HESI EXIT RN EXAM 2022- REAL

HESI EXIT RN EXAM 2022- REAL EXIT EXAM 2022 Medical Surgical Advanced HESI EXIT EXAM 2022/2023 1. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following fi ...

HESI EXIT RN EXAM 2022- REAL EXIT EXAM 2022 Medical Surgical Advanced HESI EXIT EXAM 2022/2023 1. A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? A. WBC count 8,000/mm3. B. Platelets 150,000/mm3. C. Aspartate aminotransferase 10 units/L. D. E rythrocyte sedimentation rate 75 mm/hr 2. A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? A. Platelet count. B. Potassium level. C. Creatine clearance. D. Prealbumin. 3. A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? A. Place an ice pack over the cast. B. P alpate the pulse distal to the cast. C. Teach the client to keep the cast clean and dry. D. Position the casted extremity on a pillow. 4. A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? (Select all that apply) A. Keep objects in the client’s room in the same place. B. Ensure there is high-wattage lighting in the client’s room. C . Approach the client from the side. D. Allow extra time for the client to perform tasks. E . Touch the client gently to announce presence. 5. A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection of nursing (Unable to read) articles? A. MEDLINE B. C INAHL. C. ProQuest. D. Health Source. 6. A nurse in an emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following should actions should the nurse take first? A. Obtain a baseline ECG. B. Obtain a blood specimen for ABG analysis. C. Insert an 18-gauge IV catheter. D. A dminister 100% humidified oxygen. 7. A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? A. Place food on the left side of the client’s mouth when he is ready to eat. B. Provide total care in performing the client’s ADLs. C. Maintain the client on bed rest. D. P lace the client’s left arm on a pillow while he is sitting. 8. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? A. . Confront the client about this behavior. B. Express sympathy for the client’s situation. C. Speak assertively to the client. D. Stand within 30 cm (1 ft) of the client when speaking with them. 9. A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? A. Cleanse equipment before removal from the client’s room. B. L imit the client’s visitors to 30 min per day. C. Discard the client’s linens in a double bag. D. Discard the radioactive source in a biohazard bag 10. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? a. Position the client supine b. Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV 11. A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender d. A history of being in prison 12. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? a. Place the cap from the solution sterile side up on clean surface b. Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first c. Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated. d. Set up the sterile field 5 cm (2 in) below waist level→ it says BELOW waist level; should be ABOVE waist level 13. A nurse is providing teaching to an older adult client about methods to promote nighttime sleep. Which of the following instructions should the nurse include? a. Eat a light snack before bedtime b. Stay in bed at least 1 hr if unable to fall asleep c. Take a 1 hr nap during the day d. Perform exercises prior to bedtime 14. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first? a. Educate the client about current medical diagnosis b. Refer the client to a meal delivery program c. Identify environmental hazards in the home d. Arrange for client transportation to follow-up appointments Rationale Priority: Assess first. 15. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client? a. “Can you tell me who visited you today?” b. “What high school did you graduate from c. “Can you list your current medications?” d. “What did you have for breakfast yesterday?” 16. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching a. HbA1c level greater than 8%- 6.5 - 8 is the target reference. > b. Blood glucose level greater than 200 mg/dL at bedtime c. Blood glucose level less than 60 mg/dL before breakfast- < 70 = HYPOGLYCEMIC d. HbA1c level less than 7% 17. A nurse is caring for a client who is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination? a. The client is experiencing an adverse reaction to rifampin b. The client’s seizure disorder is no longer under control c. The client is showing evidence of phenytoin toxicity c. The client is having adverse effects due to combination antimicrobial therapy 18. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse? a. Increase in frequency of swallowing→ may indicate bleeding b. Moderate sanguineous drainage on the drip pad c. Bruising to the face→ side effect d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) Rationale “Requires immediate action” choose the worst possibility that could lead to. ABC 19. A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child’s cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom 20. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? a. Use of tobacco might lead to alcohol and drug abuse b. Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction 21. A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count 22. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. “I will let the client know that I am available as the interpreter.” b. “I will receive a small fee for interpreting for this client.” c. “I am glad I’m available today, but when I’m not, you can use a family member.” d. “I will let the client know that an interpreter is unavailable during the night shift.” 23. A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year- old. Which of the following actions should the nurse take? a. (Unable to read) b. Tell the child they will feel discomfort during the catheter insertion. c. Use a mummy restraint to hold the child during the catheter insertion. d. Require the parents to leave the room during the procedure. 24. A nurse is caring for a client who has arteriovenous fistula which of the following findings should the nurse report? a. Thrill upon palpation. b. Absence of a bruit. c. Distended blood vessels d. Swishing sound upon auscultation. 25. A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? a. “I will soak in the tub rather and showering” b. “I will wear loose clothing around my ICD” c. “I will stop using my microwave oven at home because of my ICD” d. “I can hold my cellphone on the same side of my body as the ICD” 26. A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? a. “Describe your feelings to me about being pregnant” b. “You should discuss your feelings about being pregnant with your provider” c. “Have you discussed these feelings with your partner?” d. “When did you start having these feelings?” 27. A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? a. Encourage a maximum fluid intake of 1,500 ml per day. b. Increase the amount of refined grains in the client’s diet. c. Provide the client with a cold drink prior to defecation. d. Administer a rectal suppository 30 minutes prior to scheduled defecation times. 