2020 HESI EXIT Exam

2020 HESI EXIT A 20-year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precaut ...

2020 HESI EXIT A 20-year-old client has an infected leg wound from a motorcycle accident, and the client has returned home from the hospital. The client is to keep the affected leg elevated and is on contact precautions. The client wants to know if visitors can come. The appropriate response from the home health nurse is that: A) Visitors must wear a mask and a gown B) There are no special requirements for visitors of clients on contact precautions C) Visitors should wash their hands before and after touching the client D) Visitors A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first? A) Institute seizure precautions B) Monitor neurologic status every hour C) Place in respiratory/secretion precautions D) Cefotaxime IV 50 mg/kg/day divided q6h Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls? A) Sensory perceptual alterations related to decreased vision B) Alteration in mobility related to fatigue C) Impaired gas exchange related to retained secretions D) Altered patterns of urinary elimination related to nocturia A nurse who is reassigned to the emergency department needs to understand that gastric lavage is a priority in which situation? A) An infant who has been identified to have botulism B) A toddler who ate a number of ibuprofen tablets C) A preschooler who swallowed powdered plant food D) A school aged child who took a handful of vitamins A newly admitted adult client has a diagnosis of hepatitis A. The charge nurse should reinforce to the staff members that the most significant routine infection control strategy, in addition to hand washing, to be implemented is which of these? A) Apply appropriate signs outside and inside the room B) Apply a mask with a shield if there is a risk of fluid splash C) Wear a gown to change soiled linens from incontinence D) Have gloves on while handling bedpans with feces Which of these clients with associated lab reports is a priority for the nurse to report to the public health department within the next 24 hours? A) An infant with a positive culture of stool for Shigella B) An elderly factory worker with a lab report that is positive for acid-fast bacillus smear C) A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii D) A middle-aged nurse with a history of varicella-zoster virus and with crops of vesicles on an erythematous base that appear on the skin A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A) Reverse B) Airborne C) Standard precautions D) Contact The school nurse is teaching the faculty the most effective methods to prevent the spread of lice in the school. The information that would be most important to include would be which of these statements? A) "The treatment requires reapplication in 8 to 10 days." B) "Bedding and clothing can be boiled or steamed." C) Children are not to share hats, scarves and combs. D) Nit combs are necessary to comb out nits. During the care of a client with a salmonella infection, the primary nursing intervention to limit transmission is which of these approaches? A) Wash hands thoroughly before and after client contact B) Wear gloves when in contact with body secretions C) Double glove when in contact with feces or vomitus D) Wear gloves when disposing of contaminated linens A nurse is reinforcing teaching with a client about compromised host precautions. The client is receiving filgrastim (Neupogen) for neutropenia. The selection of which lunch suggests the client has learned about necessary dietary changes? A) grilled chicken sandwich and skim milk B) roast beef, mashed potatoes, and green beans C) peanut butter sandwich, banana, and iced tea D) barbecue beef, baked beans, and cole slaw After an explosion at a factory one of the workers approaches the nurse and says "I am an unlicensed assistive personnel (UAP) at the local hospital." Which of these tasks should the nurse assign to this worker who wants to help during the care of the wounded workers? A) Get temperatures B) Take blood pressure C) Palpate pulses D) Check alertness Which of these clients would the nurse recommend to keep in the hospital during an internal disaster at the agency? A) An adolescent diagnosed with sepsis 7 days ago with vital signs maintained within low normal B) A middle-aged woman documented to have had an uncomplicated myocardial infarction 4 days ago C) An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis D) A young adult in the second day of treatment for an overdose of acetometaphen Which information is a priority for the RN to reinforce to an older client after intravenous pyelography? A) Eat a light diet for the rest of the day B) Rest for the next 24 hours since the preparation and the test is tiring. C) During waking hours drink at least 1 8-ounce glass of fluid every hour for the next 2 days D) Measure the urine output for the next day and immediately notify the health care provider if it should decrease. A client has altered renal function and is being treated at home. The nurse recognizes that the most accurate indicator of fluid balance during the weekly visits is A) difference in the intake and output B) changes in the mucous membranes C) skin turgor D) weekly weight A client has been diagnosed with Zollinger-Ellison syndrome. Which information is most important for the nurse to reinforce with the client? A)It is a condition in which one or more tumors called gastronomes form in the pancreas or in the upper part of the small intestine (duodenum) B)It is critical to report promptly to your health