2020 HESI EXIT V2 2020 HESI EXIT V2

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2020 HESI EXIT V2 2020 HESI EXIT V2 2020 HESI EXIT V2 2020 HESI EXIT V2 1. The nurse is teaching parents about diet for a 4 month-old infantwith gastroenteritis and mild dehydration. In addition t... o oral rehydration fluids, the dietshould include A) Formula or breast milk B) Broth and tea C) Rice cereal and apple juice D) Gelatin and ginger ale The correct answer is A: Formula or breast milk 2. The nurse instructs the client taking dexamethasone (Decadron) totake it with food or milk. What is the physiological basis for this instruction? A) Retards pepsin production B) Stimulates hydrochloric acid production C) Slows stomach emptying time D) Decreases production of hydrochloric acid The correct answer is B: Stimulates hydrochloric acid production 3. The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needsto A) Assess for abdominal distention B) Maintain infant in an upright position C) Begin formula feedings when infant is alert D) Pump the shunt to assess for proper function The correct answer is A: Assess for abdominal distention 4. The mother of a 2 year-old hospitalized child asks the nurse's adviceabout the child's screaming every time the mother gets ready to leave the hospitalroom. What is the best response by the nurse? A) "I think you or your partner needs to stay with the child while in the hospital." B) "Oh, that behavior will stop in a few days." C) "Keep in mind that for the age this is a normal response to being in the hospital." D) "You might want to "sneak out" of the room once the child falls asleep."The correct answer is C: "Keep in mind that for the age this is a normal response to being in the hospital." 5. When caring for a client receiving warfarin sodium (Coumadin),which lab test would the nurse monitor to determine therapeutic reponse to the drug? A) Bleeding timeB) Coagulation time C) Prothrombin time D) Partial thromboplastin time The correct answer is C: Prothrombin time 6. The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately? A) Vomiting of dark emesis B) Complaints of throat pain C) Apical heart rate of 110 D) Increased restlessness The correct answer is D: Increased restlessness 7. The nurse admits a 7 year-old to the emergency room after a leginjury. The x-rays show a femur fracture near the epiphysis. The parents ask what will bethe outcome of this injury. The appropriate response by the nurse should be which of these statements? A) "The injury is expected to heal quickly because of thin periosteum." B) "In some instances the result is a retarded bone growth." C) "Bone growth is stimulated in the affected leg." D) "This type of injury shows more rapid union than that of younger children." The correct answer is B: "In some instances the result is a retarded bonegrowth." 8. A client receiving chlorpromazine HCL (Thorazine) is in psychiatrichome care. During a home visit the nurse observes the client smacking her lipsalternately with grinding her teeth. The nurse recognizes this assessment finding as what? A) Dystonia B) Akathesia C) Brady dysknesia D) Tardive dyskinesia The correct answer is D: Tardive dyskinesia 9. During the check up of a 2 month-old infant at a well baby clinic, themother expresses concern to the nurse because a flat pink birthmark on thebaby's forehead and eyelid has not gone away. What is an appropriate response by the nurse? A) "Mongolian spots are a normal finding in dark-skinned children." B) "Port wine stains are often associated with other malformations." C) "Telangiectatic nevi are normal and will disappear as the baby grows." D) "The child is too young for consideration of surgical removal of these atthis time."The correct answer is C: Telangiectatic nevi are normal and will disappearas the baby Grows 10. A client has returned to the unit following a renal biopsy. Which ofthe following nursing interventions is appropriate? A) Ambulate the client 4 hours after procedure B) Maintain client on NPO status for 24 hours C) Monitor vital signs D) Change dressing every 8 hours The correct answer is C: Monitor vital signs 11. A client has been admitted with a fractured femur and has beenplaced in skeletal traction. Which of the following nursing interventions should receivepriority? A) Maintaining proper body alignment B) Frequent neurovascular assessments of the affected leg C) Inspection of pin sites for evidence of drainage or inflammation D) Applying an over-bed trapeze to assist the client with movement in bedThe correct answer is B: Frequent neurovascular assessments of the affected leg 12. The nurse is teaching a client newly diagnosed with asthma how touse the metereddose inhaler (MDI). The client asks when they will know the canister is empty. The best response is A) Drop the canister in water to observe floating B) Estimate how many doses are usually in the canister C) Count the number of doses as the inhaler is used D) Shake the canister to detect any fluid movement The correct answer is A: Drop the canister in water to observe floating 13. While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them aboutwhich of the following actions? A) Maintain good oral hygiene and dental care B) Omit medication if the child is seizure free C) Administer acetaminophen to promote sleep D) Serve a diet that is high in iron The correct answer is A: Maintain good oral hygiene and dental care 14. A 7 month pregnant woman is admitted with complaints of painlessvaginal bleeding over several hours. The nurse should prepare the client for an immediate A) Non stress test B) Abdominal ultrasoundC) Pelvic exam D) X-ray of abdomen The correct answer is B: Abdominal ultrasound 15. The nurse is assessing a 17 year-old female client with bulimia. Which of the following laboratory reports would the nurse anticipate? A) Increased serum glucose B) Decreased albumin C) Decreased potassium D) Increased sodium retention The correct answer is C: Decreased potassium 16. An 80 year-old client on digitalis (Lanoxin) reports nausea, vomiting, abdominal cramps and halo vision. Which of the following laboratory results shouldthe nurse analyze first? A) Potassium levels B) Blood pH C) Magnesium levels D) Blood urea nitrogen The correct answer is A: Potassium levels 17. The nurse caring for a 9 year-old child with a fractured femur is toldthat a medication error occurred. The child received twice the ordered dose ofmorphine an hour ago. Which nursing diagnosis is a priority at this time? A) Risk for fluid volume deficit related to morphine overdose B) Decreased gastrointestinal mobility related to mucosal irritation C) Ineffective breathing patterns related to central nervous system depression D) Altered nutrition related to inability to control nausea and vomiting The correct answer is C: Ineffective breathing patterns related to centralnervous system Depression 18. The nurse notes that a 2 year-old child recovering from a tonsillectomy has an temperature of 98.2 degrees Fahrenheit at 8:00 AM. At 10:00 AM thechild's mother reports that the child "feels very warm" to touch. The first action by the nurse should be to A) Reassure the mother that this is normal B) Offer the child cold oral fluids C) Reassess the child's temperature D) Administer the prescribed acetaminophen The correct answer is C: Reassess the child''s temperature19. The nurse is teaching a newly diagnosed asthma client on how touse a peak flow meter. The nurse explains that this should be used to A) Determine oxygen saturation B) Measure forced expiratory volume C) Monitor atmosphere for presence of allergens D) Provide metered doses for inhaled bronchodilator The correct answer is B: Measure forced expiratory volume 20. The nurse is performing a pre-kindergarten physical on a 5 year old. The last series of vaccines will be administered. What is the preferred site for injection bythe nurse? A) Vastus intermedius B) Gluteus rainlinus C) Vastus lateralis D) DorsogluteaI The correct answer is C: Vastus lateralis 21. A couple experienced the loss of a 7 month-old fetus. In planning for discharge, what should the nurse emphasize? A) To discuss feelings with each other and use support persons B) To focus on the other healthy children and move through the loss C) To seek causes for the fetal death and come to some safe conclusion D) To plan for another pregnancy within 2 years and maintain physicalhealth The correct answer is A: To discuss feelings with each other and usesupport persons 22. The parents of a 4 year-old hospitalized child tell the nurse, “We areleaving now and will be back at 6 PM.” A few hours later the child asks the nurse whenthe parents will come again. What is the best response by the nurse? A) "They will be back right after supper." B) "In about 2 hours, you will see them." C) "After you play awhile, they will be here." D) "When the clock hands are on 6 and 12." The correct answer is A: "They will be back right after supper." 