28. A nurse is performing physical therapy for a client who has Parkinson’s disease. Which of the following statements by the client indicates the need for a referral to physical therapy? A. “I have been experiencing more tremors in my left arm than before” B. “I noticed that I am having a harder time holding on to my toothbrush” C. “ Lately, I feel like my feet are freezing up, as they are stuck to the ground” D. “Sometimes, I feel I am making a chewing motion when I’m not eating” 29. A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? A. Increased creatine. B. Increased hemoglobin. C. Increased bicarbonate. D. Increased calcium. 30. A nurse is administering a scheduled medication to a client. The client reports that the medication appears different than what they take at home. Which of the following responses should the nurse take? A. “Did the doctor discuss with you that there was a change in this medication?” B. “I recommend that you take this medication as prescribed” C. “Do you know why this medication is being prescribed to you?” D. “ I will call the pharmacist now to check on this medication” 31. A charge nurse is recommending postpartum client discharge following a local disaster. Which of the following should the nurse recommend for discharge? A. A 42-year-old client who has preeclampsia and a BP of 166/110 mm Hg. B. A 15-year-old client who delivered via emergency cesarean birth 1 day ago. C. A client who received 2 units of packed RBCs 6 hr. ago for a postpartum hemorrhage. D. A client who delivered precipitously 36 hr. ago and has a second-degree perineal laceration. 32. A nurse in a provider’s office is reviewing the laboratory results of a group of clients. Which to report? a. Herpes simplex. b. Human papillomavirus c. Candidiasis d. C hlamydia 33. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian A. A client who has a prescription for warfarin and states “I will need to limit how much spinach I eat”. B. A client who has gout and states, “I can continue to eat anchovies on my pizza.” C. A client who has a prescription for spironolactone and states “I will reduce my intake of foods that contain potassium”. D. A client who has (Unable to read) and states “I’ll plan to take my calcium carbonate with a full glass of water”. 34. A nurse is preparing to measure a temperature of an infant. Which of the following action should the nurse take? A . Place the tip of the thermometer under the center of the infant’s axilla. B . Pull the pinna of the infant’s ear forward before inserting the probe. B. Insert the probe 3.8 cm (1.5in) into the infant’s rectum. C. Insert the thermometer in front of the infant’s tongue. 35. A nurse in a pediatric clinic is teaching a newly hired nurse about the varicella rooster. Which of the following information should the nurse include? A. . Children who have varicella are contagious until vesicles are crusted. B. . Children who have varicella should receive the herpes zoster vaccination. C . Children who have varicella should be placed in droplet precaution. Children who have varicella are contagious 4 days before the first vesicle eruption. 36. A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? A. Withhold the next dose. B. Increase the dosage. C. Discontinue the medication. D. A dminister the medication. 37. A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? A. Pregabalin B. Lorazepam C.Colchicin D. Codeine. 38. A nurse is caring for a client who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? A . Prime IV tubing with 0.9% sodium chloride. B. Use a 24-gauge IV catheter C. Obtain filter less IV tubing. D. Place blood in the warmer for 1 hr. 39. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? A. Looking at alphabet flashcards. B. P laying with a large plastic truck. C. Use scissors cut out paper shapes. D. Watching a cartoon in the dayroom. 40. A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? A. Coffee with creamer. B. Lettuce with sliced avocados. C. B roiled skinless chicken breast with brown rice. D. Warm toast with margarine. 41. A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? a. Administer ondansetron. b. Place the client in a warm shower. c. Apply fundal pressure during contractions. d. Assist the client to a supine position. 42. A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below-the knee amputation b. Fractured tibia c. 95% full-thickness body burn d. 10cm (4in) laceration to the forearm 43. A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? a. Remove the client’s restraint every 4hr b. Document the client’s condition every 15 min c. Attach the restrain to the bed’s side rails d. Request a PRN restrain prescription for clients who are aggressive 44. A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? a. Acts as an advocate for the nursing unit. b. (Unable to read) for the unit c. Priorities staff request over client needs. d. Provides routine client care and documentation. 45. A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her (unable to read) care. The nurse should identify which of the following findings indicates a need to revise the client’s plan of care. a. Serum sodium 144 mEq/ b. (Unable to read) c. Hba1c 10 % d. Random serum glucose 190 mg/dl. 46. A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. 47. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. b. Skin turgor d. Bowel sounds 48. A nurse is caring for a client who has hyperthermia .Which of the following actions for the nurse to take? a. Submerge the adolescent feet in ice water b. Cover the adolescent with a thermal blanket → if hypothermia. c. Administer oral acetaminophen 49. A nurse manager is updating protocols for belt restraints. Which of the following guidelines should the nurse include? c. Request a PRN restraints prescription for clients who are aggressive d. Remove the client restraints every 4 hours 50. A nurse in emergency department is caring for a client who has full thickness burn of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention? a. Providing pain management b. Offering emotional support c. Preventing infection 51. A nurse is caring for a client who has cancer and is being transferred to hospice care. The client’s daughter tells the nurse, “I’m not sure what to say to my mom if she asks me about dying.” which of the following responses by the nurse is appropriate? (SATA) A. Hospice will take good care of your mom, so I wouldn’t worry about that. C. Tell me how you are feeling about your mom dying. D. Tell her not to worry. She still has plenty of time left. 52. A nurse is reviewing themedical records of four clients. thenurse should identify that which of thefollowing client findings follow up care? a. A client who is taking bumetanide and has potassium level of 3.6 mEq/L (normal) b. A client who is scheduled for colonoscopy and taking sodium phosphate d. A client who is taking warfarin and has INR of 1.8 (normal if taking warfarin) 53. A community health nurse receives a referral for a family home visit. Which of thefollowing tasks should thenurse perform first? b. Implement thenursing process c. Schedule a time for thehome visit d. Contact thefamily by phone 54. A nurse is caring for a client who will undergo a procedure. theclient states he does not want theprovider to discuss theresults with his partner. Which of thefollowing is an appropriate response for thenurse to make? b. Your partner can be a great source of support for you at this time c. Is there a reason you don’t want your partner to know about your procedure? d. The provider will be tactful when talking to your partner 55. A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). thenurse should identify theweight of thefollowing total percentage? b. 15% c. 8.1% d. 13.3% 56. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of thefollowing interventions should thenurse implement? a. Perform fundal massage (massage if fundus is boggy) c. Insert an indwelling urinary catheter. d. Apply cold therapy to theclient’s perineal area.( warm) 57. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of thefollowing instructions should thenurse include in theteaching? b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove thepatch for 8 hours every day to reduce therisk for tolerance. 58. A nurse is working with a client who has an anxiety disorder and is in theorientation phase of thetherapeutic relationship. Which of thefollowing statements should thenurse make during this phase? a. We should discuss resources to implement in your daily life b. Let me show you simple relaxation exercises to manage stress. c. Let’s talk about how you can change your response to stress 59. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. thenurse should instruct theclient that it is safe to eat which of thefollowing foods while taking this medication? a. Avocados c. Pepperoni pizza d. Smoked salmon 60. A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of thefollowing client information should thenurse report? A. (Unable to read) B. (Unable to read) C. A nswer might be lower platelets. D. (Unable to read) 61. A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak thesame language as clinical staff. Which of thefollowing instructions should thenurse include? A. Use theclient’s children to provide interpretation. B. ( Answer was thenurse was going to do theinterpretation) C. Offer client’s translation services for a nominal fee. D. Evaluate theclients’ understanding at regular intervals. 62. A hospice nurse is visiting with theson of a client who has terminal cancer. theson reports sleeping very little during thepast week due to caring for his mother. Which of thefollowing responses should thenurse make? a. “I can give you information about respite care if you are interested.” b. “You should consider taking a sleeping pill before bed each night” c. “It must be difficult taking care of someone who is terminally ill” d. “You are doing a great job taking care of your mother” 63. A nurse is assessing a child who is being treated for bacterial pneumonia. thenurse notes an increase in thechild’s glucose. thenurse should identify this finding as an adverse effect of which of thefollowing medications a. Methylprednisolone. b. Ondansetron. c. Guaifenesin. d. Amoxicillin. 64. The nurse is providing teaching about folic acid to a client who is prima gravida. Which of thefollowing information should thenurse include in theteaching? a. “You should take folic acid to decrease therisk of transmitting infections to your baby” b. “You should consume a maximum of 300 micrograms of folic acid every day”. c. “You can increase your dietary intake of folic acid by eating cereals and citrus fruits”. d. “You can expect your urine to appear red-tingled while taking folic acid supplements”. 65. A community health nurse is assessing an adolescent who is pregnant. Which of thefollowing assessments is thenurse’s priority? a. Social relationship with peers. b. Plans for attending school while pregnant. c. (Unable to read) (Picked this one) Medicaid? d. Understanding of infant care. 66. A nurse manager is planning to teach staff about critical pathways. Which of thefollowing information should thenurse include? a. Critical pathways have unlimited timeframe for completion b. (Unable to read) decrease health care costs. c. (Unable to read) critical pathway if variances (Unable to read) d. (Unable to read) are used to create thecritical pathway. 67. A nurse is reviewing themedical record of a client who has schizophrenia. Which of thefollowing should thenurse report to theprovider? Exhibit 1 Blood pressure: 102/56 mm Hg. Heart rate: 95/min Respiratory rate: 18/min Temperature: 37.4C (99.3F) Exhibit 2 Medication Administration Record Clozapine 150 mg PO twice daily Benztropine 0.5 mg PO twice daily as needed for tremors. Exhibit 3 Nurse’s notes: Client reports feeling dizzy when changing positions, Reports weight gain of 1kg (2.2 lb.) in thepast month. Also reports a sore throat for thepast 3 days and dry mouth. Client ate 75% of breakfast and reports slightly nauseous. a. Dietary intake b. Heart rate. c. Sore throat. d. Blood pressure. 68. A charge nurse is educating a group of unit nurses about delegating client tasks to assistive personnel a. “The nurse is legally responsible for theactions of theAP”. b. “An AP can perform tasks outside of his range if he has been trained”. c. “An experienced AP can delegate to another AP”. d. “An RN evaluates theclient needs to determine tasks to delegate” 69. A nurse is assessing a client who is in active labor. Which of thefollowing findings should thenurse report to theprovider? A. Contractions lasting 80 seconds B. FHR baseline 170/min C. Early decelerations in theFHR D. Temperature 37.4C (99.3) 70. A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia thefollowing actions is thenurse’s priority? a. Consult with a case manager about insurance coverage. b. Counsel caregivers about respite care options. c. Ensure that theclient has a referral for physical therapy. d. Refer theclient to a local stroke support group. 71. A nurse in a mental health unit is planning room assignments for four clients. Which of thefollowing client should be closest to thenurse’s station? a. A client who has an anxiety disorder and is experiencing moderate anxiety. b. A client who has somatic symptom disorder and reports chronic pain. c. A client who has depressive disorder and reports feeling hopeless. d. A client who has bipolar disorder and impaired social interactions. 72. A nurse is preparing to measure a temperature of an infant. Which of thefollowing action should thenurse take? a. Place thetip of thethermometer under thecenter of theinfant’s axilla. b. Pull thepinna of theinfant’s ear forward before inserting theprobe. c. Insert theprobe 3.8 cm (1.5in) into theinfant’s rectum. d. Insert thethermometer in front of theinfant’s tongue. 