care provider any findings of peptic ulcers c)Treatment consists of medications to reduce acid and heal any peptic ulcers and, if possible, surgery to remove any tumors D)With the average age at diagnosis at 50 years the peptic ulcers may occur at unusual areas of the stomach or intestine A primigravida in the third trimester is hospitalized for preeclampsia. The nurse determines that the client's blood pressure is increasing. Which action should the nurse take first? A) Check the protein level in urine B) Have the client turn to the left side C) Take the temperature D) Monitor the urine output The nurse is caring for a client in atrial fibrillation. The atrial heart rate is 250 and the ventricular rate is controlled at 75. Which of the following findings is cause for the most concern? A) Diminished bowel sounds B) Loss of appetite C) A cold, pale lower leg D) Tachypnea The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider? A) Nausea and vomiting B) Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) C) Diffuse macular rash D) Muscle tenderness A client who had a vasectomy is in the post recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse? A) Until the health care provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception. B)This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen and no sperm are in your ejaculate. C) After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days. D) The health care provider at this clinic recommends rest, ice, an athletic supporter or over-the-counter pain medication to relieve any discomfort. A client who is to have antineoplastic chemotherapy tells the nurses of a fear of being sick all the time and wishes to try acupuncture. Which of these beliefs stated by the client would be incorrect about acupuncture? A) Some needles go as deep as 3 inches, depending on where they're placed in the body and what the treatment is for. The needles usually are left in for 15 to 30 minutes. B) In traditional Chinese medicine, imbalances in the basic energetic flow of life — known as qi or chi — are thought to cause illness. C) The flow of life is believed to flow through major pathways or nerve clusters in your body. D) By inserting extremely fine needles into some of the over 400 acupuncture points in various combinations it is believed that energy flow will rebalance to allow the body's natural healing mechanisms to take over. The nurse is discussing with a group of students the disease Kawasaki. What statement made by a student about Kawasaki disease is incorrect? A)It also called mucocutaneous lymph node syndrome because it affects the mucous membranes (inside the mouth, throat and nose), skin and lymph nodes. B)In the second phase of the disease, findings include peeling of the skin on the hands and feet with joint and abdominal pain C)Kawasaki disease occurs most often in boys, children younger than age 5 and children of Hispanic descent D)Initially findings are a sudden high fever, usually above 104 degrees Fahrenheit, which lasts 1 to2 weeks A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during first 12 hours after admission? A) Side-lying on the left with the head elevated 10 degrees B) Side-lying on the left with the head elevated 35 degrees C) Side-lying on the right wil the head elevated 10 degrees D) Side-lying on the right with the head elevated 35 degrees A client has an indwelling catheter with continuous bladder irrigation after undergoing a transurethral resection of the prostate (TURP) 12 hours ago. Which finding at this time should be reported to the health care provider? A) Light, pink urine B) occasional suprapubic cramping C) minimal drainage into the urinary collection bag D) complaints of the feeling of pulling on the urinary catheter A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse? A) Relieve the nurse performing CPR B) Go get the code cart C) Participate with the compressions or breathing D) Validate the client's advanced directive The nurse assesses a 72-year-old client who was admitted for right sided congestive heart failure. Which of the following would the nurse anticipate finding? A) Decreased urinary output B) Jugular vein distention C) Pleural effusion D) Bibasilar crackles A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication A) Can predispose to dysrhythmias B) May lead to oliguria C) May cause irritability and anxiety D) Sometimes alters consciousness A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern? A) Flaccid paralysis B) Pupils fixed and dilated C) Diminished spinal reflexes D) Reduced sensory responses A 14-year-old with a history of sickle cell disease is admitted to the hospital with a diagnosis of vaso-occlusive crisis. Which statements by the client would be most indicative of the etiology of this crisis? A)"I knew this would happen. I've been eating too much red meat lately." B)"I really enjoyed my fishing trip yesterday. I caught 2 fish." C)"I have really been working hard practicing with the debate team at school." D)"I went to the health care provider last week for a cold and I have gotten worse." Which these findings would the nurse more closely associate with anemia in a 10 month-old infant? A) Hemoglobin level of 12 g/dI B) Pale mucosa of the eyelids and lips C) Hypoactivity D) A heart rate between 140 to 160 The nurse is caring for a client in hypertensive crisis in an intensive care unit. The priority assessment in the first hour of care is A) Heart rate B) Pedal pulses C) Lung sounds D) Pupil responses Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump? A) A young adult with