23. The nurse is providing instructions for a client with asthma. Which ofthe following should the client monitor on a daily basis? A) Respiratory rate B) Peak air flow volumes C) Pulse oximetry D) Skin color The correct answer is B: Peak air flow volumes24. Therapeutic nurse-client interaction occurs when the nurse A) Assists the client to clarify the meaning of what the client has said B) Interprets the client’s covert communication C) Praises the client for appropriate feelings and behavior D) Advises the client on ways to resolve problems The correct answer is A: Assists the client to clarify the meaning of whatthe client has said 25. A 14 month-old child ingested half a bottle of aspirin tablets. Whichof the following would the nurse expect to see in the child? A) Hypothermia B) Edema C) Dyspnea D) Epistaxis The correct answer is D: Epistaxis 26. The nurse is caring for a client with a distal tibia fracture. The clienthas had a closed reduction and application of a toe to groin cast. 36 hours aftersurgery, the client suddenly becomes confused, short of breath and spikes a temperature of103 degrees Fahrenheit. The first assessment the nurse should perform is A) Orientation to time, place and person B) Pulse oximetry C) Circulation to casted extremity D) Blood pressure The correct answer is B: Pulse oximetry 27. Which nursing intervention will be most effective in helping a withdrawn client to develop relationship skills? A) Offer the client frequent opportunities to interact with 1 person B) Provide the client with frequent opportunities to interact with otherclients C) Assist the client to analyze the meaning of the withdrawn behavior D) Discuss with the client the focus that other clients have similar problems The correct answer is A: Offer the client frequent opportunities to interactwith one Person 28. The nurse is assessing a client with a Stage 2 skin ulcer. Which of the following treatments is most effective to promote healing? A) Covering the wound with a dry dressing B) Using hydrogen peroxide soaks C) Leaving the area open to dry D) Applying a hydrocolloid or foam dressing The correct answer is D: Applying a hydrocolloid or foam dressing29. A female client is admitted for a breast biopsy. She says, tearfully tothe nurse, "If this turns out to be cancer and I have to have my breast removed, mypartner will never come near me." The nurse's best response would be which of thesestatements? A) "I hear you saying that you have a fear for the loss of love." B) "You sound concerned that your partner will reject you." C) "Are you wondering about the effects on your sexuality?" D) "Are you worried that the surgery will change you?" The correct answer is D: "Are you worried that the surgery will changeyou?" 30. When teaching suicide prevention to the parents of a 15 year-oldwho recently attempted suicide, the nurse describes the following behavioral cue A) Angry outbursts at significant others B) Fear of being left alone C) Giving away valued personal items D) Experiencing the loss of a boyfriend The correct answer is C: Giving away valued personal items 31. The nurse is caring for a 4 year-old admitted after receiving burns tomore than 50% of his body. Which laboratory data should be reviewed by the nurse as apriority in the first 24 hours? A) Blood urea nitrogen B) Hematocrit C) Blood glucose D) White blood count The correct answer is A: Blood urea nitrogen 32. The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What areais a priority for the nurse to discuss at this time? A) Daily needs and concerns B) The overview cardiac rehabilitation C) Medication and diet guideline D) Activity and rest guidelines The correct answer is A: Daily needs and concerns 33. The nurse is preparing a client with a deep vein thrombosis (DVT) fora Venous Doppler evaluation. Which of the following would be necessary forpreparing the clientfor this test? A) Client should be NPO after midnight B) Client should receive a sedative medication prior to the test C) Discontinue anti-coagulant therapy prior to the test D) No special preparation is necessary The correct answer is D: No special preparation is necessary 34. While interviewing a client, the nurse notices that the client isshifting positions, wringing her hands, and avoiding eye contact. It is important for thenurse to A) Ask the client what she is feeling B) Assess the client for auditory hallucinations C) Recognize the behavior as a side effect of medication D) Re-focus the discussion on a less anxiety provoking topicThe correct answer is A: Ask the client what she is feeling 35. Which statement made by a client indicates to the nurse that hemay have a thought disorder? A) "I'm so angry about this. Wait until my partner hears about this." B) "I'm a little confused. What time is it?" C) "I can't find my 'mesmer' shoes. Have you seen them?" D) "I'm fine. It's my daughter who has the problem." The correct answer is C: "I can''t find my ''mesmer'' shoes. Have you seenthem?" 36. The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis? A) Repeatedly checking that the door is locked B) Verbalized suspicions about thefts C) Preference for consistent care givers D) Repetitive, involuntary movements The correct answer is A: Repeatedly checking that the door is locked 37. A young adult seeks treatment in an outpatient mental health center. The client tells the nurse he is a government official being followed by spies. On further questioning, he reveals that his warnings must be heeded to prevent nuclear war. What isthe most therapeutic approach by the nurse? A) Listen quietly without comment B) Ask for further information on the spies C) Confront the client on a delusion D) Contact the government agency The correct answer is A: Listen quietly without comment38. A client is admitted to a psychiatric unit with delusions. What findings can the nurse expect? A) Flight of ideas and hyperactivity B) Suspiciousness and resistance to therapy C) Anorexia and hopelessness D) Panic and multiple physical complaints The correct answer is B: Suspiciousness and resistance to therapy 39. A client who is a former actress enters the day room wearing a sheer nightgown, high heels, numerous bracelets, bright red lipstick and heavily rougedcheeks. Which nursing action is the best in response to the client’s attire? A) Gently remind her that she is no longer on stage B) Directly assist client to her room for appropriate apparel C) Quietly point out to her the dress of other clients on the unit D) Tactfully explain appropriate clothing for the hospital The correct answer is B: Directly assist client to her room for appropriateapparel 40. Handshaking is the preferred form of touch or contact used withclients in a psychiatric setting. The rationale behind this limited touch practice is that A) Some