V3 2020 NURSING nursing 1 2020 HESI RN EXIT v3

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V3 2020 NURSING nursing 1 2020 HESI RN EXIT v3 V3 2020 NURSING nursing 1 2020 HESI RN EXIT v3 1. An adult client being admitted to the psychiatric unit with a diagnosis of bipolar disorder arrives... in an elated state. What is the best room assignment the nurse can make for this client? A) a quiet room away from the nurse’s station B) a bright-colored room located near the recreation room C) a room that contains very little furniture D) a room that has at least two other clients assigned to it 2. The community health nurse is planning to visit four clients with schizophrenia. Which client should the nurse see first? A) a mother who took her children from school because of aliens were after them B) a young man who has a history of substance abuse and has no telephone C) a newly diagnosed client who needs to be evaluated for medication compliance D) a young man recently released from prison who requires an intake assessment 3. A female client, the mother of two small children, appears depressed after learning from her healthcare provider that she has multiple sclerosis. Which nursing intervention should the nurse implement first? A) encourage the family to be available to the client as much as possible B) provide the client with information about the Multiple Sclerosis Society C) sit quietly with the client and answer questions she may ask D) leave the room so the client has privacy to grieve 4. Which statement by a client with emphysema indicates the best understanding of the purpose of pulmonary function testing? A) “I won’t pass the test because I smoke and have emphysema” B) “It will measure how well my lungs are working” C) “This test measures how much oxygen I have in my lungs” D) “I’m afraid I’ll find out that I have lung cancer” 5. An adolescent male client is admitted to the hospital. Based on Erikson’s theory of psychosocial development, which nursing intervention best assists this adolescent’s adjustment to his hospital stay? A) invite him to participate in the evening group activity B) schedule frequent private phone calls to his parents C) provide access to a variety of video games in his room D) encourage him to learn his way around the hospital 6. Which individual may legally sign an informed consent? A) a 16-year-old mother for her newborn B) the friend of an 84-year-old married client C) a 56-year-old who questions a proposed treatment plan D) a 42-year-old client who is sedated 7. The nurse is working on a psychiatric unit is concerned about providing ethical and legally defensible care for clients on the unit. Which occurrence is an indication that a client’s civil rights are being violated? A client who A) is anorexic is not allowed to go to the bathroom after meals unless accompanied by a staff member B) attempted suicide recently is not allowed to wear a belt or have shoelacesV3 2020 C) made threatening phone calls is allowed to make phone calls only under the supervision of a staff member D) refused to take an oral psychiatric medication is administered the same medication as an IM injection 8. Which statement by the mother of a toddler girl indicates to the nurse that a scheduled vaccine should not be administered? A) “Her arms gets all red and hurts a lot every time she gets a vaccination” B) “Her throat closed up so bad she couldn’t breathe the last time she got this shot” C) “My child has been running a little fever and has a runny nose and cough” D) “Her baby brother has a virus and has had diarrhea for three days now” 9. Thirty-six hours after delivery, the nurse assesses a client’s fundus just above the umbilicus and displaced to the right of midline. What action should the nurse take first? A) assess the amount of lochia B) ask the client when her last bowel movement occurred C) catheterize the client and record the amount D) palpate the bladder for distention 10. A hospitalized 81-year-old female client has numerous complaints and uses her call button often to summon staff to help her with activities that she is capable of performing for herself. Which plan might be most beneficial in dealing with this client? A) set up a meeting with the client, her family, and all staff members to discuss the client’s demands B) check on the client at designated time intervals and let the client know when the nurse will return C) ask the nursing supervisor to move the client to another unit where the nurse-client ratio is higher D) rotate assignment of this client among staff members so that one nurse is not overworked 11. When giving a cooling bath to reduce the fever of a 3-year-old child, which action should the nurse include? A) gently massage the arms and legs with rubbing alcohol B) pour tepid water over the child’s back and chest C) stroke the child’s abdomen with cooling lotion D) apply an ice pack to the back of the child’s neck 12. The nurse determines that a client has a potential (high risk) problem. What is important for the nurse to do when planning care? A) document the current manifestations of the problem B) limit the number of interventions being planned C) direct nursing actions toward reducing risk factors D) Identify the problem as having a low priority 13. The nurse notes that the influenza immunization rates are much lower for certain demographic groups than for others. Which intervention is likely to be most useful in increasing the rates of immunization in these low immunization groups? A) legislative proposal that mandates influenza vaccinations for all B) designated clinics conveniently located in target neighborhoods C) reports describe influenza rates during times of greatest prevalence D) radio announcements about the availability of the influenza vaccineV3 2020 14. The first time a male client stands at the bedside following a total hip replacement, he reports severe pain in his left calf. What intervention should the nurse take first? A) remind the client of the importance of postoperative mobility B) use a pain scale to evaluate the severity of the pain C) return the client to bed and assess the lower extremities D) transfer the client to a chair and elevate the lower extremities 15. A client is receiving an IV of 5% dextrose in Lactated Ringer’s solution at a rate of 100 ml/hour. The client tells the nurse, “I don’t need to eat because I’m getting all the nutrition I need through this IV needle.” What initial response would be best for the nurse to provide this client? A) “It is very important to keep eating. Why don’t you want to eat?” B) “The IV does contain nutrients, but eating is very important” C) “This IV is called hypertonic, and is more concentrated than your blood” D) “Only a very small amount of the calories you need are provided by your IV” 16. The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this assessment? A) “The nurse at night is trying to poison me with pills” B) “The voices are telling me to kill the next person I see” C) “The fire is burning my skin away right now” D) “The snakes on the wall are going to eat me” 17. A male client returns to the acute care unit following surgery with sequential compression devices in place. The nurse observes that the client dorsiflexes his feet frequently. What action should the nurse implement? A) advise the client to avoid flexing his feet while wearing the compression devices B) offer to massage the client’s feet and legs while assisting him with personal care C) remove the sequential compression devices while the client exercises his feet D) encourage the client to perform foot exercises regularly while his mobility is limited 18. Which statement by a 16-year-old male client with acute osteomyelitis in his leg indicates the best understanding of the appropriate activity level for his disorder? A) “During this illness, I need to keep my leg as immobile as possible” B) “As long as I don’t re-injure my leg, I can resume my normal activities” C) “I need to exercise my leg as much as possible to maintain muscle tone” D) “I will not be able to participate in contact sports ever again” 19. The nurse has conducted a cancer prevention community education program. In evaluating the participants’ understanding of the carcinogens, what statement indicates an accurate understanding? A) environmental factors such as sunlight and chemicals can cause cancer to spread B) substances that change a cell so that it becomes cancerous are potential