a history of Down's syndrome B) A teenager who reads at a 4th grade level C) An elderly client with numerous arthritic nodules on the hands D) A preschooler with intermittent episodes of alertness The nurse is about to assess a 6-month-old child with nonorganic failure-to thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be A) Irritable and "colicky" with no attempts to pull to standing B) Alert, laughing and playing with a rattle, sitting with support C)Skin color dusky with poor skin turgor over abdomen D) Pale, thin arms and legs, uninterested in surroundings As the nurse is speaking with a group of teens which of these side effects of chemotherapy for cancer would the nurse expect this group to be more interested in during the discussion? A) Mouth sores B) Fatigue C) Diarrhea D) Hair loss While caring for a client who was admitted with myocardial infarction (MI) 2 days ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5 degrees Celsius). The appropriate nursing intervention is to A) Call the health care provider immediately B) Administer acetaminophen as ordered as this is normal at this time C) Send blood, urine and sputum for culture D) Increase the client's fluid intake A client is admitted for first and second degree burns on the face, neck, anterior chest and hands. The nurse's priority should be A) Cover the areas with dry sterile dressings B) Assess for dyspnea or stridor C) Initiate intravenous therapy D) Administer pain medication Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider? A) I started my period and now my urine has turned bright red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I went to the bathroom and my urine looked very red and it didn't hurt when I went. A middle-aged woman talks to the nurse in the health care provider's office about uterine fibroids also called leiomyomas or myomas. What statement by the woman indicates more education is needed? A) I am one out of every 4 women that get fibroids, and of women my age - between the 30s or 40s, fibroids occurs more frequently. B) My fibroids are noncancerous tumors that grow slowly. C) My associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention and constipation. D) Fibroids that cause no problems still need to be taken out. An elderly client admitted after a fall begins to seize and loses consciousness. What action by the nurse is appropriate to do next? A) Stay with client and observe for airway obstruction B) Collect pillows and pad the side rails of the bed C) Place an oral airway in the mouth and suction D) Announce a cardiac arrest, and assist with intubation A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor? A) FHT 168 beats/min B) Temperature 100 degrees Fahrenheit. C) Cervical dilation of 4 D) BP 138/88 A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse's initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication? A) "I have a sharp pain in my chest when I take a breath." B) "I have been coughing up foul-tasting, brown, thick sputum." C) "I have been sweating all day." D) "I feel hot off and on." The nurse is performing an assessment on a client in congestive heart failure. Auscultation of the heart is most likely to reveal A) S3 ventricular gallop B) Apical click C) Systolic murmur D) Split S2 Which of these observations made by the nurse during an excretory urogram indicate a complication? A) The client complains of a salty taste in the mouth when the dye is injected B) The client's entire body turns a bright red color C) The client states "I have a feeling of getting warm." D) The client gags and complains " I am getting sick." A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client? A) "The tube will drain fluid from your chest." B) "The tube will remove excess air from your chest." C) "The tube controls the amount of air that enters your chest." D) "The tube will seal the hole in your lung." The nurse is reviewing laboratory results on a client with acute renal failure. Which one of the following should be reported immediately? A) Blood urea nitrogen 50 mg/dl B) Hemoglobin of 10.3 mg/dl C) Venous blood pH 7.30 D) Serum potassium 6 mEq/L The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention? A) Pallor B) Increased temperature C) Dyspnea D) Involuntary muscle spasms The nurse is performing a physical assessment on a client who just had an endotracheal tube inserted. Which finding would call for immediate action by the nurse? A) Breath sounds can be heard bilaterally B) Mist is visible in the T-Piece C) Pulse oximetry of 88 D) Client is unable to speak A nurse checks a client who is on a volume-cycled ventilator. Which finding indicates that the client may need suctioning? A) drowsiness B) complaint of nausea C) pulse rate of 92 D) restlessness The most effective nursing intervention to prevent atelectasis from developing in a post-operative client is to A) Maintain adequate hydration B) Assist client to turn, deep breathe, and cough C) Ambulate client within 12 hours D) Splint incision When caring for a client with a post right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote A) Relaxation and sleep B) Deep breathing and coughing C) Incisional healing D) Range of motion exercises A nurse is to collect a sputum specimen for acid-fast bacillus (AFB) from a client. Which action should the nurse take first? A) Ask client to cough sputum into container B) Have the client take several deep breaths C) Provide a appropriate specimen container D) Assist with oral hygiene The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority? A) Blanch nail beds for