clients misconstrue hugs as an invitation to sexual advances B) Handshaking keeps the gesture on a professional level C) Refusal to touch a client denotes lack of concern D) Inappropriate touch often results in charges of assault and battery The correct answer is A: Some clients misconstrue hugs as an invitation tosexual Advances 41. A client with paranoid delusions stares at the nurse over a period ofseveral days. The client suddenly walks up to the nurse and shouts "You think you’re soperfect and pure and good." An appropriate response for the nurse is A) "Is that why you’ve been starring at me?" B) "You seem to be in a really bad mood." C) "Perfect? I don’t quite understand." D) "You are angry right now." The correct answer is D: "You are angry right now." 42. An important goal in the development of a therapeutic inpatientmilieu is to A) Provide a businesslike atmosphere where clients can work on individualgoalsB) Provide a group forum in which clients decide on unit rules, regulations,and policies C) Provide a testing ground for new patterns of behavior while the clienttakes responsibility for his or her own actions D) Discourage expressions of anger because they can be disruptive toother clients The correct answer is C: Provide a testing ground for new patterns ofbehavior while the client takes responsibility for his or her own actions 43. The nurse's primary intervention for a client who is experiencing apanic attack is to A) Develop a trusting relationship B) Assist the client to describe his experience in detail C) Maintain safety for the client D) Teach the client to control his or her own behaviorThe correct answer is C: Maintain safety for the client 44. Which intervention best demonstrates the nurse's sensitivity to a 16year old’s appropriate need for autonomy? A) Alertness for feelings regarding body image B) Allows young siblings to visit C) Provides opportunity to discuss concerns without presence of parents D) Explores his feelings of resentment to identify causes The correct answer is C: Provides opportunity to discuss concerns withoutpresence of Parents 45. A client with anorexia is hospitalized on a medical unit due to electrolyte imbalance and cardiac dysrhythmias. Additional assessment findings that the nursewould expect to observe are A) Brittle hair, lanugo, amenorrhea B) Diarrhea, nausea, vomiting, dental erosion C) Hyperthermia, tachycardia, increased metabolic rate D) Excessive anxiety about symptoms The correct answer is A: Brittle hair, lanugo, amenorrhea 46. A depressed client in an assisted living facility tells the nurse that"life isn't worth living anymore." What is the best response to this statement? A) "Come on, it is not that bad." B) "Have you thought about hurting yourself?" C) "Did you tell that to your family?" D) "Think of the many positive things in life."The correct answer is B: "Have you thought about hurting yourself?" 47. A client, recovering from alcoholism, asks the nurse, "What can I dowhen I start recognizing relapse triggers within myself?" How might the nurse bestrespond? A) "When you have the impulse to stop in a bar, contact a sober friendand talk with him." B) "Go to an AA meeting when you feel the urge to drink." C) "It is important to exercise daily and get involved in activities that willcause you not to think about drug use." D) "Identify your relapse triggers as part of getting better." The correct answer is D: "Identify your relapse triggers as part of gettingbetter." 48. A client was admitted to the eating disorder unit with bulimia nervosa. The nurse assessing for a history of complications of this disorder expects A) Respiratory distress, dyspnea B) Bacterial gastrointestinal infections, over hydration C) Metabolic acidosis, constricted colon D) Dental erosion, parotid gland enlargement The correct answer is D: Dental erosion, parotid gland enlargement 49. A nurse entering the room of a postpartum mother observes thebaby lying at the edge of the bed while the woman sits in a chair. The mother states," Thisis not my baby, and I do not want it." The nurse's best response is A) ”This is a common occurrence after birth, but you will come to acceptthe baby." B) ”Many women have postpartum blues and need some time to love thebaby." C) ”What a beautiful baby! Her eyes are just like yours." D) ”You seem upset; tell me what the pregnancy and birth were like foryou." The correct answer is D: "You seem upset; tell me what the pregnancyand birth were like for you." 50. Which of the following times is a depressed client at highest risk for attempting suicide? A) Immediately after admission, during one-to-one observationB) 7 to 14 days after initiation of antidepressant medication and psychotherapy C) Following an angry outburst with family D) When the client is removed from the security room The correct answer is B: Seven to 14 days after initiation ofantidepressant medication and psychotherapy 51. A man diagnosed with epididymitis 2 days ago calls the nurse at ahealth clinic to discuss the problem. What information is most important for the nurse toask about at this time? A) What are you taking for pain and does it provide total relief? B) What does the skin on the testicles look and feel like? C) Do you have any questions about your care? D) Did you know a consequence of epididymitis is infertility? The correct answer is B: What does the skin on the testicles look and feellike? 52. A client has had heart failure. Which intervention is most importantfor the nurse to implement prior to the initial administration of Digoxin to this client? A) Assess the apical pulse, counting for a full 60 seconds B) Take a radial pulse, counting for a full 60 seconds C) Use the pulse reading from the electronic blood pressure device D) Check for a pulse deficit The correct answer is A: Assess the apical pulse, counting for a full 60seconds 53. A client is admitted with a tentative diagnosis of congestive heartfailure. Which of the following assessments would the nurse expect to be consistent withthis problem? A) Chest pain B) Pallor C) Inspiratory crackles D) Heart murmur The correct answer is C: Inspiratory crackles 54. A nurse is providing care to a 17 year-old client in the post-operativecare unit (PACU) after an emergency appendectomy. Which finding is an earlyindication that the client is experiencing poor oxygenation? A) Abnormal breath sounds B) Cyanosis of the lips C) Increasing pulse rateD) Pulse oximeter reading of 92% The correct answer is C: Increasing pulse rate 55. Which order can be associated with the prevention of atelectasis and pneumonia in a client with amyotrophic lateral sclerosis? A) Active and passive range of motion exercises twice a day B) Every 4 hours incentive spirometer C) Chest physiotherapy twice a day D) Repositioning every 2 hours around the clock The correct answer is C: Chest physiotherapy twice a day 56. A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for painrelated to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complication? A) Acute compartment syndrome B) Thromboemolitic complications C) Fatty embolism D) Osteomyelitis The correct answer is A: Acute compartment syndrome 57. The nurse is assessing an 8 month-old child with atonic cerebralpalsy. Which statement from the mother supports the presence of this problem? A) When I put my finger in the left hand the baby doesn’t respond with agrasp. B) My baby doesn’t seem to follow when I shake toys in front of the face. C) When it thundered loudly last night the baby didn’t even jump. D) When I put the baby in a back lying position that’s how I find the baby.The correct answer is D: Unable to roll from 58. Which statements by the client would indicate to the nurse an understanding of the issues with end stage renal disease? A) I have to go at intervals for epoetin (Procrit) injections at the health department. B) I know I have a high risk of clot formation since my blood is thick fromtoo many red cells. C) I expect to have periods of little water with voiding and then sometimes to have a lot of water. D) My bones will be stronger with this disease since I will have higher calcium thannormal. The correct answer is A: I have to go at intervals for epoetin (Procrit)injections at the health department. 