sources of cancer C) carcinogens are in the environment and cannot be avoided D) carcinogens are substances that contain cancerous cells 20. A 25-year-old female client is diagnosed with endometriosis by her headline provider. Which nursing diagnosis has the highest priority? A) low self-esteem related to potential infertility B) anxiety related to the possibility of surgical intervention C) pain related to extrauterine tissue inflammation D) anxiety related to the fear of infertilityV3 2020 21. The charge nurse is supervising a newly licensed practical nurse (PN) who is administering medications. The PN notes that a client with exophthalmos is scheduled to receive artificial tear drops. What action should the charge nurse implement? A) instruct the PN to hold the medication until the healthcare provider is contacted B) remind the PN to evaluate the effectiveness of the medication after administration C) change staff assignments so an RN can administer medications to this client D) advise the PN that the charge nurse will administer the medication to this client 22. The charge nurse is assessing the morning lab work on four clients. Which client’s laboratory findings should prompt the charge nurse to contact the healthcare provider immediately? A) a 35-year-old diagnosed with pneumonia having a white blood cell (WBC) of 13,000 mm3 B) a 29-year-old diagnosed with ulcerative colitis having a serum potassium level of 3.1 mEq/L C) a 74-year-old diagnosed with COPD who has ABGs of pH 7.35, PaCO2 49, PaO2 74, HCO3 26 D) a 50-year-old diagnosed with myocardial infarction who has an elevated CPK-MB on serial cardiac isoenzymes 23. When assessing a client with Raynaud’s disease, which symptoms should the nurse expect the client to exhibit? A) complaints of cramps in the feet or legs after exercise B) feeling of heart beating in the abdomen when lying down C) headache, epistaxis and papilledema D) coldness, pain and pallor of fingertips, toes, and tip of nose 24. A client is currently receiving an infusion of 25,000 units Heparin in 500 ml of normal saline at 10 ml/hour. A prescription is received to change the rate of the infusion to 700 units of Heparin per hour. The nurse should set the infusion pump to deliver how many ml/hour? (Enter numeric value only.) Answer: 14 Rationale: 1) 25,000 units/500 ml = 50 units/1ml 2) Using desired/have x volune: 700 units/50 units x 1 ml = 14 ml/hour 25. An elderly client is suspected of having a cardiac dysrhythmia. The nurse knows that it is most important to obtain which information when assessing this client? A) changes in mentation, personality, and behavior B) blood glucose level C) nutritional history, focusing on fat content of the diet D) ability to perform range of motion exercises 26. A client has developed drug toxicity after receiving a high dose of a medication with prolonged half life. After consulting with the healthcare provider, the nurse expects to administer which treatment plan? A) hold the administration of any fluids or medications until the toxic drug is cleared from the client’s body B) several doses of an antagonistic medication with a short half life administered at frequent time intervals C) a high dose of an antagonistic medication with a short half life administered rapidly as a one time dose D) continuous IV infusion of a synergistic drug for the duration of the toxic drug’s half life 27. The nurse is assigned to care for a group of four clients. Based on priority of need, arrange in the order in which the nurse should assess these four clients, with the first client the nurse should assess on top and the last client the nurse should assess on the bottom. The client who has:V3 2020 Answer in correct order: 1) Type 1 diabetes mellitus with a blood sugar of 55 mg/dl 2) a T6 spinal cord injury with a blood pressure of 180/89 3) end stage renal disease with a serum creatinine of 10 mg/dl 4) a total hip prosthesis with a 12 g hemoglobin 28. A 22-year-old female client calls the public health clinic because her breasts are tender and she felt several small lumps during a breast self-examination (BSE). What information should the nurse elicit from the client first? A) technique used to examine the breasts B) daily intake of foods and fluids containing caffeine C) date of last menstrual period D) history of familial breast cancer 29. An adolescent female who has been a lacto-ovo-vegetarian for six months tells the nurse she is experiencing increasing fatigue. What dietary recommendation should the nurse provide? A) eat spinach three times a week B) increase intake of fruit to 6 servings per day C) decrease saturated fat intake D) eliminate carbonated soft drinks from the diet 30. A client who has been admitted to the Emergency Department following a sexual assault tells the nurse that she wants to use emergency contraception. Pending the results of a pregnancy test, what information is most important for the nurse to obtain from this client? A) length of time since the rape occurred B) ability to access and pay for emergency contraception C) date of last normal menstrual period D) understanding of the emergency contraception regimen 31. A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? A) offer information about ultrasonography and genotyping to determine sex assignment B) explain that corrective surgical procedures consistent with sex assignment can be delayed C) discuss the need for cortisol and aldosterone replacement therapy after discharge D) support the parents in their decision to assign sex of their child according to their preference 32. A nurse is assessing a client who has an arteriovenous (AV) graft in the right forearm for hemodialysis access. The nurse auscultates a bruit over the graft area. What intervention should the nurse implement? A) assess the client’s temperature B) elevate the extremity C) apply gentle pressure D) document the findings 33. What assessment finding places a client at risk for problems associated with impaired skin integrity? A) absence of skin tenting B) smooth nail texture C) scattered macula on the face D) capillary refill 5 seconds 34. The nurse is evaluating discharge teaching of an adolescent who had a long leg cast applied in the emergency department. Which statement by the adolescent indicates an understanding of cast care? A) “I should wrap a cloth around a stick before using it to scratch under my cast”V3 2020 B) “I will not be able to take a shower until the cast is removed from my leg” C) “I will put adhesive tape around the edges of the cast if they become sharp” D) “If my toes are tingling I will elevate my leg above my heart, on several pillows” 35. What instruction should the nurse include in the discharge teaching plan of a client who has recently been diagnosed with Parkinson’s disease? A) increasing fluid intake to compensate for the chronic diarrhea associated with Parkinson’s B) a progressive program of daily exercise to increase muscle strength C) how to care for hand splints and prevent skin irritation associated with their use D) side effects to anticipate with the regular use of NSAIDs (non-steroidal anti-inflammatory drugs) 36. Which type of therapeutic bath should the nurse recommend to a client who is complaining of pruritis? A) an emollient bath B) a colloidal bath C) an antibacterial bath D) a Betadine bath 37. A child is to receive vancomycin (Vancocin) 40 mg/kg IV one hour before a scheduled procedure. The child weighs 44 pounds. How many mg of the medication should the nurse administer? (Enter numeric value only.) Answer: 800 Rationale: 1) First, convert the child’s weight to kg: 44 pounds divded by 2.2 pounds/kg = 20 kg 2) Next, calculate the mg/kg dose, 40 mg x 20 kg = 800 mg 38. While interviewing an elderly client, the nurse observes that the client’s hands tremble uncontrollably while reaching for a glass of water. How should the nurse document this finding? A) muscle flaccidity B) intention tremor C) sensory dysfunction D) transient ischemic attack 39. A 60-year-old male client is admitted to the hospital with the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client? A) optic nerve using an ophthalmoscope B) Glasgow coma scale C) pulses, paresthesia, paralysis distal to the right knee D) pulses, paresthesia, paralysis proximal to the right knee 40. The parents of a 4-week-old infant phone the pediatric clinic to report that their infant eats well but vomits after each feeding. To differentiate