color and refill B) Assess for post-operative arrhythmias C) Auscultate for pulmonary congestion D) Monitor equality of peripheral pulses . A client has a history of chronic obstructive pulmonary disease (COPD). As the nurse enters the client's room, his oxygen is running at 6 liters per minute, his color is flushed and his respirations are 8 per minute. What should the nurse do first? A) Obtain a 12-lead EKG B) Place client in high Fowler's position C) Lower the oxygen rate D) Take baseline vital signs A 4-year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first? A) Notify the health care provider B) Readjust the traction C) Administer the ordered prn medication D) Reassess the foot in fifteen minutes The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to A) Wrap the leg with elastic bandages B) Apply pressure at the bleeding site C) Reinforce the dressing and elevate the leg D) Remove the dressings and re-dress the incision A client is receiving external beam radiation to the mediastinum for treatment of bronchial cancer. Which of the following should take priority in planning care? A) Esophagitis B) Leukopenia C) Fatigue D) Skin irritation A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action? A) Clamp the chest tube B) Call the surgeon immediately C) Prepare for blood transfusion D) Continue to monitor the rate of drainage A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure? A) Increased blood pressure B) Increased heart rate C) Loss of pulse in the extremity D) Decreased urine output A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him avoid? A) Have him drink several glasses of water B) Crede' the bladder from the bottom to the top C) Assist him to stand by the side of the bed to void D) Wait 2 hours and have him try to void again The nurse is caring for a client who requires a mechanical ventilator for breathing. The high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform? A) Disconnect the client from the ventilator and use a manual resuscitation bag B) Perform a quick assessment of the client's condition C) Call the respiratory therapist for help D) Press the alarm re-set button on the ventilator The nurse is preparing a client who will undergo a myelogram. Which of the following statements by the client indicates a contraindication for this test? A) "I can't lie in 1 position for more than thirty minutes." B) "I am allergic to shrimp." C) "I suffer from claustrophobia." D) "I developed a severe headache after a spinal tap." The health care provider order reads "aspirate nasogastric feeding (NG) tuber every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take? A) Hold the tube feeding and notify the provider B) Administer the tube feeding as scheduled C) Irrigate the tube with diet cola soda D) Apply intermittent suction to the feeding tube To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must A) Apply suction for no more than 10 seconds B) Maintain sterile technique C) Lubricate 3 to 4 inches of the catheter tip D) Withdraw catheter in a circular motion An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to A) administer the medication in 2 separate injections B) give the medication in the dorsal gluteal site C) call to get a smaller volume ordered D) check with pharmacy for a liquid form of the medication skip The nurse receives an order to give a client iron by deep injection. The nurse know that the reason for this route is to A) enhance absorption of the medication B) ensure that the entire dose of medication is given C) provide more even distribution of the drug D) prevent the drug from tissue irritation A client with heart failure has Lanoxin (digoxin) ordered. What would the nurse expect to find when evaluating for the therapeutic effectiveness of this drug? A) diaphoresis with decreased urinary output B) increased heart rate with increase respirations C) improved respiratory status and increased urinary output D) decreased chest pain and decreased blood pressure While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response? A) "As you urinate more, you will need less medication to control fluid." B) "You will have to take this medication for about a year." C) "The medication must be continued so the fluid problem is controlled." D) "Please talk to your health care provider about medications and treatments." A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report? A) Change in libido, breast enlargement B) Sore throat, fever C) Abdominal pain, nausea, diarrhea D) Dyspnea, nasal congestion A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic? A) Bruising at the operative site B) Elevated heart rate C) Decreased platelet count D) No bowel movement for 3 days A client is being maintained on heparin therapy for deep vein thrombosis. The nurse must closely monitor which of the following laboratory values? A) Bleeding time B) Platelet count C) Activated PTT D) Clotting time A client with amyotrophic lateral sclerosis has a percutaneous endoscopic gastrostomy (PEG) tube for the administration of feedings and medications. Which nursing action is appropriate? A) Pulverize all medications to a powdery condition B) Squeeze the tube before using it to break up stagnant liquids C) Cleanse the skin around the tube daily with hydrogen peroxide D) Flush adequately with water before and after using the tube The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective? A) "We will call the health care provider if the child develops acne." B) "Our child should brush and floss carefully after every meal." C) "We will skip the next dose if vomiting or