59. The nurse is caring for a client with uncontrolled hypertension. Whichfindings require priority nursing action? A) Lower extremity pitting edema B) Rales C) Jugular vein distension D) Weakness in left arm The correct answer is D: Weakness in left arm 60. A 2 year-old child is brought to the emergency department at 2:00 inthe afternoon. The mother states: “My child has not had a wet diaper all day.” The nursefinds the child is pale with a heart rate of 61. What assessment data should the nurse obtain next? A) Status of the eyes and the tongue B) Description of play activity C) History of fluid intake D) Dietary patterns The correct answer is A: Status of skin turgor 62.The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child? A) "I strap the infant car seat on the front seat to face backwards." B) "I place my infant in the middle of the living room floor on a blanket to play with my 4 year old while I make supper in the kitchen." C) "My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year old naps on the sofa." D) "I have the 4 year-old hold and help feed the four month-old a bottle in the kitchen while I make supper." The correct answer is D: "I have the four year-old hold and help feed the four month-old a bottle in the kitchen 63.Upon completing the admission documents, the nurse learns that the 87 year-old client does not have an advance directive. What action should the nurse take? A) Record the information on the chart B) Give information about advance directives C) Assume that this client wishes a full code D) Refer this issue to the unit secretary The correct answer is B: Give information about advance directives 64.A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes after the immunization was given, the client complains of itchy and watery eyes, increasedanxiety, and difficulty breathing. The nurse expects that the first action in the sequence of care for this client will be to A) Maintain the airway B) Administer epinephrine 1:1000 as ordered C) Monitor for hypotension with shock D) Administer diphenhydramine as ordered The correct answer is B: Administer epinephrine 1:1000 as ordered . 65.Which of these children at the site of a disaster at a child day care center would the triage nurse put in the "treat last" category? A) An infant with intermittent bulging anterior fontanel between crying episodes B) A toddler with severe deep abrasions over 98% of the body C) A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture D) A school-age child with singed eyebrows and hair on the arms The correct answer is B: A toddler with severe deep abrasions over 98% of the body . 66.When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse’s best action is to A) Change whichever item is incorrect to the correct information B) Use the bracelet and admission form until a replacement is supplied C) Notify the admissions office and wait to apply the bracelet D) Make a corrected identification bracelet for the client The correct answer is C: notify the admissions office and wait to apply the bracelet 67.The nurse is having difficulty reading the health care provider's written order that was written right before the shift change. What action should be taken? A) Leave the order for the oncoming staff to follow-up B) Contact the charge nurse for an interpretation C) Ask the pharmacy for assistance in the interpretation D) Call the provider for clarification The correct answer is D: Call the provider for clarification 68.An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to: A) check the carotid pulse B) deliver 5 abdominal thrusts C) give 2 rescue breaths D) open the client's airway The correct answer is D: open the client''s airway 69.A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action? A) Ask the client if there are any breathing problems B) Have the client void as much as possible C) Check the vital signs D) Auscultate the lungs The correct answer is D: Auscultate the lungs70. Following change-of-shift report on an orthopedic unit, which client should the nurse see first? A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago B) 20 year-old in skeletal traction for 2 weeks since a motor cycle accident C) 72 year-old recovering from surgery after a hip replacement 2 hours ago D) 75 year-old who is in skin traction prior to planned hip pinning surgery. The correct answer is C: 72 year-old recovering from surgery after a hip replacement 2 hours ago 71. A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make? A) Why don’t we now have the client turn back to the left side. B) That was done correctly. Did you have any problems with the insertion? C) Let’s check to see if the suppository is in far enough. D) Did you feel any stool in the intestinal tract? The correct answer is B: That was done correctly. Did you have any problems with the insertion? 72.A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is the appropriate type to use when performing postmortem care? A) airborne precautions B) droplet precautions C) contact precautions D) compromised host precautions The correct answer is C: contact precautions 73.The nurse is reviewing with a client how to collect a clean catch urine specimen. Which sequence is appropriate teaching? A) Void a little, clean the meatus, then collect specimen B) clean the meatus, begin voiding, then catch urine stream C) Clean the meatus, then urinate into container D) Void continuously and catch some of the urine The correct answer is B: clean the meatus, begin voiding, then catch urine stream 74.The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40 mg every day. Which of these foods would the nurse reinforce for the client to eat at least daily? A) spaghetti B) watermelon C) chicken D) tomatoes The correct answer is B: watermelon 75.A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take? A) Look up the policy on needle sticksB) Contact employee health services C) Immediately wash the hands with vigor D) Notify the supervisor and risk management The correct answer is C: Immediately wash the hands with vigor 76.As the nurse observes the student nurse during the administration of a narcotic analgesic IM injection, the nurse notes that the student begins to give the medication without first aspirating. What should the nurse do? A) Ask the student: "What did you forget to do?” B) Stop. Tell me why aspiration is needed. C) Loudly state: “You forgot to aspirate.” D) Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” The correct answer is D: Walk up and whisper in the student’s ear “Stop. Aspirate. Then inject.” 