between normal regurgitation and pyloric stenosis, which information is most important for the nurse to obtain? A) degree of forcefulness of vomiting episodes B) level of infant’s distress after vomiting C) position of the infant when vomiting occurs D) odor and texture associated with emesis 41. Proper nutrition is crucial for a client who is in acute renal failure. What is the recommended diet for this client? A) high protein, low carbohydrate, low sodium, high potassium B) high protein, low carbohydrate, low sodium, low potassiumV3 2020 C) low protein, high carbohydrate, low sodium, high potassium D) low protein, high carbohydrate, low sodium, low potassium 42. During a home visit, the nurse learns that a client is taking calcium polycarbophil (FiberCon), an overthe-counter laxative. A single tablet contains 500 mg and the maximum daily dose is 6 grams. What is the maximum number of tablets the client should take in one day? (Enter the numeric value only.) Answer: 12 Rationale: 1) 6 g = 6000 mg 2) Using the desired/have formula to determine the maximum safe dose in tablets: 6000 mg/500 mg = 12 tablets 43. A 9-year-old girl is diagnosed with nontropical sprue (celiac disease), and the nurse is evaluating teaching about a gluten-free diet. What action indicates that the teaching is successful? A) family members state that they will read the brochures about the diet B) the girl’s mother tells the nurse that the entire family will adhere to the diet C) the girl chooses a rice cake instead of whole-wheat toast for breakfast D) the entire family plans to attend a topic-related support group 44. What intervention is most important to include in the nursing care plan of a client who is receiving chemotherapy and has a platelet count of 30,000/mm3? A) observe for signs of dehydration B) assess the client for abnormal bleeding C) place the client in reverse isolation D) frequently assess the client’s blood pressure 45. When conducting a postpartum assessment, the nurse notes that the client has a positive Homan’s sign. Based on this finding, what action should the nurse take? A) assess the client’s temperature and respirations B) tell the client to remain in bed and notify the healthcare provider C) assess the client’s bladder and bowel functioning D) chart the finding and assess the client’s hemoglobin 46. When is the best time for the nurse to assess a client for residual urine? A) after draining the urinary catheter bag B) when the client’s bladder is distended C) immediately after the client voids D) just prior to the client voiding 47. The nurse determines that the serum lithium level of a client who is admitted in an acute manic episode is 0.9 mEq/L. What action should the nurse implement? A) collect a specimen for serum sodium B) hold the next dose of lithium C) give the next dose of lithium D) observe the client for lithium toxicity 48. The hospital nurse-educator is planning a prenatal education class for adolescents in their third trimester of pregnancy. Which teaching technique should the nurse use to meet the needs of this group of clients? A) limit attendance at the classes to the client and one other designated person B) practice bathing and diapering dolls that look and feel like newborn infants C) invite new adult mothers and fathers to help present course materials D) emphasize how labor preparation will affect the client rather than the babyV3 2020 49. It would be of greatest benefit for the client with which problem related to diabetes mellitus to change from the use of insulin syringes to using an insulin pen for medication administration? A) diminished dexterity due to finger paresthesias B) blindness secondary to diabetic retinopathy C) lipodystrophy from continuous use of one injection site D) hyperglycemia due to noncompliance with diet 50. A client’s case is being reviewed by the hospital’s mutli-disciplinary ethics committee. What information could the nurse provide to the committee regarding this case? A) descriptions of client behavior during the hospitalization that indicate ineffective coping B) information about treatment alternatives that offer the greatest chance of recovery C) counsel on how to legally document the client’s wishes to have the living will enacted D) advice about handling a spiritual conflict a client may experience as a result of an ethical crisis 51. Which turning schedule demonstrates the best positioning routine for a client on prescribed bedrest? A) alternating right and left lateral positions B) right lateral to supine to left lateral positions C) supine to Fowler’s to lateral positions D) supine to Semi-Fowler’s positions 52. The nurse-manager of a pediatric unit needs to assign a room to a 6-month-old diagnosed with respiratory syncytial virus (RSV). Which room assignment is best for this child? A) single room with a sink inside the room B) double room with a 3-month-old who has RSV C) double room with a 6-month-old who has fifth disease D) single room with negative air pressure 53. When caring for a client who had a craniotomy yesterday for removal of a pituitary tumor, which finding indicates to the nurse that further information is needed? A) suture line is slightly reddened and swollen B) Glasgow coma scale (GCS) score is 14 C) urine output for 8 hours is 2,000 ml with specific gravity of 1.001 D) white blood cells (WBC) are 1100/mm3 and glucose is 138 mg/dl 54. A 59-year-old female client who has diabetes is receiving 25 units of NPH-100 insulin each morning. What assessment finding indicates that this amount of insulin is inadequate to meet this client’s current needs? A) a wound on the client’s ankle starts to drain and she complains of pain B) client complains of blurred vision and an inability to focus her eyes, especially during the evening hours C) the client’s serum glucose reading has been over 260 mg/dl for the past two evenings D) client complains of being slightly nauseated in the morning, but was able to eat her meal the night before 55. In assessing a client four hours after a total knee replacement, the nurse observes that the amount of drainage in the client’s autotransfusion collection container has increased from 50 ml/hour to 200 ml/hour. What is the priority nursing action? A) assess the client’s level of pain B) test the drainage for occult bloodV3 2020 C) notify the surgeon immediately D) increase the amount of suction 56. A client with a C-7 spinal cord injury is experiencing autonomic dysreflexia. The nurse should first assess the client for which precipitating factor? A) misalignment of the skeletal traction B) profuse diaphoresis on the forehead C) a severe pounding headache D) a distended bladder 57. The healthcare provider prescribed 3 liters of D6W to infuse in 24 hours. The IV administration set delivers 10 gtt/ml. The nurse should program the infusion pump to deliver how many ml per hour? (Enter numeric value only.) Answer: 125 Rationale: 1) 3000 ml/24 hours = 125 ml/hr 2) The drop factor is not used to calculate the infusion pump rate of ml/hour because the roller clamp should be fully open to provide free flow access to the pump for regulation. 58. An adult male client, two days postoperative knee surgery, is diaphoretic and experiencing visual hallucinations. He has been using a PCA pump with morphine for pain control since surgery. On admission, he described a daily intake of six cans of beer nightly. What is the priority nursing intervention? A) discontinue the PCA pump B) obtain the client’s vital signs C) assess the amount of morphine used in the last 8 hours D) notify the healthcare provider immediately 59. The nurse notes that a female client with a T-tube excreted a total of 300 ml of greenish-brown drainage in the sixteen hours since her cholecystectomy. What nursing action has the highest priority at this time? A) place the client in Fowler’s position B) begin clamping the tube for one hour during meals C) document findings in the client record D) notify the healthcare provider of the findings 60. A 3-month-old with developmental dysplasia of the hip (DDH) is being discharged with a Pavlik harness. Which information should the nurse provide the parents about the use of the harness? A) the harness is worn continuously until the hip is clinically and radiographically stable, about 3 to 5 months B) the harness should be worn for 6 months during the day and at night while the child is doublediapered C) the harness is worn for 4 to 6 weeks and