fever occur." D) "When our child is seizure-free for 6 months, we can stop the medication." Although non-steroidal anti-inflammatory drugs such as ibuprofen (Motrin) are beneficial in managing arthritis pain, the nurse should caution clients about which of the following common side effects? A) Urinary incontinence B) Constipation C) Nystagmus D) Occult bleeding The nurse is caring for a client with clinical depression who is receiving a MAO inhibitor. When providing instructions about precautions with this medication, which action should the nurse stress to the client as important? A) Avoid chocolate and cheese B) Take frequent naps C) Take the medication with milk D) Avoid walking without assistance A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse? A) Cut the child's hair short to remove the nits B) Apply warm soaks to the head twice daily C) Wash the child's linen and clothing in a bleach solution D) Application of pediculicides The nurse is teaching a client about precautions with Coumadin therapy. The client should be instructed to avoid which over-the-counter medication? A) Non-steroidal anti-inflammatory drugs B) Cough medicines with guaifenesin C) Histamine blockers D) Laxatives containing magnesium salts A client diagnosed with cirrhosis of the liver and ascites is receiving Spironolactone (Aldactone). The nurse understands that this medication spares elimination of which element? A) Sodium B) Potassium C) Phosphate D) Albumin The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take? A) Stop the infusion B) Slow the rate of infusion C) Take vital signs and observe for further deterioration D) Administer Benadryl and continue the infusion Discharge instructions for a client taking alprazolam (Xanax) should include which of the following? A) Sedative hypnotics are effective analgesics B) Sudden cessation of alprazolam (Xanax) can cause rebound insomnia and nightmares C) Caffeine beverages can increase the effect of sedative hypnotics D) Avoidance of excessive exercise and high temperature is recommended A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely? A) Bleeding time B) Hemoglobin and hematocrit C) White blood cells D) Platelets A client is receiving intravenous heparin therapy. What medication should the nurse have available in the event of an overdose of heparin? A) Protamine B) Amicar C) Imferon D) Diltiazem The nurse has been teaching a client with Insulin Dependent Diabetes Mellitus. Which statement by the client indicates a need for further teaching? A) "I use a sliding scale to adjust regular insulin to my sugar level." B) "Since my eyesight is so bad, I ask the nurse to fill several syringes." C) "I keep my regular insulin bottle in the refrigerator." D) "I always make sure to shake the NPH bottle hard to mix it well." Why is it important for the nurse to monitor blood pressure in clients receiving antipsychotic drugs? A) Orthostatic hypotension is a common side effect B) Most antipsychotic drugs cause elevated blood pressure C) This provides information on the amount of sodium allowed in the diet D) It will indicate the need to institute anti parkinsonian drugs The nurse is teaching the client to select foods rich in potassium to help prevent digitalis toxicity. Which choice indicates the client understands dietary needs? A) Three apricots B) Medium banana C) Naval orange D) Baked potato An 86-year-old nursing home resident who has decreased mental status is hospitalized with pneumonic infiltrates in the right lower lobe. When the nurse assists the client with a clear liquid diet, the client begins to cough. What should the nurse do next? A) Add a thickening agent to the fluids B) Check the client's gag reflex C) Feed the client only solid foods D) Increase the rate of intravenous fluids The nurse is planning care for a client with a CVA. Which of the following measures planned by the nurse would be most effective in preventing skin breakdown? A) Place client in the wheelchair for four hours each day B) Pad the bony prominence C) Reposition every two hours D) Massage reddened bony prominence A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for development of decubitus ulcers? A) A 79-year-old malnourished client on bed rest B) An obese client who uses a wheelchair C) A client who had 3 incontinent diarrhea stools D) An 80-year-old ambulatory diabetic client Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority? A) Obtain a complete blood count B) Obtain a health and dietary history C) Refer to a provider for a physical examination D) Measure height and weight After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is A) Abdominal x-ray B) Auscultation C) Flushing tube with saline D) Aspiration for gastric contents A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile colored liquids. Which nursing measure will provide the most comfort to the client? A) Allow the client to melt ice chips in the mouth B) Provide mints to freshen the breath C) Perform frequent oral care with a tooth sponge D) Swab the mouth with glycerin swabs The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to A) Exercise doing weight bearing activities B) Exercise to reduce weight C) Avoid exercise activities that increase the risk of fracture D) Exercise to strengthen muscles and thereby protect bones The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction? A) Cheese sandwich with a glass of 2% milk B) Sliced turkey sandwich and canned pineapple C) Cheeseburger and baked potato D) Mushroom pizza and ice cream Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol? A) All 4 side