73. A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of thefollowing interventions should thenurse include in theplan? a. Encourage theclient to spend time in theday room b. Withdraw theclient’s TV privileges is thedoes not attend group therapy c. Encourage theclient to take frequent rest periods d. Place thecline in seclusion when he exhibits signs of anxiety 74. A nurse is admitting medications to a group of clients. Which of thefollowing occurrences requires thecompletion of an incident report? a. A client receives his antibiotics 2hr late b. A client vomits within 20min of taking his morning medications c. A client requests his statin to be administered at 2100 d. A client asks for pain medication 1hr early 75. A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. theclient asks thenurse to warm up seaweed soup that theclient’s partner brought for her. Which of thefollowing responses should thenurse make? a. “Does thedoctor know you are eating that?” b. “Why are you eating seaweed soup?” c. “Of course I will heat that up for you” d. “The hospital good is more nutritious” 76. A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of thefollowing examples should thenurse include in theteaching? a. Leaving a nasogastric tube clamped after administering oral medication b. Documenting communication with a provider in theprogress notes of theclient’s medical records c. Administering potassium via IV bolus d. Placing a yellow bracelet on a client who is at risk for falls 77. A nurse is providing teaching to family members of a client who has dementia. Which of thefollowing instructions should thenurse include in theteaching? a. Establish a toileting schedule for theclient b. Use clothing with buttons and sippers c. Discourage physical activity during theday d. Engage theclient in activities that increase sensory stimulation 78. The nurse is reviewing themedical record of a client who is requesting combination oral contraceptives. Which of thefollowing conditions in theclient’s history is a contradiction to theuse of oral contraceptives? a. Hyperthyroidism. b. Thrombophlebitis. c. Diverticulosis. d. Hypocalcemia. 79. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. theclient states, “It’s hard not to listen to thevoices.” Which of thefollowing questions should thenurse ask theclient? a. “Do you understand that thevoices are not real?” b. “Why do you think thevoices are talking to you?” c. “Have you tried going to a private place when this occurs?” d. “What helps you ignore what you are hearing?” 80. A charge nurse is teaching a group of newly licensed nurses about thecorrect use of restraints. Which of thefollowing should thenurse include in theteaching? a. Placing a belt restraint on a school-age child who has seizures. b. Securing wrist restraints to thebed rails for an adolescent. c. Applying elbow immobilizers of an infant receiving cleft lip injury d. Keeping theside rails of a toddler’s crib elevated. 81. A nurse is preparing to mix NPH and regular insulin in thesame syringe. Which of thefollowing a. Inject air into theNPH insulin vial. b. (Unable to read) c. Withdraw theprescribed dose of regular insulin d. Withdraw theprescribed dose of NPH insulin 82. A Nurse is working with a client who has an anxiety disorder and is in theorientation phase of thetherapeutic relationship. Which of thefollowing statements should thenurse make during this phase? a. “Let’s talk about how you can change your response to stress.” B. “We should establish our roles in theinitial session.” C. “Let me show you simple relaxation exercises to manage stress.” D. “We should discuss resources to implement in your daily life.” 83. A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of thefollowing interventions should thenurse implement? a. Perform fundal massage ( massage if fundus is boggy) e. Insert an indwelling urinary catheter. f. Apply cold therapy to theclient’s perineal area.( warm) 84. A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of thefollowing instructions should thenurse include in theteaching? e. Apply patch to your forearm f. Avoid high-fiber foods while taking this medication g. Remove thepatch for 8 hours every day to reduce therisk for tolerance. 85. A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. theclient has an area of non-blanchable erythema over his ischium. Which of thefollowing interventions should thenurse include in thecare plan? b. Place theclient upright on a donut-shaped cushion c. Assess pressure points every 24 hr.- must assess d. Turn and reposition theclient every 3 hrs. while in bed. - must be q 2 hours in bed, 1 hour in chair. 86. A nurse is working with a client who has an anxiety disorder and is in theorientation phase of thetherapeutic relationship. Which of thefollowing statements should thenurse make during this phase? d. We should discuss resources to implement in your daily life e. Let me show you simple relaxation exercises to manage stress. f. Let’s talk about how you can change your response to stress 87. A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. thenurse should instruct theclient that it is safe to eat which of thefollowing foods while taking this medication? a. Avocados e. Pepperoni pizza f. Smoked salmon 88. A nurse is caring for a client who is experiencing mild anxiety. Which of thefollowing findings should thenurse expect? c. Feelings of dread d. Purposeless activity 89. A nurse is caring for a client who has type 1 diabetes mellitus. theclient reports that she is not feeling well. Which of thefollowing findings should indicate to thenurse that theclient is hypoglycemic? (Select all that apply.) ab.. TPorelymdoiprssia = hyperglycemia c. Acetone Breath odor = DKA e. Inability to concentrate 90. A nurse is caring for an infant who has coarctation of theaorta. Which of thefollowing should thenurse identify as an expected finding? a. Upper extremity hypotension b. Increased intracranial pressure c. Frequent nosebleeds 91. A community health nurse is planning primary prevention activities to reduce theoccurrence of abuse. Which of thefollowing strategies should thenurse include in theplan? a. Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) b. Locate financial support to open a shelter for abuse survivors (3rd) d. Connect abuse survivors with legal counsel (3rd) 92. A nurse and an assistive personnel (AP) are caring for a group of clients. Which of thefollowing tasks is appropriate for thenurse to delegate to theAP? a. Documenting thereport of pain for a client who is postoperative b. Administering oral fluids to a client who has dysphagia- d. Reviewing active range-of-motion exercise with a client who had a stroke 93. A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of thefollowing statements by theclient indicates an understanding of theteaching? a. “I will take sucralfate with meals three times per day” c. “I will decrease my daily protein intake to 15 grams per day” d. “I will use ibuprofen as needed to control abdominal pain” 94. A nurse is caring for a client who reports xerostomia following radiation therapy to themandible. Which of thefollowing is an appropriate action by thenurse? a. Offer theclient saltine crackers between meals b. Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of theroom air d. Instruct theclient on theuse of esophageal speech 95. A nurse is caring for four clients. Which of thefollowing tasks can thenurse delegate to an assistive personnel? a. Assess effectiveness of antiemetic medication- b. Perform chest compressions during cardiac resuscitation- c. Perform a dressing change for a new amputee- d. Apply a transdermal nicotine patch- 96. A nurse is caring for a client who states he recently purchased lavender oil to use when he gets theflu. thenurse should recognize which of thefollowing findings as a potential contraindication for using lavender? a. The client takes vitamin C daily b. The client has a history of alcohol use disorder d. theclient takes furosemide twice daily 97. A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. thenurse should monitor for which of thefollowing adverse effects? a. Increased salivation- dry it will cause - anticholinergic effects b. Weight loss d. Hypertension- orthostatic hypotension it will cause instead 98. A nurse is conducting a health promotion class about theuse of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? a. Asthma c. Fibromyalgia d. Fibrocystic breast condition 99. A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of thefollowing statements is appropriate to include in theteaching? c. “The nurse will ask you to wear protective eyewear during this procedure.” d. “The nurse will ask you to remove any transdermal patches prior to the procedure.” 100. A nurse in a provider’s office is reviewing a female client’s medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 101. A nurse is teaching who has chronic pain about avoiding constipation from opioid medications. Which of the following should the nurse include in the teaching? a. Drink 1.5L fluids each day. b. Take mineral oil at bedtime. c. Increase exercise activity d. Decrease insoluble fiber. 102. A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections. Which of the following interventions should the nurse include in the teaching? a. “Drink 2 liters of warm water per day”. b. “Empty your bladder every 6 weeks.”. c. “Soak in a warm bath everyday”. d. “Take an oral estrogen tablet”. 103. A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first? A. A client who has sinus arrhythmia and is receiving monitoring B. A client who has a hip fracture and a new onset of tachypnea C. A client who has epidural analgesia and weakness in the lower extremities D. A client who has diabetes and a hemoglobin A1C of 6.8% 104. A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include? a. Consume food high in bran fiber b. Increase intake of milk products c. Sweeten foods with fructose corn syrup d. Increase foods high in gluten 105. A nurse is caring for a 1-day-old newborns who has jaundice and is receiving phototherapy. Which of the following actions should the nurse take? a. the infant 30 ml (1 oz) glucose water every 2 hr. b. Keep the infants head covered with a cap. c. Ensure that the newborn wears a diaper. d. Apply lotion to the newborn every 4 hr. 106. A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following statements by a newly licensed nurse indicates an understanding of the teaching? a. “(Unable to read) I feel to be in his best health care decision” b. “I will intervene if there is conflict between a client and his provider” c. “I should not advocate for a client unless he is able to ask me himself” d. “I will inform a client that his family should help make his health care decisions.” 107. A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? a. Raise the side rails on both sides of the client’s bed during repositioning. b. Reposition the client without assistive devices. c. Discuss the client’s preferences for determining a reposition schedule. d. Evaluate the client’s ability to help with repositioning. 108. A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? a. Weak femoral pulses b. Frequent nosebleeds c. Upper extremity hypotension d. Increased intracranial pressure 109. A nurse is auscultating for crackles on a client who has pneumonia. Which of the following anterior chest wall locations should the nurse auscultate? 110. A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include? A. A statement that participants can leave the study at will. B. An assignment of the participant to either the experimental or control group. C. A list of the clients participating in the study. D. A description of the framework the researchers will use to evaluate the data. 111. A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? a. Excessive sweating b. Increased urinary frequency c. Dry cough d. Metallic taste in mouth 112. A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? a. The client’s pulse oximetry level is 96%. b. (Unable to read) c. The client develops hiccups. d. The ECG shows pacing spikes after the QRS complex. 113. A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? a. Personal blogs about managing the adverse effects of diabetes medications b. Food label recommendations from the Institute of Medicine c. Diabetes medication information from the Physicians’ Desk Reference d. Food exchange lists for meal planning from the American Diabetes Association 114. A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? a. “The PCA will deliver a double dose of medication when you push the button twice.” b. “You can adjust the amount of pain medication you receive by pushing on the keypad.” c. “Continuous PCA infusion is designed to allow fluctuating plasma medication levels.” d. “You should push the button before physical activity to allow maximum pain control.” 115. A nurse is caring for a client who has diabetes mellitus and is receiving long- acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? a. Glargine insulin. b. Regular insulin. c. NPH insulin. d. Insulin aspart. 116. A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? a. Looking at alphabet flashcards. b. Playing with a large plastic truck. c. Use scissors cut out paper shapes. d. Watching a cartoon in the dayroom. 117. A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? a. Administer a refrigerated feeding. b. Increased the amount of water use to flush the tubing. c. (Unable to read) rate of the client’s feedings. d. Instruct the client to move onto their right side. 118. A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse’s priority? a. Monitor the client’s ECG b. Take the client’s vital signs. c. Administer oxygen d. Insert an IV line. 119. A nurse is caring for a client who has Raynaud’s disease. Which of the following actions should the nurse take? a. Provide information about stress management. b. Maintain a cool temperature in the client’s room. c. Administer epinephrine for acute episodes. d. Give glucocorticoid steroid twice per day. 120. A nurse is reviewing the medical history of a client who has angina. Which of the following findings in the client’s medical history should identify as a risk factor for angina? a. Hyperlipidemia. b. COPD c. Seizure disorder d. Hyponatremia. 