then a hip spica cast is applied for the remainder of the treatment D) to avoid interfering with normal movement, the harness is worn for one year while the child is sleeping 61. Which information should the nurse offer family members to support the administration of vitamin K to a newborn infant? A) newborns do not ingest adequate amounts of fat soluble vitamins from feedings B) state law requires that all newborns receive an injection of vitamin K C) healthcare providers routinely recommend and prescribe vitamin K for newbornsV3 2020 D) vitamin K is administered to stimulate the production of clotting factors 62. A client two days postoperative after receiving a coronary artery bypass graft is suspected of having a pulmonary embolus (PE). Which assessment finding should the nurse recognize as characteristic of PE? A) urine output of 200 ml every hour B) heart rate of 52 beats/minute C) blood pressure of 170/90 D) respiratory rate of 34 breaths/minute 63. While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. What action should the nurse implement next? A) reposition the stethoscope in the antecubital fossa over the palpable brachial pulse point B) inflate the cuff quickly to a higher mm of Hg reading than the previously auscultated systolic sound C) continue the blood pressure assessment until the last Korotkoff sound is heard D) release the air and reinflate the cuff to 30 mm Hg above the client’s previous systolic reading 64. A male client tells the home health nurse that he has started taking magnesium hydroxide and aluminum hydroxide (Maalox) to treat occasional heartburn. It is most important for the nurse to review the client’s medical history regarding the presence of which disorder? A) renal disease B) diabetes mellitus C) chronic bronchitis D) deep vein thrombosis 65. The nurse assigns an unlicensed assistive personnel (UAP) to take the vital signs of a client who is positive for Human Immunodeficiency Virus (HIV). What protective apparel should the nurse counsel the UAP to wear when carrying out this assignment? A) none B) gown, gloves, mask, C) gloves only D) gloves and mask 66. A 4-year-old is admitted to intensive care following heart surgery for Tetrology of Fallot and the nurse is planning immediate postoperative care. Which intervention should the nurse include in this child’s plan of care? A) elevate the head of the bed to 30 degrees B) continued use of hypothermia blanket C) increase fluids to maintain the blood pressure D) turn, cough, and deep breathe every shift 67. The nurse administers acetylcysteine (Mucomyst) to a client with thick mucous and a nonproductive cough. To evaluate the effectiveness of the medication, what question should the nurse ask the client? A) “How much phlegm are you coughing up?” B) “Are you still coughing?” C) “What color is the mucous?” D) “Are you experiencing any pain when you cough?” 68. The nurse is preparing to administer 1,000 ml of dextrose 25% total parenteral nutrition (TPN) to a client with ulcerative colitis. Which intervention is most important for the nurse to implement?V3 2020 A) review the client’s intake and output B) evaluate the client’s nutritional history C) assess vital signs prior to administration D) administer the TPN through a central line 69. A high-school girl asks the school nurse what to do about her fingernails that look “so awful” since she had her artificial nails removed 6 weeks ago. On inspection, the nurse finds the girl’s nails are thickened, cracked, and yellowing. What instruction should the nurse provide? A) avoid harsh chemicals and abrasives on the nails B) do not use manicure products that dry the nails c) use a prescribed systemic antifungal medication D) keep nails short and trimmed straight across 70. The nurse is preparing to administer an injection to a 5-year-old boy, and he asks the nurse if it is going to hurt. What response is best for the nurse to provide? A) reassure the child that the injection will not hurt B) instruct the child to look the other way during the injection C) tell the child that the injection will hurt some D) instruct the mother to hold the child securely 71. When assessing a male client who is receiving a unit of packed red blood cells (PRBCs), the nurse notes that the infusion was started 30 minutes ago, and 50 ml of blood is left to be infused. The client’s vital signs are within normal limits. He reports feeling “out of breath” but denies any other complaints. What action should the nurse take at this time? A) ask the respiratory therapist to administer PRN albuterol (Ventolin) B) administer a PRN prescription for diphenhydramine (Benadryl) C) start the normal saline attached to the Y-tubing at the same rate D) decrease the intravenous flow rate of the PRBC transfusion 72. The nurse is evaluating a client’s central venous pressure (CVP) readings that are trending upwards. What nursing diagnosis is supported by the pathophysiologic mechanism most likely causing the increases? A) inadequate airway clearance B) impaired cardiac output C) ineffective tissue perfusion D) fluid volume deficit 73. The unlicensed assistive personnel (UAP) helping the nurse with the care of a client with Clostridium difficile infection has obtained a box of disposable gowns and placed them in the client’s room. What action should the nurse implement? A) remind the UAP to obtain face masks and goggles as well as gowns B) inform the UAP that gowns will not be needed in caring for this client C) advise the UAP to place the box of gowns outside the client’s room D) determine why the UAP felt that gowns were needed for the client 74. A client comes to the prenatal clinic on April 20th and her estimated date of birth (EDB) is July 15th. Identify the location where the nurse expects to locate the fundus. (Click the chosen location. To change, click on the new location.)V3 2020 Answer in box area (correct area). Rationale: The number of weeks between April 22 and July 15 is 28. (12 weeks remaining in pregnancy.) The client is now at 28-weeks gestation, so the fundus should be beween the umbilicus and xiphoid process. 75. Which statement would the nurse consider characteristic of a client diagnosed with diabetes insipidus (DI)? A) “I am always thirsty and crave cold water” B) “I stay hungry all of the time” C) “I have gained a lot of weight” D) “I urinate about 4 times a day, and it is straw-colored” 76. Which discharge instruction has the greatest priority for the mother of a 6-year-old who was diagnosed with Type 1 diabetes mellitus one week ago? A) “Draw regular insulin into a syringe before NPH insulin” B) “Measure blood sugar at least four times daily” C) “Always carry a quick source of sugar” D) “Eat a well-balanced diet” 77. To assess for the presence of lower extremity parasthesia, what action should the nurse take? A) tap the client’s knee tendons with a reflex hammer B) palpate the client’s calf muscles while at rest C) observe the client’s gait while ambulating D) apply touch and pain stimuli to the client’s legs 78. A client in the first trimester of pregnancy calls the prenatal clinic to report she is nauseated and her stools are black and thick since she started taking iron supplements last week. How should the nurse respond? (Select all that apply.) A) changes in color and consistency of stool are normal B) take the iron with breakfast C) increase the consumption of milk while taking iron D) drink a full glass of tea with each iron tablet E) take the iron supplement at bedtime F) come to the clinic today 79. An infant admitted to the neonatal intensive care unit is tachypneic, tachycardiac, and has bounding brachial pulses. The healthcare provider suspects that the infant has coarctation of the aorta. Which intervention is most important for the nurse to include in this infant’s plan of care? A) assess for centralized cyanosis 4 times daily B) auscultate for a diastolic murmur daily C) correct respiratory alkalosis related to tachypnea D) monitor for congestive heart failure 80. A client with which problem requires the most immediate intervention by the nurse? A) increasing sharp pain related to plantar fasciitis B) finger paresthesias related to carpal tunnel syndrome C) increasing sharp pain related to compartment syndrome D) increasing burning pain related to a Morton’s neuromaV3 2020 81. A client at 40-weeks gestation is admitted to labor and delivery. Her obstetrical history includes 3 live births at 39-, 38-, and 35-weeks