxicity
58. A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let's talk about how you can change your response to stress d. we should establish our roles in the initial session
d. we should establish our roles in the initial session
89. A nurse is caring for a client who has type 1 diabetes mellitus. The client reports that she is not feeling well. Which of the following findings should indicate to the nurse that the client is hypoglycemic? (Select all that apply.) a. Tremors b. Polydipsia = hyperglycemia c. Acetone Breath odor = DKA d. Diaphoresis e. Inability to concentrate
tremors and diaphoresis