121. A nurse is caring for a client who is 12 hr. postpartum and has a third- degree perineal laceration. The client reports not having a bowel movement for 4 days. Which of the following medications should the nurse administer? a. Bisacodyl 10 mg rectal suppository. b. Magnesium hydroxide 30 ml PO. c. Famotidine 20 mg PO. d. Loperamide 4 mg PO. 122. A nurse overhears two assistive personnel (AP) discussing care for a client while in the elevator. Which of the following actions should the nurse take? a. Contact the client’s family about the incident. b. Notify the client’s provider about the incident. c. File a complaint with the facility’s ethics committee. d. Report the incident to the AP’s charge nurse. 123. A nurse is providing teaching about the gastrostomy tube feedings to the parents of a school age child. Which of the following instructions should the nurse take? a. . Administer the feeding over 30 min. b. Place the child in as supine position after the feeding. c. Charge the feeding bag and tubing every 3 days. d. Warm the formula in the microwave prior to administration. 124. A nurse is administering digoxin 0.125 mg Po to an adult client. For which of the following findings should the nurse report to the provider? A. Potassium level 4.2 mEq/L. B. Apical pulse 58/min. C. D igoxin level 1 ng/ml. D. Constipation for 2 days. 125. A nurse is caring for a client who is comatose and has advance directives that indicate the client does not want life-sustaining measures. The client’s family want the client to have life-sustaining measures. Which of the following action should the nurse take? A . Arrange for an ethics committee meeting to address the family’s concerns. B . Support the family’s decision and initiate life-sustaining measures. C. . Complete an incident report. D. . Encourage the family to contact an attorney. 126. A nurse is caring for a client who wears glasses. Which of the following actions should the nurse take? B. Clean the glasses with hot water. C. Clean the glasses with a paper towel. D. Store the glasses on the bedside table. 127. A nurse is teaching a group of newly licensed nurses about measures to take when caring for a client who is on contact precautions. Which of the following should the nurse include in the teaching? A. Remove the protective gown after the client’s room. B. Place the client in a room with negative pressure. C. Wear gloves when providing care to the client. 128. A nurse is caring for a client who is at 38 weeks gestation, is in active labor, and has ruptured membrane. Which of the following actions should the nurse take? a. Insert an indwelling urinary catheter. b. Apply fetal heart rate monitor. c. Initiate fundal massage. d. Initiate an oxytocin IV infusion. 129. A home health nurse is preparing to make an initial visit to a family following a referral from a local provider. Identify the sequence of steps the nurse should take when conducting a home visit. (Move the steps into the box on the right. Placing them in the order of performance) a. Identify family needs interventions using the nursing process. b. Record information about the home visit according to agency policy. c. Contact the family to determine availability and readiness to make an appointment d. Discuss plans for future visits with the family. e. Clarify the reason for the referral with the provider’s office. 130. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for paternal fluid therapy. The guardian asks. “What are the indications that my baby needs an IV?” Which of the following responses should the nurse make? a. “Your baby needs an IV because she is not producing any tears” b. “Your baby needs an IV because her fontanels are budging” c. “Your baby needs an IV because she is breathing slower than normal” d. “Your baby needs an IV because her heart rate is decreasing” 131. A nurse is caring for a client who is receiving intermittent eternal tube feeding. Which of the following places the client at risk for aspiration? a. A residual of 65mL 1 hr postprandial b. A History of gastroesophageal reflux disease c. Sitting in a high-Fowler’s position during the feeding d. Receiving a high osmolarity formula 132. A nurse is providing discharge teaching to a client who has chronic kidney disease and is receiving hemodialysis. Which of the following instructions should the nurse include in the teaching? a. Take magnesium hydroxide for indigestion b. Drink at least 3L of fluid daily C. Eat 1g/kg of protein per day D. Consume foods high in potassium 133. A nurse on a telemetry unit is assessing a client who is receiving continuous cardiac monitoring. The client’s heart rate is 69/min and the PR interval is 0.24 seconds. The nurse should interpret this finding as which of the following cardiac rhythms? a. First degree AV block b. Premature ventricular contraction. c. Sinus bradycardia. d. Atrial fibrillation. 134. A nurse is supervising an assistive personnel (AP) who is feeding a client. The nurse observes that the client coughs after each bite. After asking the AP to stop feeding the client, which of the following actions should the nurse take next? a. Provide the client with an instructional handout about swallowing exercises. b. Ask a speech therapist to evaluate the client’s ability to swallow. c. Discuss the manifestations of impaired swallowing with the AP. d. Listens to the client’s lung sounds. 135. A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan? a. Ask the client directly what he is hearing b. Encourage the client to lie down in a quiet room c. Avoid eye contact with the client d. Refer to the hallucinations as if they are real 136. The nurse is teaching a group of clients at a community health fair about genetic disease. Which of the following statements by a client indicates an understanding of the teaching? a. “If there is a genetic risk for future pregnancies, we can get treatment now to prevent the disease” b. “There is no need to have genetic counseling if I know that I have a family history of mental illness.” c. “My family has genetic risk for breast cancer, so I am considering a total mastectomy” d. “Even if I have a genetic risk for a disease the chance I will get the disease is probably low due to current medical treatments.” 137. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse plan to include in the teaching? a. “The cord stump will fall off in 5 days.” b. “Contact the provider if the cord stump turns black.” c. “Clean the base of the cord with hydrogen peroxide daily.” d. “Keep the cord stump dry until it falls off.” 138. A nurse is providing teaching to a client who is on glucocorticoid therapy. Which of the following statements by the client indicates an understanding of the teaching? a. “I have my eyes examines annually” b. “I take a calcium vitamin supplement daily” c. “I limit my intake of foods with potassium” d. “I constantly take my medication between 8 and 9 each evening” 139. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by a newly licensed nurse indicates an understanding of the teaching? a. Stands with feet together when lifting a client up in bed. b. Raises the client’s head of bed before pulling the cline up. c. Uses a mechanical lift to move client from bed to chair. d. Places a gait belt around the client’s upper chest before assisting a client to stand. 