gestation, 2 miscarriages at 6- and 8-weeks gestation, and a fetal demise at 33-weeks gestation. Which is an accurate summary of this client’s obstetrical history? A) gravida 7 term 1 preterm 3 abortion 2 living 4 B) gravida 6 term 3 preterm 1 abortion 2 living 3 C) gravida 6 term 2 preterm 2 abortion 2 living 4 D) gravida 7 term 2 preterm 2 abortion 2 living 3 82. A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant’s eyes. He asks the nurse what the purpose of the ointment is. The nurse would be correct in stating that the purpose for using the ointment is to A) prevent eye infections B) dilate the pupil so the red reflex can be visualized C) clear the infant’s vision D) prevent herpes infection 83. Which client situation requires the most immediate intervention by the nurse? A) a four centimeter area of dehiscence is observed on a client’s abdominal incision one day after surgery B) a stage IV pressure ulcer has a five centimeter area of necrosis surrounded by pale pink tissue C) a stage II pressure ulcer located on a client’s sacrum is draining a moderate amount of purulent drainage D) a six centimeter area of reactive hyperemia is observed over the left trochanter of a bedfast client 84. A client is having trouble breathing while lying in a dorsal recumbent position. What action should the nurse implement first? A) elevate the head of the bed B) obtain a pulse oximeter C) document the presence of orthopnea D) assess the client’s vital signs 85. When assessing the oral temperature of an adult client at 6:00 p.m., the nurse notes that the client’s temperature at 6:00 a.m. was 97.2F, and is now 98.8F. What intervention should the nurse implement? A) notify the healthcare provider of the increase in temperature B) document this temperature variation on the graphic sheet C) administer a PRN dose of medication to reduce the fever D) document this intermittent fever in the nurse’s notes 86. The nurse is planning to provide mouth care for an unconscious client. Which statement is accurate in regard to implementing mouth care for this client? A) unconscious clients need less frequent mouth care than conscious clients because they are not eating B) positioning the unconscious client flat with the head turned to the side is the key to providing safety during mouth care C) cleaning the inner cheeks and outer gum surfaces with glycerin swabs is the best method of providing mouth care for an unconscious client D) brushing an unconscious client’s teeth should be avoided because of his/her ability to cooperate with the procedureV3 2020 87. In monitoring a client receiving antibiotics for acute glomerulonephritis, which laboratory test result requires the most immediate intervention by the nurse? A) serum potassium of 6 mEq/L B) serum sodium of 150 mEq/L C) presence of protein in the urine D) white blood cell count of 14,000 mm3 88. A client is in the emergency center following a thoracic injury. Assessment data include: a 50 palpable systolic blood pressure, an increased in the right atrial pressure (RAP) from 6 to 25, distended neck veins, and very distant heart sounds. What intervention should the nurse anticipate based on these findings? A) pericardiocentesis B) endotracheal intubation C) emergency tracheostomy D) chest tube insertion 89. The nurse assesses that a client has nailbed clubbing. What additional information is consistent with this finding? A) oxygen saturation of 85% B) +3 peripheral dependent edema C) capillary refill < 3 seconds D) absent deep tendon reflexes 90. What finding would warrant further investigation to determine if a client in septic shock was experiencing the serious complication of disseminated intravascular coagulation (DIC)? A) the mucous membranes are pink but appear dry and cracked B) there is a marked increase in atelectasis visible on x-ray C) the jugular catheter is oozing blood at the insertion site D) the urine is frothy and is dark amber in color 91. While conducting an interview to obtain a health history, the nurse notices that the client pauses frequently and looks at the nurse expectantly. Which response is best for the nurse to provide? A) sit quietly to allow the client to respond comfortably B) reassure the client that there are no wrong answers C) tell the client to return later for another interview D) continue to ask questions until the client responds 92. During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe a PRN dose of an oral over-the-counter laxative for a client who is constipated. What instruction should the RN provide the unit clerk? A) ask the healthcare provider to remain on “hold” until the RN can confirm the prescription B) tell the healthcare provider the RN will return the phone call as soon as possible C) be sure to write down what is prescribed and then repeat it back to the healthcare provider D) remain with this client and monitor the vital signs while the RN takes the call 93. In assigning care on a telemetry unit, it is most important for the charge nurse to assign which client to an RN rather than an LPN? A) a 62-year-old with coronary artery disease who is receiving clopidogrel (Plavix) for transient ischemic attacks (TIA)V3 2020 B) a 55-year-old with orthostatic hypotension who is receiving low-molecular-weight heparin (Lovenox) C) a middle-aged client with hyperlipidemia who just received a new prescription for lovastatin (Mevacor) D) an older adult with dyspnea and edema due to heart failure who is receiving nesiritide (Natrecor) 94. Following two defibrillation shocks, the client’s ECG continues to indicate ventricular fibrillation (VF). Which intervention should the nurse implement next? A) administer an IV bolus of epinephrine B) resume CPR immediately C) perform the third defibrillation shock D) obtain an arterial blood gas sample 95. The nurse is triaging a 50-year-old male client in the emergency department. He is complaining of severe mid-chest pain of sudden onset. What other information should the nurse obtain during the initial assessment? (Select all that apply.) A) does anything make his pain worse? B) does the pain radiate to any particular area of the body? C) has he previously experienced a similar type of pain D) on a 10-point scale, how does he rate the pain he is currently experiencing? E) does he think he is having a heart attack? 96. Despite repeated instruction, an 80-year-old client with Parkinson’s disease is unable to instill ophthalmic medication without assistance because of hand tremors. What action is best for the nurse to take? A) document the client’s inability to instill the medication without assistance B) obtain a prescription for a visiting nurse to instill the medication twice a day C) continue to reinforce the instructions to enhance the client’s self-confidence D) determine if a family member is available and willing to instill the medication 97. After assessing a client, the nurse identifies three nursing diagnoses. When developing the client’s plan of care, which action should the nurse take next? A) identify client care interventions B) prioritize the identified nursing diagnoses C) collaborate with client to establish goals D) cluster supportive client data 98. What instruction should the nurse include in the teaching plan for the family of a school-aged child with AIDS? A) avoid exposure to chickenpox B) keep the child away from other children and begin a home school program C) obtain an injection of penicillin G 1000 units weekly D) obtain a booster for all immunizations as soon as possible 99. A male client admitted the morning of same day surgery states he drank a glass of water during the night. What intervention should the nurse implement first? A) notify the healthcare provider of the client’s fluid intake B) determine the amount of water and exact time it was taken C) assess the client for active bowel sounds and ability to urinate D) reassure the client that a small amount of water is not harmfulV3 2020 100. The nurse is assessing a client on a ventilator. The endotracheal tube (ET) lip line measurement is 24 cm. Four hours ago the lip line measurement was 20 cm. Which intervention should the nurse implement first? A) reposition the ET back to the 20 cm mark B) assess the client’s bilateral breath sounds C) request a STAT portable chest x-ray D) monitor the client’s arterial blood gases 101. A client is ambulating with a two-wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client’s elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, what action should the nurse implement? A) demonstrate more coordinated movement of the legs and walker B) encourage the client to continue using the walker as observed C) explain the need to remove the wheels from the walker D) offer to adjust the height of the walker 102. A postoperative client is receiving meperidine hydrochloride (Demerol) 60 mg and hydroxyzine (Vistaril) 35 mg IM q3h PRN pain. Demerol is available in a prefilled syringe labeled 100 mg/ml, and the vial of Vistaril is labeled 50 mg/ml. What is the total volume, in ml, that the nurse should administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.) Answer: 1.3 Rationale: 1) Two drugs make this a 2-part problem. Use a ratio and proportion formula. 