rails up, wheels locked, bed closest to door B) Lower side rails up, bed facing doorway C) Knees bent, head slightly elevated, bed in lowest position D) Bed in lowest position, wheels locked, place bed against wall When administering enteral feeding to a client via a jejunostomy tube, the nurse should administer the formula A) Every four to six hours B) Continuously C) In a bolus D) Every hour The nurse is teaching 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID A) Glycerin suppositories B) Fiber supplements C) Laxatives D) Stool softeners A client with diarrhea should avoid which of the following? A) Orange juice B) Tuna C) Eggs D) Macaroni Which statement best describes the effects of immobility in children? A) Immobility prevents the progression of language and fine motor development B) Immobility in children has similar physical effects to those found in adults C) Children are more susceptible to the effects of immobility than are adults D) Children are likely to have prolonged immobility with subsequent complications A nurse is providing care to a 63-year-old client with pneumonia. Which intervention promotes the client's comfort? A) Increase oral fluid intake B) Encourage visits from family and friends C) Keep conversations short D) Monitor vital signs frequently After a myocardial infarction, a client is placed on a sodium restricted diet. When the nurse is teaching the client about the diet, which meal plan would be the most appropriate A) 3 oz. broiled fish, 1 baked potato, cup canned beets, 1 orange, and milk B) 3 oz. canned salmon, fresh broccoli, 1 biscuit, tea, and 1 apple C) A bologna sandwich, fresh eggplant, 2 oz fresh fruit, tea, and apple juice D) 3 oz. turkey, 1 fresh sweet potato, 1/2 cup fresh green beans, milk, and 1 orange The nurse is caring for a 7-year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate? A) Decreased carbohydrates and fat B) Decreased sodium and potassium C) Increased potassium and protein D) Increased sodium and fluids What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction? A) Presence of blood in stools B) Oozing liquid stool C) Continuous rumbling flatulence D) Absence of bowel movements A client in a long-term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to A) have the client identify coping methods B) get the description of the location and intensity of the pain C) accept the client's report of pain D) determine the client's status of pain An 85-year-old client complains of generalized muscle aches and pains. The first action by the nurse should be A) Assess the severity and location of the pain B) Obtain an order for an analgesic C) Reassure him that this is not unusual for his age D) Encourage him to increase his activity The mother of a toddler who is being treated for pesticide poisoning asks: "Why is activated charcoal used? What does it do?" What is the nurse's best response? A) "Activated charcoal decreases the systemic absorption of the poison from the stomach." B) "The charcoal absorbs the poison and forms a compound that doesn't hurt your child." C) "This substance helps to get the poison out of the body by the gastrointestinal system." D) "The action may bind or inactivate the toxins or irritants that are ingested by children or adults." The nurse is to administer a new medication to a client. Which actions are in the best interest of the client? Verify the order for the medication. Prior to giving the medication the nurse should say A) "Please state your name?" Upon entering the room the nurse should ask: B) "What is your name? What allergies do you have?" then check the client's name band and allergy band As the room is entered say C) "What is your name?" then check the client's name band Verify the client's allergies on the admission sheet and order. D) "Verify the client's name on the name plate outside the room then as the nurse enters the room ask the client "What is your first, middle and last name?" Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which medical condition? A) Autoimmune deficiency syndrome (AIDS) with cytomegalovirus (CMV) B) A positive purified protein derivative with an abnormal chest x-ray C) A tentative diagnosis of viral pneumonia with productive brown sputum D) Advanced carcinoma of the lung with hemostasis A client is scheduled to receive an oral solution of radioactive iodine (131I). In order to reduce hazards, the priority information for the nurse to include during the instructions to the client is which of these statements? A) In the initial 48 hours avoid contact with children and pregnant women, and after urination or defecation flush the commode twice. B) Use disposable utensils for 2 days and if vomiting occurs within 10 hours of the dose, do so in the toilet and flush it twice. C) Your family can use the same bathroom that you use without any special precautions. D) Drink plenty of water and empty your bladder often during the initial 3 days of therapy. Which approach is the best way to prevent infections when providing care to clients in the home setting? A) Hand washing before and after examination of clients B) Wearing non powdered latex free gloves to examine the client C) Using a barrier between the client's furniture and the nurse's bag D) Wearing a mask with a shield during any eye/mouth/nose examination A 10-year-old child has a history of epilepsy with tonic-clonic seizures. The school nurse should instruct the classroom teacher that if the child experiences a seizure in the classroom, the most important action during the seizure would be to A) Move any chairs or desks at