140. A client is requesting information from a nurse about a nitrazine test. Which of the following statements should the nurse make? a. “Your bladder should be full prior to me performing this test b. “If this test is positive you will be required to have a non-stress test. c. “This test will determine if there is leaking amniotic fluid” d. “I will be taking a blood sample to test for changes in your hormones levels” 141. A Nurse is assessing a client who has hyponatremia and is receiving IV fluid therapy. Which of the following findings indicate the client is developing a complication of therapy? a. Peripheral edema b. Increased thirst. c. Flattened neck veins. d. Hypotension 142. A nurse is conducting a home visit for a family who has two young children. The nurse notes several welts across the backs of the legs of one of the children. Which of the following actions should the nurse take first? a. Document clinical findings. b. Contact child protective services. c. Refer the parents to a self-help group. d. Instruct the parents about methods of discipline. 143. A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include? a. Encourage the client to floss daily. b. Remove fresh flowers from the client’s room. c. Provide the client what a stool softener. d. Avoid serving the client raw vegetable. 144. A nurse is assessing a client who is 30 min postoperative following an arterial thrombectomy. Which of the following findings should the nurse to report? a. Chest pain b. Muscle spasms. c. Cool, moist skin. d. Incisional pain. 145. A nurse is caring for a client who has left-sided heart failure, and the provider is concerned that the client might develop (Unable to read) Which of the following actions should the nurse take? a. Maintain the client’s oxygen saturation level at 89%. b. Place the client’s lower extremities on two pillows. c. Recommended that the client follow a 3g sodium diet. d. Place the client in high fowler’s position. 146. A nurse is reviewing the medical record of a client who has a prescription for intermittent heat therapy for a foot injury. Which if the following findings should the nurse identify as a contraindication for heat therapy? A. Phlebitis B. Abdominal aortic aneurysm C. Osteoarthritis D. Peripheral neuropathy 147. A nurse is providing teaching to a client who is to undergo a cardiac catheterization. Which of the following findings is expected during the procedure? A. Sensation of skin warmth B. Headache C. Increased salivation D. Numbness and tingling of the extremities 148. A nurse is transcribing new medication prescriptions for a group of clients. For which of the following prescriptions should the nurse contact the provider for clarification? A. Lorazepam .5 mg PO one tablet daily B. Hydrochlorothiazide 12.5 mg PO BID C. Triamcinolone acetonide 100 mcg/inhalation two puffs TID D. Zolpidem 10 mg PO one tablet at bedtime 149. A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching? A. Swelling of the face B. Urinary frequency C. Faintness upon rising D. Bleeding gums 150. A nurse is providing care for a client who has esophageal cancer and has received radiation therapy. Which of the following finding should the nurse identify as the priority? A. Excoriation of the skin on the neck and chest B. Dysphagia C. Client reports a pain level of 6 on scale from 0-10 D. Xerostomia 151. A nurse is assessing a client who is 2 hrs postpartum for uterine atony. Which of the following action should the nurse take? A. Monitor the client’s urinary output B. Check the client VS C. Evaluate the client's pain level D. Palpate the client’s fundus 152. A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include? A. “This type of seizure can be mistaken for daydreaming” B. “The child usually has an aura prior to onset” C. This type of seizure last 30-60 sec” D. “This type of seizure has a gradual onset” 153. A nurse in a surgical suite is planning care for a client who requires surgery and has a latex sensitivity. Which of the following is appropriate for this client? A. Disinfect and powder any latex products before use B. Tape stockinet over monitoring device and cords C. Schedule the client as the last surgery of the day D. Remove poop-socks from the IV 154. A nurses is assessing a preschooler who has recently experienced an unexpected death in the family. Which of the following should the nurse recognize as an expected finding? a. The child expresses curiosity about the death process. b. The child refuses to talk about death. c. The child believes the person will return. d. The child focuses on his own mortality. 155. A nurse is assessing a client in the emergency department. Which of the following actions should the nurse take first? Exhibit 1 Laboratory Results Cerebrospinal fluid WBC 2,000/mm3 Neutrophils 88% Protein 320 mg/dl Glucose 35 mg/dl Cloudy in appearance Exhibit 2 History and Physical Reports severe headache and photophobia. Disoriented to person, place, and time. Lethargic. Exhibit 3 Vital Signs BP 166/96 mm Hg Respiratory rate 24/min Pulse rate 112/min Temperature 39.3C (102.8F) Pain of 6 on a scale from 0 to 10 Glasgow score 9 a. Place the client on a cooling blanket. b. Administer an analgesic. c. Obtain arterial blood gas levels. d. Elevate the head of the client’s bed 30 degrees. 156. A client is caring for a client following a paracentesis. Which of the following findings should the nurse identify as an indication of a complication? a. Decreased hematocrit. b. Increased blood pressure. c. Tachycardia. d. Hypothermia. 157. A certified IV nurse is providing education about peripherally inserted catheters (PICC) to a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? a. “Use a vein in the middle of the lower arm to insert a PICC.” b. “Flush a PICC using a 3-milliliter syringe.” c. “Informed consent is required prior to PICC placement.” d. “Position the client’s arm in adduction for PICC placement.” 158. A nurse is reviewing admission prescriptions for a group of clients. Which of the following prescriptions should the nurse identify as complete? a. Furosemide 20 mg BID b. Nitroglycerin transdermal patch. c. Aspirin 1 tablet daily. d. Metoprolol 5mg IV now. 159. A nurse is caring a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take? a. Hold hand flat to perform percussion on the child b. Perform the procedure twice a day c. Administer a bronchodilator after the procedure d. D. Perform the procedure prior to meals 160. A nurse is reviewing the medical records of four clients. The nurse should identify that which of the following client findings requires follow up care? a. A client who received a Mantoux test 48hr ago and has an induration b. A client who is schedule for a colonoscopy and is taking sodium phosphate c. A client who is taking warfarin and has an INR of 1.8 d. A client who is takin bumetanide and has a potassium level of 3.6 mEq/ L 161. A nurse is caring for a client who is postpartum and request information about contraception. Which of the following instructions should the nurse include? a. “The lactation amenorrhea method is effective for your first year postpartum” b. “You can continue to use the diaphragm used before your pregnancy” c. “Place transdermal birth control patch on your upper arm” d. “I should avoid vaginal spermicides while breast feeding.” 