1) Demerol: 100 mg: 1 ml = 60 mg: X ml 2) 100X = 60, then X = 0.6ml 3) Vistaril: 50 mg : 1 ml = 35 mg: X ml 4) 50X = 35, then X = 0.7ml 5) total dose = 0.6ml + 0.7ml = 1.3 ml 103. A male client with an HIV infection is placed on a “drug cocktail” consisting of three antiretroviral agents and a protease inhibitor. He asks the nurse why he must take so many drugs at once. Which response by the nurse best addresses this client’s question? A) “The drug combination decreases the side effects of the medications” B) “Taking several drugs at once decreases your viral load more quickly” C) “A multi-drug approach decreases the risks of developing drug resistance” D) “The drugs will interact with each other and shorten your overall drug therapy” 104. The nurse notices that the catheter of a client who had a transurethral resection of the prostate (TURP) 2 days ago is not draining and his bladder is distended. What action should the nurse take initially? A) milk the catheter tubing B) irrigate the catheter C) change the catheter D) discontinue the catheter 105. What is the priority nursing diagnosis when caring for a client with a Jackson-Pratt drain and a surgical wound that is healing by secondary intention? A) risk for impaired skin integrity related to wound drainage B) body image disturbance related to draining wound C) risk for infection related to open wound D) knowledge deficit related to inadequate information about drains 106. A 17-year-old male who was arrested last month for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today his mother calls the clinic nurseV3 2020 to report that her son became angry last night and put his fist through a window. Which intervention is most important for the nurse to implement? A) tell the mother to describe her feelings of helplessness to her son B) advise the mother to call the police if violent behavior occurs again C) reinforce the need for the adolescent to attend group therapy sessions D) refer the mother for psychiatric evaluation for anxiety and depression 107. An 8-year-old girl is brought to the clinic by her mother who reports that her daughter has had a severe sore throat for the last three days and suddenly began drooling. The child’s tympanic temperature is 103F and she is struggling to breathe. What initial action should the nurse take? A) ask the child to cough several times B) use a tongue blade to inspect the throat C) review immunization records for influenza vaccine D) notify the healthcare provider immediately 108. The nurse is caring for a client in active labor. What action should the nurse implement? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s record.) (Note: answer choices not complete!) A) change.. B) increase.. C) apply oxygen D) stop the.. 109. A newly-delivered infant with which condition should be assessed by the nurse first? A) born to a mother who was in labor for 14 hours B) delivered by caesarean section for breech presentation C) caput succedaneum D) a fetal scalp pH of 7.05 before birth 110. The nurse-manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse-manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. What is the priority action by the nurse-manager? A) close the door to the room to avoid disturbing other clients in nearby rooms B) advise the staff nurse to remove the restraints from the client’s wrists C) determine if the client has a PRN prescription for an antianxiety agent D) contact the healthcare provider to ensure that a prescription for restraints was written 111. While preparing a client with suspected appendicitis for an abdominal ultrasound, the nurse notes that the client is experiencing localized rebound tenderness in the right lower quadrant of the abdomen. Based on this information, what is the most important nursing intervention? A) administer the oral analgesic prescribed for PRN use B) continue to prepare the client for the ultrasound C) hold the ultrasound until the healthcare provider is notified D) obtain a chest x-ray in preparation for surgery 112. The American Diabetes Association recommends diabetic screening every three years for those over the age of 45. This is an example of which type of public service? A) tertiary prevention B) primary preventionV3 2020 C) secondary prevention D) initial screening 113. The nurse is monitoring a 6-month-old infant with a closed head injury. Which assessment finding is the earliest indication of neurological deterioration? A) decorticate posturing B) sluggish, unequal papillary response C) projectile vomiting after eating D) irritable and unable to rest 114. While the nurse is inserting a nasogastric tube, the client becomes cyanotic. What intervention should the nurse implement? A) notify the healthcare provider B) initiate oxygen per face mask C) slowly continue to insert the tube D) withdraw the nasogastric tube 115. In reviewing the medical record, the nurse notes that a client’s last eye examination revealed an intraocular pressure (IOP) of 28 mmHg. What information should the nurse ask the client? A) recent experience of seeing light flashes or floaters B) complaints of any blind spots in the client’s field of vision C) use of prescribed eye drops since last exam by ophthalmologist D) length of time the client has been wearing prescription lenses 116. While the nurse is bathing a bedfast client with generalized weakness, the client develops labored respirations and an audible pharyngeal rattle. The nurse auscultates coarse rattles in the upper lung fields. What action should the nurse implement first? A) assess the client’s temperature B) complete the client’s personal care C) perform oropharyngeal suctioning D) encouraging increased fluid intake 117. An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for an assault and battery conviction, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement? A) examine the client for evidence of physical abuse B) assist the client in developing an emergency safety plan C) discuss becoming a survivor rather than a victim of abuse D) refer to a program for victims of domestic violence 118. A female client presents to the emergency department in the early evening complaining of abdominal cramping, watery diarrhea, and vomiting. She tells the nurse that she was at a picnic and ate barbeque that afternoon. What question is most important for the triage nurse to ask this client? A) “Is anyone else sick who was also at the picnic?” B) “How high was your temperature when you returned home?” C) “Have you taken any medication to treat this problem?” D) “Have you recently traveled outside the United States?” 