77.A client with Guillain Barre is in a non responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition? A) Comatose, breathing unlabored B) Glascow Coma Scale 8, respirations regular C) Appears to be sleeping, vital signs stable D) Glascow Coma Scale 13, no ventilator required The correct answer is B: Glascow Coma Scale 8, respirations regular 78.A client enters the emergency department unconscious via ambulance from the client’s work place. What document should be given priority to guide the direction of care for this client? A) The statement of client rights and the client self determination act B) Orders written by the health care provider C) A notarized original of advance directives brought in by the partner D) The clinical pathway protocol of the agency and the emergency department The correct answer is C: A notarized original of advance directives brought in by the Partner 79.The charge nurse has a health care team that consists of 1 PN, 1 unlicensed assistive personnel (UAP) and 1 PN nursing student. Which assignment should be questioned by the nurse manager? A) An admission at the change of shifts with atrial fibrillation and heart failure - PN B) Client who had a major stroke 6 days ago - PN nursing student C) A child with burns who has packed cells and albumin IV running - charge nurse D) An elderly client who had a myocardial infarction a week ago - UAP The correct answer is A: An admission at the change of shifts with atrial fibrillation and heart failure – PN 80.A mother brings her 3 month-old into the clinic, complaining that the child seems to be spitting up all the time and has a lot of gas. The nurse expects to find which of the following on the initial history and physical assessment? A) Increased temperature and lethargy B) Restlessness and increased mucus productionC) Increased sleeping and listlessness D) Diarrhea and poor skin turgor The correct answer is B: Restlessness and increased mucus production 81.As the nurse takes a history of a 3 year-old with neuroblastoma, what comments by the parents require follow-up and are consistent with the diagnosis? A) "The child has been listless and has lost weight." B) "The urine is dark yellow and small in amounts." C) "Clothes are becoming tighter across her abdomen." D) "We notice muscle weakness and some unsteadiness." The correct answer is C: "Clothes are becoming tighter across her abdomen." 82.A 16 year-old enters the emergency department. The triage nurse identifies that this teenager is legally married and signs the consent form for treatment. What would be the appropriate action by the nurse? A) Ask the teenager to wait until a parent or legal guardian can be contacted B) Withhold treatment until telephone consent can be obtained from the partner C) Refer the teenager to a community pediatric hospital emergency department D) Proceed with the triage process in the same manner as any adult client The correct answer is D: Proceed with the triage process in the same manner as any adult Client 83.A newly admitted elderly client is severely dehydrated. When planning care for this client, which task is appropriate to assign to an unlicensed assistive personnel (UAP)? A) Converse with the client to determine if the mucous membranes are impaired B) Report hourly outputs of less than 30 ml/hr C) Monitor client's ability for movement in the bed D) Check skin turgor every 4 hours The correct answer is B: Report output of less than 30 ml/hr 84.The nurse has admitted a 4 year-old with the diagnosis of possible rheumatic fever. Which statement by the parent would cause the nurse to suspect an association with this disease? A) Our child had chickenpox 6 months ago. B) Strep throat went through all the children at the day care last month. C) Both ears were infected over 3 months age. D) Last week both feet had a fungal skin infection. The correct answer is B: Strep throat went through all the children at the day care last month. 85.A nurse assigned to a manipulative client for 5 days becomes aware of feelings for a reluctance to interact with the client. The next action by the nurse should be to A) Discuss the feeling of reluctance with an objective peer or supervisor B) Limit contacts with the client to avoid reinforcement of the manipulative behavior C) Confront the client about the negative effects of behaviors on other clients and staff D) Develop a behavior modification plan that will promote more functional behavior The correct answer is A: Discuss the feeling of reluctance with an objective peer or Supervisor86.A client is being treated for paranoid schizophrenia. When the client became loud and boisterous, the nurse immediately placed him in seclusion as a precautionary measure. The client willingly complied. The nurse’s action A) May result in charges of unlawful seclusion and restraint B) Leaves the nurse vulnerable for charges of assault and battery C) Was appropriate in view of the client’s history of violence D) Was necessary to maintain the therapeutic milieu of the unit The correct answer is A: May result in charges of unlawful seclusion and restraint 87.A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority? A) Pain related to ischemia B) Risk for altered elimination: constipation C) Risk for complication: dysrhythmias D) Anxiety related to pain The correct answer is A: Pain related to ischemia 88.The provisions of the law for the Americans with Disabilities Act require nurse managers to A) Maintain an environment free from associated hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider both mental and physical disabilities The correct answer is B: Provide reasonable accommodations for disabled individuals 89.A 42 year-old male client refuses to take propranolol hydrochloride (Inderal) as prescribed. Which client statement s from the assessment data is likely to explain his noncompliance? A) "I have problems with diarrhea." B) "I have difficulty falling asleep." C) "I have diminished sexual function." D) "I often feel jittery." The correct answer is C: "I have diminished sexual function." 90.A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate? A) ”I will keep the cast for the next day uncovered to prevent burning of the skin." B) ”I can apply an ice pack over the area to relieve itching inside the cast." C) ”The cast should be propped on at least 2 pillows when my child is lying down." D) ”I think I remember that standing cannot be done until after 72 hours." The correct answer is D: "I think I remember that standing cannot be done until after 72 hours." 91.Which statement best describes time management strategies applied to the role of a nurse manager? A) Schedule staff efficiently to cover the needs on the managed unit B) Assume a fair share of direct client care as a role model C) Set daily goals with a prioritization of the workD) Delegate tasks to reduce work load associated with direct care and meetings The correct answer is C: Set daily goals with a prioritization of the work 92.The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that is associated with this problem include which of these? A) Lymphedema and nerve palsy B) Hearing loss and ataxia C) Headaches and vomiting D) Abdominal mass and weakness The correct answer is D: Abdominal mass and weakness 93.A 15 year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching? A) "I will only have to wear this for 6 months." B) "I should inspect my skin daily." C) "The brace will be worn day and night." D) "I can take it off when I shower." The correct answer is A: "I will only have to wear this for 6 months." 94.The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self scheduling knowing that this method will A) Improve the quality of care B) Decrease staff turnover C) Minimize the amount of overtime payouts D) Improve team morale The correct answer is D: Improve team morale 95.A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse? A) Diffuse expiratory wheezing B) Loose, productive cough C) No relief from inhalant D) Fever and chills The correct answer is A: Diffuse expiratory wheezing 96.The nurse manager hears a health care provider loudly criticize one of the staff nurses within the hearing of others. The employee does not respond to the health care provider's complaints. The nurse manager's next action should be to A) Walk up to the health care provider and quietly state: "Stop this unacceptable behavior." B) Allow the staff nurse to handle this situation without interference C) Notify the of the other administrative persons of a breech of professional conduct D) Request an immediate private meeting with the health care provider and staff nurse The correct answer is D: Request an immediate private meeting with the health care provider and staff nurse97.A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states “I demand to be released now!” The appropriate action is for the nurse to A) You cannot be released because you are still suicidal. B) You can be released only if you sign a no suicide contract. C) Let’s discuss your decision to leave and then we can prepare you for discharge. D) You have a right to sign out as soon as we get an order from the health care provider's discharge order. The correct answer is C: Let’s discuss your decision to leave and then we can prepare you for discharge. 