162. A nurse is reviewing the facility’s safety protocols considering newborn abduction with the parent of a newborn. Which of the following statements indicates an understanding of the teaching? a. “Staff will apply identification band after first bath” b. “I will not publish public announcement about my baby’s birth” c. “I can remove my baby’s identification band as long as she is in my room” d. “I can leave my baby in my room while I walk in the hallway” 163. A nurse is developing a plan of care for a client who has preeclampsia and is to receive magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse include in the plan? a. Restrict the client’s total fluid intake to 250 mL/hr b. Give the protamine if signs of magnesium sulfate toxicity occur c. Monitor the FHR via Doppler every 30min d. Measure the client’s urine output every hour 164. A nurse is receiving a telephone prescription from a provider for a client who requires additional medication for pain control. Which of the following entries should the nurse make in the medical record? a. “Morphine 3 mg SQ every 4 hr. PRN for pain.” b. “Morphine 3 mg Subcutaneous (Unable to read) c. “Morphine 3.0 mg sub q every 4 hr. PRN for pain.” d. “Morphine 3 mg SC q 4 hr. PRN for pain.” 165. A nurse is assessing a client who has acute kidney injury and a respiratory rate of 34/min. The client’s ABG results are ph. 7.28 HCO3 18 mEq/L. (Unable to read) PaO2 90 mm Hg. Which of the following conditions should the nurse expect? a. Metabolic acidosis. b. Metabolic alkalosis. c. Respiratory acidosis. d. Respiratory alkalosis. 166. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first? a. Notify the provider. b. Report the incident to the nurse manager. c. Monitor vital signs. d. Fill out an incident report. 167. A nurse receives a telephone call from a parent reporting that their school- age child has a nosebleed and that they cannot stop the bleeding. Which of the following instructions should the nurse provide to the provider? a. “Have your child lie down and turn their head to their side for 10 minutes” b. “Use your thumb and forefinger to apply pressure to the (Unable to read) of your child’s nose” c. “Place a warm wet washcloth over your child’s forehead and the bridge of their nose” d. “Tell your child to blow their nose gently and then sit down and tilt your head back” 168. A nurse is preparing to administer an autologous blood product to a client. Which of the following actions should the nurse take to identify the client? a. Match the client’s blood type with the type and cross match specimens. b. Confirm the provider’s prescription matches the number on the blood component. c. Ask the client to state the blood type and the date of their last blood donation. d. Ensure that the client’s identification band matches the number on the blood unit. 169. A nurse is transcribing new medication prescriptions for a group of client. For which of the following prescriptions should the nurse contact the provider for clarifications? a. Zolpidem 10mg PO one tablet at bedtime b. Hydrochlorothiazide 12.5 mg PO BID c. Triamcinolone acetonide 100 mcg/inhalation two puffs TID d. Lorazepam .5mg PO one tablet daily 170. A nurse is admitting a client who has acute heart failure. Which of the following prescriptions from the provider should the nurse anticipate? a. Administer enalapril 2.5 mg PO twice daily b. Ambulate the client every 4 hr while awake(bedrest) c. Provide the client with 4 g sodium diet( d. Infuse 0.9% sodium chloride 500 mL IV bolus over 1 hr 171. A nurse is collecting a specimen for urinalysis and culture from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take during collection? a. Drain the specimen from the drainage bag(not sterile use the port for culture and UA) b. Clamp the catheter distal to the injection port c. Collect 2 mL of urine for each specimen d. Obtain the urinalysis specimen before the culture specimen 172. A nurse is caring for a client who reports diarrhea for 3 days. The nurse should monitor the client for which of the following manifestations? A. Orthostatic Hypertension B. Dependent Edema C. Decreased Hematocrit D. Neck Vein Distension 173. A nurse is devdeloping an in-service about personality disorders. Which of the following information should the nurse include when discussing borderline personality disorder? A. The client is overly concerned about minor details. B. The client exhibits impulsive behavior. C. The client is exceptionally clingy to others. D. The client may act seductively.- histrionic 174. A nurse is assessing a client who is 36 weeks of gestation. Which of the following findings should the nurse report to the provider? A. 3+ deep tendon reflexes (common finding in women with preeclampsia and does not require action unless there are symptoms of magnesium toxicity.) B. Protruding Hemorrhoids C. Urinary Frequency (expected) D. Supine Hypotension 175. A nurse is administering an analgesic to a client who has a chest tube. The provider is preparing to discontinue the chest tube before the medication has taken affect. Which of the following actions should the nurse prepare to take first? A. Inform the provider of the time of the last dose of pain medication. B. Document the sequence of events as they occur. C. Provide non-pharmacological pain management interventions. D. Instruct the client about the steps of the procedure. 176. A nurse in a PACU is transferring care of a client to a nurse on the medical-surgical unit. Which of the following statements should the nurse include in the hand-off report? A. The client was intubated without complications. B. The estimated blood loss was 250 milliliters. C. There was a total of 10 sponges used during the procedures. D. The client is a member of the board of directors. 177. A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching? A. “You can add the medication to a half-cup of your child’s favorite juice.” B. “Repeat the dose if your child vomits within 1 hour after taking the medication.” C. “Limit your child’s potassium intake while she is taking this medication.” D. “Have your child drink a small glass of water after swallowing the medication.” 178. A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications? A. Left ventricular failure B. Cardiogenic shock C. Hypovolemia D. Hypotension 179. A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community. In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge? A. A client who has COPD and a respiratory rate of 44/min B. A client who has cancer with a sealed implant for radiation treatment. C. A client who is 1 day postoperative following a vertebroplasty D. A client who is receiving heparin for deep vein thrombosis. 180. A nurse is caring for four clients who are scheduled for surgery the same day. Which of the following laboratory values indicates the need for intervention before surgery? A. Fasting blood glucose 108 mg/dl (WNL) B. WBC 9,800/mm (WNL) C. Creatinine 0.9 mg/dl (WNL) D. Potassium 5.2 mEq/L