119. A client has severe bradycardia following the administration of metoprolol (Toprol XL). What medication should the nurse anticipate administering?V3 2020 A) diltiazem (Cardizem) B) atropine sulfate C) naloxone (Narcan) D) digoxin (Lanoxin) 120. The first day postoperative, a client’s vital signs are: temperature 99F orally, respirations 29 breaths/minute, blood pressure 120/74 mm Hg, heart rate 88 beats/minute. Based on these findings, what nursing action should the nurse implement first? A) auscultate the lung sounds B) retake temperature rectally C) administer an antipyretic D) confirm heart rate with an ECG 121. The nurse is assessing a client with hypothyroidism and knows that these clients are at risk for myxedema coma. What symptoms indicate that the client is developing this condition? A) weight loss, sinus tachycardia, and exophthalmus B) chest pain, dyspnea, and temperature above 37.7C C) hypothermia, decreased cardiac output, and decreased respiratory functioning D) hair loss, brittle nails, numbness and tingling of the fingers 122. A client received a stent following angioplasty and is being monitored postprocedure in a cardiac unit. Which discharge prescription, written by the cardiology resident, should the nurse question? A) schedule MRI of the head to visualize carotids within one week after angiography B) take clopidogrel (Plavix) 75 mg and aspirin 325 mg PO daily for the next 6 months C) do not lift heavy objects or vigorously exercise for two weeks following the procedure D) carry a patient identification card at all times indicating that a stent was placed 123. A school-aged child with asthma is intubated and placed on a mechanical ventilator. The parents of the child are pale, holding onto each other, and have tears in their eyes. What statement by the nurse is most therapeutic when first interacting with these parents? A) “Your child is resting comfortably at the present time” B) “It must be difficult for you to see your child go through this” C) “Your child is in good hands. Everything is going to be okay” D) “The ventilator is making sure your child is getting enough oxygen” 124. A male client who is diagnosed with schizophrenia and takes clozapine (Clozaril), tells the nurse that he does not understand the reason why he must have his blood drawn. What is the most important reason for drawing blood levels? Because Clozaril A) can cause agranulocytosis, so the white blood cell count needs to be monitored B) can cause hyperglycemia, so serum glucose levels should be evaluated periodically C) drug blood levels need to be assessed to monitor for toxicity D) can cause liver damage, so liver function tests are necessary 125. A 27-year-old gravida 2, at 40-weeks gestation, is experiencing firm contractions occurring 4 to 5 minutes apart. Three hours after initiation of labor, she begins moaning and crying, is restless, belches, and states that she needs to have a bowel movement. Which intervention should the nurse implement? A) assist the client onto a bedpan B) assess the client’s cervical dilation C) have the client turn to her left side D) tell the client to bear down with the next contraction 126. A gravida 3 para 3 who is Rh-negative delivers a full-term infant at home with the assistance of a nurse-midwife. Two days later, the client calls the clinic to ask if it is necessary to see the healthcareV3 2020 provider since the infant is healthy, and she is not having any complications. The woman’s history indicates that both previously born infants were Rh-negative. Which response should the nurse provide? A) the newborn’s blood type should be tested to determine the need for RhoGAM B) it is likely that the husband is Rh-negative , and if so RhoGAM is not needed C) RhoGAM injections must be administered within 24 hours after delivery D) RhoGAM is not indicated since both previous babies were Rh-negative 127. The healthcare provider prescribes the antibiotic erythromycin (Erythrocin) for a client with pneumonia. Before administering the medication, which intervention should the nurse implement? A) take the client’s apical pulse B) make sure a sputum culture has been obtained C) assess the serum electrolyte levels D) obtain a sterile urine specimen 128. A client is admitted to the emergency center with a flail chest after an automobile accident. Which set of arterial blood gases should the nurse reports to the healthcare provider immediately? A) PaO2 84 mm Hg, SaO2 93%, pH 7.35, PaCO2 35 mm Hg, HCO3 20 B) PaO2 85 mm Hg, SaO2 90%, pH 7.49, PaCO2 40 mm Hg, HCO3 28 C) PaO2 90 mm Hg, SaO2 90%, pH 7.45, PaCO2 42 mm Hg, HCO3 23 D) PaO2 80 mm Hg, SaO2 95%, pH 7.30, PaCO2 55 mm Hg, HCO3 25 (resp. acidosis) 129. Pursed-lip breathing is a controlled breathing technique helpful to many clients with emphysema. What instruction given by the nurse is the most accurate description of the pursed-lip breathing technique for clients with emphysema? A) “Inhale through the nose and exhale through pursed lips” B) “Inhale through the nose, exhale through the nose, purse the lips and hold your breath for 30 seconds” C) “Hold your breath for 10 to 15 seconds, purse the lips and inhale through your mouth, then exhale through pursed lips” D) “Purse the lips, inhale through the mouth and exhale through the mouth” 130. An older client with chronic liver failure and metastatic cancer is admitted with bilateral subdural hematomas. The healthcare provider discontinues the client’s dialysis treatments, stating that death is inevitable, but the client is unconscious, and there is no DNR directive. What is the priority nursing action? A) ask the nurse-manager to request an ethics committee decision B) encourage the family to request hospice care for their relative C) notify the healthcare provider that the DNR prescription cannot be implemented D) determine if a family member has the client’s legal power of attorney 131. A female college student presents to the health center complaining of anxiety related to her fear that she has contracted genital herpes. The coed tells the nurse that she has vaginal irritation and is embarrassed by the possibility of having acquired a sexually transmitted disease. What response is best for the nurse to provide? A) “We need to conduct some tests to validate that you have herpes” B) “Are you more worried about what others think than your own well-being?” C) “What makes you think that you might have herpes?” D) “Illnesses like herpes can be embarrassing, but they are also serious” 132. What adverse effect(s) of chemotherapy place the client with cancer at highest risk for sepsisinduced distributive shock?V3 2020 A) bone marrow depression B) oral candidiasis C) nausea and diarrhea D) fatigue and weakness 133. When obtaining subjective data from a client, what intervention should the nurse implement first? A) listen attentively B) establish rapport C) list problems D) clarify inferences 134. A client with reflux esophagitis reports relief of symptoms. The nurse instructs the client that symptom relief is most likely the result of which of the client’s prescriptions? A) clarithromycin (Biaxin), an antibiotic B) celecoxib (Celebrex), a COX-2 inhibitor C) lansoprazole (Prevacid), a proton pump inhibitor D) promethazine hydrochloride (Phenergan), an antiemetic 135. The healthcare provider prescribes Cyanocabalmin Injection, USP 100 mcg IM every 3 days for a client with pernicious anemia. The vial is labeled, “1 mg/ml.” How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.) Answer: 0.1 Rationale: 1) Change mg to mcg, 1 mg = 1,000 mcg 2) Use ratio and proportion to calculate the dose, 1,000 mcg : 1 ml :: 100 mcg : X 3) 1,000X = 100 4) X= 0.1ml 136. A client is admitted with a diagnosis of right lower lobe pneumonia. Which breath sound is the nurse most likely to auscultate over the right lower lobe? A) coarse crackles B) audible rhonchi C) wheezing D) friction rub 137. A 48-year-old female client who has been treated for metastasized breast cancer for the past year is told by her healthcare provider that chemotherapy is not producing the desired remission. The next morning the client is crying and asks the nurse, “Who will care for my children?” Which response is best for the nurse to provide? A) “Have you talked to your family about who will be responsible for your children?” B) “What would you like to see happen with your children?” C) “Try to think about getting well. Someone will care for your children” D) “Your husband will have to be there for your children” 138. A male client with a fungal infection of the toenail reports to the nurse that he has been applying an over-the-counter triple antibiotic ointment to the infection daily for two weeks without any improvement. What action should the nurse take? A) advise the client to obtain a prescription-strength formulation of the ointment B) suggest that the client use the ointment twice a day to be more effective C) reassure the client that treatment of fungus-infected toenails often takes several months D) instruct the client to obtain a prescription for oral terbinafine (Lamisil) 139. A male client who had a lumbar laminectomy has a prescription to be turned every two hours. One hour after being positioned on the right side, the client reports he is uncomfortable and requests to be moved. Which action should the nurse take?V3 2020 A) inform the client that he will be turned in one hour B) instruct the client to flex his toes to help his discomfort C) logroll the client to the left side with two personnel D) offer a PRN analgesic for the