98.A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition? A) Dyspnea B) Heart murmur C) Macular rash D) Hemorrhage The correct answer is B: Heart murmur Large, soft, rapidly developing vegetations attach to the heart valves. 99.A nurse admits a premature infant who has respiratory distress syndrome. In planning care, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to A) Stabilize thermoregulation B) Maintain alveolar surface tension C) Begin normal pulmonary blood flow D) Regulate intra cardiac pressure The correct answer is B: Maintain alveolar surface tension 100. An 18 year-old client is admitted to intensive care from the emergency room following a diving accident. The injury is suspected to be at the level of the 2nd cervical vertebrae. The nurse's priority assessment should be A) Response to stimuli B) Bladder control C) Respiratory function D) Muscle weakness The correct answer is C: Respiratory function 101. The nurse is caring for a client who was successfully resuscitated from a pulseless dysrhythmia. Which of the following assessments is CRITICAL for the nurse to include in the plan of care? A) Hourly urine output B) White blood count C) Blood glucose every 4 hours D) Temperature every 2 hours The correct answer is A: Hourly urine output 102. The charge nurse on the night shift at an urgent care center has to deal with admitting clients of a higher acuity than usual because of a large fire in the area. Which style ofleadership and decision-making would be best in this circumstance? A) Assume a decision-making role B) Seek input from staff C) Use a non-directive approach D) Shared decision-making with others The correct answer is A: Assume a decision making role 103. The nurse admitting a 5 month-old who vomited 9 times in the past 6 hours should observe for signs of which overall imbalance? A) Metabolic acidosis B) Metabolic alkalosis C) Some increase in the serum hemoglobin D) A little decrease in the serum potassium The correct answer is B: Metabolic alkalosis 104. Which activity can the RN ask an unlicensed assistive personnel (UAP) to perform? A) Take a history on a newly admitted client B) Adjust the rate of a gastric tube feeding C) Check the blood pressure of a 2 hours post operative client D) Check on a client receiving chemotherapy The correct answer is C: Check the blood pressure of a 2 hours post operative client 105. A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is A) Call for emergency transport to the hospital B) Immobilize the limb and joints above and below the injury C) Assess the child and the extent of the injury D) Apply cold compresses to the injured area The correct answer is C: Assess the child and the extent of the injury 106. When interviewing the parents of a child with asthma, it is most important to gather what information about the child's environment? A) Household pets B) New furniture C) Lead based paint D) Plants such as cactus The correct answer is A: Household pets 107. An 80 year-old client admitted with a diagnosis of possible cerebral vascular accident has had a blood pressure from 180/110 to 160/100 over the past 2 hours. The nurse has also noted increased lethargy. Which assessment finding should the nurse report immediately to the health care provider? A) Slurred speech B) Incontinence C) Muscle weakness D) Rapid pulse The correct answer is A: Slurred speech 108. A 3 year-old child is brought to the clinic by his grandmother to be seen for"scratching his bottom and wetting the bed at night." Based on these complaints, the nurse would initially assess for which problem? A) Allergies B) Scabies C) Regression D) Pinworms The correct answer is D: Pinworms 109. A 72 year-old client with osteomyelitis requires a 6 week course of intravenous antibiotics. In planning for home care, what is the most important action by the nurse? A) Investigating the client's insurance coverage for home IV antibiotic therapy B) Determining if there are adequate hand washing facilities in the home C) Assessing the client's ability to participate in self care and/or the reliability of a caregiver D) Selecting the appropriate venous access device The correct answer is C: Assessing the client''s ability to participate in self care and/or the reliability of a caregiver 110. The mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse? A) "Folic acid should be taken before and after conception." B) "Multivitamin supplements are recommended during pregnancy." C) "A well balanced diet promotes normal fetal development." D) "Increased dietary iron improves the health of mother and fetus." The correct answer is A: "Folic acid should be taken before and after conception." 111. A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse? A) Telfa dressing with antibiotic ointment B) Moist sterile non adherent dressing C) Dry sterile dressing that is occlusive D) Sterile occlusive pressure dressing The correct answer is B: Moist sterile non adherent dressing 112. A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning? A) Use ready-to-feed commercial infant formula B) Boil the tap water for 10 minutes prior to preparing the formula C) Let tap water run for 2 minutes before adding to concentrate D) Buy bottled water labeled "lead free" to mix the formula The correct answer is C: Let tap water run for 2 minutes before adding to concentrate 113. A client is admitted to the rehabilitation unit following a CVA and mild dysphagia. The most appropriate intervention for this client is A) Position client in upright position while eating B) Place client on a clear liquid dietC) Tilt head back to facilitate swallowing reflex D) Offer finger foods such as crackers or pretzels The correct answer is A: Position client in upright position while eating 114. The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, "I will receive tissue from… A) a tissue bank." B) a pig." C) my thigh." D) synthetic skin." The correct answer is C: my thigh." 115. The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority? A) Risk for dehydration B) Ineffective airway clearance C) Altered nutrition D) Risk for injury The correct answer is B: Ineffective airway clearance 116. A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to A) Promote the client's comfort B) Reduce the drying time C) Decrease irritation to the skin D) Improve venous return The correct answer is D: Improve venous return 117. During the initial home visit a nurse is discussing the care of a newly diagnosed client with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time? A) Leave a book about relaxation techniques B) Write out a daily exercise routine for them to assist the client to do C) List actions to improve the client's daily nutritional intake D) Suggest communication strategies The correct answer is D: Suggest communication strategies 118. The nurse is teaching a client with non-insulin dependent diabetes mellitus about the prescribed diet. The nurse should teach the client to A) Maintain previous calorie intake B) Keep a candy bar available at all times C) Reduce carbohydrates intake to 25% of total calories D) Keep a regular schedule of meals and snacks The correct answer is D: Keep a regular schedule of meals and snacks 119. The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and HIB immunizations. She reports that the baby feels very warm, criesinconsolably for as long as 3 hours, and has had several shaking spells. In addition to