client’s discomfort 140. A client is discussing feelings related to a recent loss with the nurse. The nurse remains silent when the client says, “I don’t know how I will go on.” What is the most likely reason for the nurse’s behavior? A) the nurse is respecting the client’s loss B) silence is reflecting the client’s sadness C) silence allows the client to reflect on what was said D) the nurse is stating disapproval of the statement 141. The nurse is planning to flush a heparin-loc on a central venous catheter with a total of 300 units of heparin flush solution. Which concentration of solution should the nurse select? A) 100 units heparin/ml B) 1000 units heparin/ml C) 0.1 units heparin/ml D) 10 units heparin/ml 142. The nurse finds a female client crying quietly in her room. What action should the nurse take first? A) review the client’s record before attempting to intervene B) pull up a chair and sit beside the client C) provide the client privacy and quietly close the door D) ask the client why she is crying 143. A client is taking a cromolyn sodium (Intal) inhaler for chronic asthma. Which statement indicates the client understands the medication teaching? A) “I will have my liver enzymes checked monthly” B) “I should keep my inhaler with me at all times” C) “It is important to take this medication with food” D) “I will not discontinue taking this medication abruptly” 144. What information in a client’s history indicates the highest risk factor for hepatitis C? A) recent travel to an underdeveloped country B) monogamous sexual activity C) intravenous drug abuse D) eating contaminated shellfish 145. When providing diet teaching for a client who is experiencing thrombocytopenia as the result of chemotherapy, which instruction is most important for the nurse to include? A) chew foods completely B) avoid hard foods C) warm all foods D) floss teeth after meals 146. An elderly client seems confused and reports the onset of nausea, dysuria, and urgency with incontinence. Which action should the nurse implement? A) begin to strain the client’s urine B) auscultate for renal bruits C) obtain a clean catch mid-stream specimenV3 2020 D) use a dipstick to measure for urinary ketones 147. A male client receiving fentanyl (Duragesic) via transdermal patch reports to the nurse that he is experiencing abdominal discomfort. The nurse’s assessment indicates abdominal distention with decreased bowel sounds. Which intervention should the nurse initiate? A) notify the healthcare provider of the symptoms B) remove the transdermal patch C) administer a prescribed PRN laxative D) perform a digital exam for impaction 148. The father of an 11-year-old boy tells the nurse that he feels unsure about talking to his son about nocturnal emissions. How should the nurse address this issue with this parent? A) inform the father that it is most important to let the son know that nocturnal emissions are normal B) reassure the father that he does not need to have this discussion with his son unless his son asks about nocturnal emissions C) refer the father and son for counseling with a therapist that specializes in sexual dysfunctions D) tell the father to begin discussion of this issue if his son seems embarrassed by the occurrence of nocturnal emissions 149. Which gastrointestinal findings should the nurse be concerned about in a client at 28-weeks gestation? A) pica B) pyrosis C) ptyalism D) decreased peristalsis 150. A client was admitted with an exacerbation of congestive heart failure secondary to COPD. Which observation(s) by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply.) A) two glasses of water are on the bedside table B) a peripheral IV is saline-locked C) the client is resting supine in bed D) oxygen is flowing at 5L/min. via mask E) the call light cord is wrapped on the siderail F) a bedside commode is located near the bed 151. The pediatric unit is extremely busy when the admission office notifies the charge nurse that a child who has acute lymphocytic leukemia (ALL) needs to be admitted to the unit. The parents brought prescriptions from the healthcare provider for their child to have a chest x-ray and blood work drawn on admission. What action should the charge nurse take? A) ask the radiology department to complete the chest x-ray before admitting the child to the unit B) have hospital transportation take the child to the central laboratory for blood work before admission C) ask the family to wait in the visiting area until a nurse can assist them with the admission process D) tell the admission clerk to bring the child immediately to the unit and place the child in a private room 152. A female student nurse is paired with a staff nurse as a learning experience. The student nurse has an offensive body odor, her uniform is wrinkled, and she is acting sluggish and tired. What action should the staff nurse implement? A) tell the student to freshen up before allowing her to see clients B) ask the student to wait in the lounge until her faculty member is contactedV3 2020 C) inform the charge nurse that the student is unprepared for the clinical area D) complete an incident report and refer the student for counseling 153. Following a traumatic delivery, an infant receives an initial Apgar score of 3. What intervention is most important for the nurse to implement? A) page the pediatrician STAT B) continue resuscitative efforts C) inform the parents of the infant’s condition D) repeat the Apgar assessment in 5 minutes 154. The nurse is caring for a 10-year-old who is diagnosed with acute glomerulonephritis. Which outcome is the priority for this child? A) activity tolerance as evidenced by performing appropriate age-level activities B) adequate nutritional status as evidenced by no weight gain or loss C) fluid balance maintained as evidenced by a urine output of 1 to 2 ml/kg/hr D) no signs of skin breakdown as evidenced by intact skin and no redness 155. A female client who is scheduled to be discharged within several hours shows the nurse a knife on her tray and states that she could use it to cut herself. What intervention is most important for the nurse to implement? A) inform the family of the client’s statement B) inform the healthcare provider who discharged the client C) call dietary and ask them to send plastic utensils D) include guidelines for coping in the discharge plan 156. An older client is transferred to the rehabilitation unit with the diagnosis of cerebrovascular accident with left sided hemiplegia. The nurse addresses the client from the right side, and the client points to the left leg and sates, “There is someone’s leg in my bed!” What is the best response by the nurse? A) “Your stroke has impaired your ability to recognize that it is your leg” B) “Can you tell me your name? Do you know where you are?” C) “Push against my hands at the same time using both your feet” D) “Where are your glasses? Can you see clearly?” 157. A client returns to the acute care unit following surgery with 0.9% normal saline infusing at 45 drops/minute through tubing with a drop factor of 60 drops per ml. The postoperative prescriptions include 0.9% normal saline at 75 ml/hour to alternate with Lactated Ringer’s solution at 75 ml/hour. An intravenous infusion pump is not available. What action should the nurse implement? A) switch the saline to Lactated Ringer’s solution infusing at 75 drops per minute B) leave the normal saline at the current rate until an infusion pump is available C) change the normal saline to keep open rate until an infusion pump is available D) increase the rate of the present normal saline infusion to 75 drops per minute 158. When conducting a physical examination, the nurse is assessing a client’s abdomen and identifies a centrally localized distention that is pulsating. This finding should direct the nurse to consider what pathology? A) hernia B) aneurysm C) appendicitis D) tympanyV3 2020 159. Which of these women, all of whom have recently discovered a new breast lump, is at greatest risk for a diagnosis of breast cancer? A) a 51-year-old whose mother had breast cancer and describes the lump as non-tender B) a 55-year-old whose weight is normal for her height, and had one child at age 31 C) a 45-year-old who is taking estrogen therapy and has had four children before the age of 28 D) a 22-year-old who has fibrocystic breast disease and describes the lump as painful [Show More]

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