referring her to the emergency room, the nurse should document the reaction on the baby's record and expect which immunization to be most associated to the findings in the infant? A) DTaP B) Hepatitis B C) Polio D) H. Influenza The correct answer is A: DTaP 120. The nurse is teaching a class on HIV prevention. Which of the following should be emphasized as increasing risk? A) Donating blood B) Using public bathrooms C) Unprotected sex D) Touching a person with AIDS The correct answer is C: Unprotected sex 121. The charge nurse is planning assignments on a medical unit. Which client should be assigned to the unlicensed assistive personnel (UAP)? A client with A) Difficulty swallowing after a mild stroke B) an order of enemas until clear prior to colonoscopy C) an order for a post-op abdominal dressing change D) transfer orders to a long term facility The correct answer is B: an order of enemas until clear prior to colonoscopy 122. A 6 year-old child is seen for the first time in the clinic. Upon assessment, the nurse finds that the child has deformities of the joints, limbs, and fingers, thinned upper lip, and small teeth with faulty enamel. The mother states: ”My child seems to have problems in learning to count and recognizing basic colors.” Based on this data, the nurse suspects that the child is most likely showing the effects of which problem? A) Congenital abnormalities B) Chronic toxoplasmosis C) Fetal alcohol syndrome D) Lead poisoning The correct answer is C: Fetal alcohol syndrome 123. The nurse has performed the initial assessments of 4 clients admitted with an acute episode of asthma. Which assessment finding would cause the nurse to call the health care provider immediately? A) Prolonged inspiration with each breathB) Expiratory wheezes that are suddenly absent in 1 lobe C) Expectoration of large amounts of purulent mucous D) Appearance of the use of abdominal muscles for breathing The correct answer is B: Expiratory wheezes that are suddenly absent in one lobe 124. The nurse is planning a meal plan that would provide the most iron for a child with anemia. Which dinner menu would be best? A) Fish sticks, french fries, banana, cookies, milk B) Ground beef patty, lima beans, wheat roll, raisins, milk C) Chicken nuggets, macaroni, peas, cantaloupe, milk D) Peanut butter and jelly sandwich, apple slices, milk The correct answer is B: Ground beef patty, lima beans, wheat roll, raisins, milk 125. A 10 year-old client is recovering from a splenectomy following a traumatic injury. The clients laboratory results show a hemoglobin of 9 g/dL and a hematocrit of 28 percent. The best approach for the nurse to use is to A) Limit milk and milk products B) Encourage bed activities and games C) Plan nursing care around lengthy rest periods D) Promote a diet rich in iron The correct answer is C: Plan nursing care around lengthy rest periods 126. The nurse planning care for a 12 year-old child with sickle cell disease in a vasoocclusive crisis of the elbow should include which one of the following as a priority? A) Limit fluids B) Client controlled analgesia C) Cold compresses to elbow D) Passive range of motion exercise The correct answer is B: Client controlled analgesia 127. As the nurse provides discharge teaching to the parents of a 15 month-old child with Kawasaki disease. The child has received immunoglobulin therapy. Which instruction would be appropriate? A) High doses of aspirin will be continued for some time B) Complete recovery is expected within several days C) Active range of motion exercises should be done frequently D) The measles, mumps and rubella vaccine should be delayed The correct answer is D: The measles, mumps and rubella vaccine should be delayed 128. The nurse is giving instructions to the parents of a child with cystic fibrosis. The nurse would emphasize that pancreatic enzymes should be taken A) Once each day B) 3 times daily after meals C) With each meal or snack D) Each time carbohydrates are eaten The correct answer is C: With each meal or snack 129. The nurse is assessing an 8 month-old infant with a malfunctioning ventriculoperitoneal shunt. Which one of the following manifestations would the infant be most likely to exhibit? A) Lethargy B) Irritability C) Negative Moro D) Depressed fontanelThe correct answer is B: Irritability 130. The nurse is performing a physical assessment on a toddler. Which of the following should be the first action? A) Perform traumatic procedures B) Use minimal physical contact C) Proceed from head to toe D) Explain the exam in detail The correct answer is B: Use minimal physical contact 131. A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse? A) A report of 10 pounds weight loss in the last month B) A comment by the client "I just can't sit still." C) The appearance of eyeballs that appear to "pop" out of the client's eye sockets D) A report of the sudden onset of irritability in the past 2 weeks The correct answer is C: The appearance of eyeballs that appear to "pop" out of the client''s eye sockets 132. Which serum blood findings with diabetic ketoacidosis alerts the nurse that immediate action is required? A) pH below 7.3 B) Potassium of 5.0 C) HCT of 60 D) Pa O2 of 79% The correct answer is C: HCT of 60 133. The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate? A) The parents' name and telephone number B) The currency of the immunization and allergy history of the child C) The estimated time of the accidental poisoning and a confirmation that the parents will bring the containers of the ingested substance D) The affected child's age and weight The correct answer is D: The affected child''s age and weight 134. A 2 year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement? A) Place the child on clear liquids and gelatin for 24 hours B) Continue with the regular diet and include oral rehydration fluids C) Give bananas, apples, rice and toast as tolerated D) Place NPO for 24 hours, then rehydrate with milk and water The correct answer is B: Continue with the regular diet and include oral rehydration fluids 135. The nurse is teaching an elderly client how to use MDI's (multi-dose inhalers). The nurse is concerned that the client is unable to coordinate the release of the medication with the inhalation phase. What is the nurse's best recommendation to improve delivery of the medication? A) Nebulized treatments for home care B) Adding a spacer device to the MDI canisterC) Asking a family member to assist the client with the MDI D) Request a visiting nurse to follow the client at home The correct answer is B: Adding a spacer device to the MDI canister 136. Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students? A) Scratching the head more than usual B) Flakes evident on a student's shoulders C) Oval pattern occipital hair loss D) Whitish oval specks sticking to the hair The correct answer is D: Whitish oval specks sticking to the hair 137. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, the nurse would suggest for the parents to give sips of which substance? A) Tea B) Water C) Milk D) Soda The correct answer is B: Water 138. A client is scheduled for an IVP (Intravenous Pyelogram). Which of the following data from the client’s history indicate a potential hazard for this test? A) Reflex incontinence B) Allergic to shellfish C) Claustrophobia D) Hypertension The correct answer is B: Allergic to shellfish 139. The nurse is preparing a handout on infant feeding to be distributed to families visiting the clinic. Which notation should be included in the teaching materials? A) Solid foods are introduced 1 at a time beginning with cereal B) Finely ground meat should be started early to provide iron C) Egg white is added early to increase protein intake D) Solid foods should be mixed with formula in a bottle The correct answer is A: Solid foods are introduced 1 at a time beginning with cereal 140. The nurse is caring for a client with sickle cell disease who is scheduled to receive a unit of packed red blood cells. Which of the following is an appropriate action for the nurse when administering the infusion? A) Storing the packed red cells in the medicine refrigerator while starting IV B) Slow the rate of infusion if the client develops fever or chills C) Limit the infusion time of each of the unit to a maximum of 4 hoursD) Assess vital signs every 15 minutes throughout the entire infusion The correct answer is C: Limit the infusion time of each of the unit to a maximum of four hours 141. A client with a documented pulmonary embolism has the following arterial blood gases: PO2 - 70 mm hg, PCO2 - 32 mm hg, pH - 7.45, SaO2 - 87%, HCO3 - 22. Based on this data, what is the first nursing action? A) Review other lab data B) Notify the health care provider C) Administer oxygen D) Calm the client The correct answer is C: Administer oxygen 142. A client diagnosed with hepatitis C discusses his health history with the admitting nurse. The nurse should recognize which statement by the client as the most important? A) I got back from Central America a few weeks ago. B) I had the best raw oysters last week. C) I have many different sex partners. D) I had a blood transfusion 15 years ago. The correct answer is D: I had a blood transfusion 143. A client is recovering from a thyroidectomy. While monitoring the client's initial post operative condition, which of the following should the nurse report immediately? A) Tetany and paresthesia B) Mild stridor and hoarseness C) Irritability and insomnia D) Headache and nausea The correct answer is A: Tetany and paresthesia 144. A client is admitted with a right upper lobe infiltrate and to rule out tuberculosis. The most appropriate action by the nurse to protect the self would be which of these? A) Negative room ventilation B) Face mask with sheild C) Particulate respirator mask D) Airborne precautions The correct answer is C: Particulate respirator mask 145. A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report? A) The client lost 2 pounds in 24 hours B) The client’s potassium level is 4 mEq/liter. C) The client’s urine output was 1500 cc in 5 hours D) The client is to receive another dose of Lasix at 10 PM The correct answer is C: The client’s urine output was 1500 cc in five hours 146. The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied A) When it is 1/3 to 1/2 full B) Prior to meals C) After each fecal elimination D) At the same time each day The correct answer is A: When it is 1/3 to 1/2 full 147. Lactulose (Chronulac) has been prescribed for a client with advanced liver disease. Which of the following assessments would the nurse use to evaluate the effectiveness ofthis treatment? A) An increase in appetite B) A decrease in fluid retention C) A decrease in lethargy D) A reduction in jaundice The correct answer is C: A decrease in lethargy 148. The mother of a 3 month-old infant tells the nurse that she wants to change from formula to whole milk and add cereal and meats to the diet. What should be emphasized as the nurse teaches about infant nutrition? A) Solid foods should be introduced at 3-4 months B) Whole milk is difficult for a young infant to digest C) Fluoridated tap water should be used to dilute milk D) Supplemental apple juice can be used between feedings The correct answer is B: Whole milk is difficult for a young infant to digest 149. The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period? A) Estrogen replacement therapy B) 10% less than ideal body weight C) Hypersensitivity to heparin D) History of hepatitis The correct answer is A: Estrogen replacement therapy 150. The nurse is planning discharge for a 90 year-old client with musculoskeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls? A) Place nightlight in the bedroom B) Wear eyeglasses at all times C) Install grab bars in the bathroom D) Teach muscle strengthening exercises The correct answer is A: Place nightlight in the bedroom 151. An 8 year-old client is admitted to the hospital for surgery. The child’s parent reports the following allergies. Of these allergies which one should all health care personnel be aware of? A) Shellfish B) Molds C) Balloons D) Perfumed soap The correct answer is C: Balloons 152. The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Continue to monitor the client to see if the bubbling increases D) Instruct the client to try to avoid coughing The correct answer is C: Continue to monitor the client to see if the bubbling increases 153. The nurse is reinforcing teaching to a 24 year-old woman receiving acyclovir(Zovirax) for a Herpes Simplex Virus type 2 infection. Which of these instructions should the nurse give the client? A) Complete the entire course of the medication for an effective cure B) Begin treatment with acyclovir at the onset of symptoms of recurrence C) Stop treatment if she thinks she may be pregnant to prevent birth defects D) Continue to take prophylactic doses for at least 5 years after the diagnosis The correct answer is B: Begin treatment with acyclovir at the onset of symptoms of recurrence 154. An 8 year-old child is hospitalized during the edema phase of minimal change nephrotic syndrome. The nurse is assisting in choosing the lunch menu. Which menu is the best choice? A) Bologna sandwich, pudding, milk B) Frankfurter, baked potato, milk C) Chicken strips, corn on the cob, milk D) Grilled cheese sandwich, apple, milk The correct answer is C: Chicken strips, corn on the cob, milk 155. The nurse is teaching parents about accidental poisoning in children. Which point should be emphasized? A) Call the Poison Control Center once the situation is identified B) Empty the child's mouth in any case of possible poisoning C) Have the child move minimally if a toxic substance was inhaled D) Do not induce vomiting if the poison is a hydrocarbon The correct answer is B: Empty the child''s mouth in any case of possible poisoning 156. Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose? A) Drowsiness, lethargy, and inactivity B) Dry mouth, nasal congestion, and blurred vision C) Rash, blood dyscrasias, severe depression D) Hyperglycemia, weight gain, and edema The correct answer is C: Rash, blood dyscrasias, severe depression 157. The nurse is planning care for a 14 year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan? A) Antibiotic therapy for 10 days B) Teach client isometric exercises for legs C) Assess movement and sensation of extremities D) Assist to stand up at bedside within the first 24 hours The correct answer is C: Assess movement and sensation of extremities 158. A 3 year-old child diagnosed as having celiac disease attends a day care center. Which of the following would be an appropriate snack? A) Cheese crackers B) Peanut butter sandwich C) Potato chipsD) Vanilla cookies The correct answer is C: Potato chips 159. A client with moderate persistent asthma is admitted for a minor surgical procedure. On admission the peak flow meter is measured at 480 liters/minute. Post- operatively the client is complaining of chest tightness. The peak flow has dropped to 200 liters/minute. What should the nurse do first? A) Notify the health care provider B) Administer the PRN dose of Albuterol C) Apply oxygen at 2 liters per nasal cannula D) Repeat the peak flow reading in 30 minutes The correct answer is B: Administer the PRN dose of Albuterol 160. What finding signifies that children have attained the stage of concrete operations (Piaget)? A) Explores the environment with the use of sight and movement B) Thinks in mental images or word pictures C) Makes the moral judgement that "stealing is wrong" D) Reasons that homework is time-consuming yet necessary The correct answer is C: Makes the moral judgment that "stealing is wrong" [Show More]

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