least 3 feet away from the child B) Note the sequence of movements with the time lapse of the event C) Provide privacy as much as possible to minimize fighting the other children D) Place the hands or a folded blanket under the head of the child A mother calls the hospital hot line and is connected to the triage nurse. The mother proclaims: "I found my child with odd stuff coming from the mouth and an unmarked bottle nearby." Which of these comments would be the best for the nurse to ask the mother to determine if the child has swallowed a corrosive substance? A) Ask the child if the mouth is burning or throat pain is present B) Take the child's pulse at the wrist and see if the child is has trouble breathing lying flat. C) What color is the child's lips and nails and has the child voided today? D) Has the child had vomiting or diarrhea or stomach cramps yet? The nurse is assigned to a client newly diagnosed with active tuberculosis. Which of these protocols would be a priority for the nurse to implement? A) Have the client cough into a tissue and dispose in a separate bag B) Instruct the client to cover the mouth with a tissue when coughing C) Reinforce for all to wash their hands before and after entering the room D) Place client in a negative pressure private room and have all who enter the room use masks with shields The charge nurse is planning assignments on a medical unit. Which client should be assigned to the PN? A) Test a stool specimen for occult blood B) Assist with the ambulation of a client with a chest tube C) Irrigate and redress a leg wound D) Admit a client from the emergency room When assessing a client, it is important for the nurse to be informed about cultural issues related to the client's background because A) Normal patterns of behavior may be labeled as deviant, immoral, or insane B) The meaning of the client's behavior can be derived from conventional wisdom C) Personal values will guide the interaction between persons from 2 cultures D) The nurse should rely on her knowledge of different developmental mental stages The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client? A) Assign an RN to provide total care of the client B) Assign a nursing assistant to help the client with self-care activities C) Delegate complete care to unlicensed assistive personnel D) Supervise a nursing assistant for skin care The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process? A) Assist a client post cerebral vascular accident to ambulate B) Feed a 2-year-old in balanced skeletal traction C) Care for a client with discharge orders D) Collect a sputum specimen for acid fast bacillus After working with a very demanding client, unlicensed assistive personnel (UAP) tells the nurse, "I have had it with that client. I just can't do anything that pleases him. I'm not going in there again." The nurse should respond by saying A) "He has a lot of problems. You need to have patience with him." B) "I will talk with him and try to figure out what to do." C) "He is scared and taking it out on you. Let's talk to figure out what to do." D) "Ignore him and get the rest of your work done. Someone else can take care of him for the rest of the day." A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements? A) I am sorry. Referral information can only be provided by the client's health care providers. B) "I can never give any information out by telephone. How do I know who you are?" C) Since this is a referral, I can give you this information. D) I need to get the client's written consent before I release any information to you. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that A) A referral is needed to the psychiatrist who is to provide the client with answers B) The client has a right to know about the prescribed medications C) Such education is an independent decision of the individual nurse whether or not to teach clients about their medications D) Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects Which statement by the nurse is appropriate when asking an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time? A) "Have the client sit on the side of the bed for at least 2 minutes before helping him stand." B) "If the client is dizzy on standing, ask him to take some deep breaths." C) "Assist the client to the bathroom at least twice on this shift." D) "After you assist him to the chair, let me know how he feels." The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow up rather than delegate care to the nursing assistant? The client A) Has had a change in respiratory rate by an increase of 2 breaths B) Has had a change in heart rate by an increase of 10 beats C) Was minimally responsive to voice and touch D) Has had a blood pressure change by a drop in 8 mmHg systolic A client tells the nurse, "I have something very important to tell you if you promise not to tell." The best response by the nurse is A) "I must document and report any information." B) "I can't make such a promise." C) "That depends on what you tell me." D) "I must report everything to the treatment team." Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)? A) Be with a client who self-administers insulin B) Cleanse and dress a small decubitus ulcer C) Monitor a client's response to passive range of motion exercises D) Apply and care for a client's rectal pouch A client asks the nurse to call the police and states: "I need to report that I am being abused by a nurse." The nurse should first A) Focus on reality orientation to place and person B) Assist with the report of the client's complaint to the police C) Obtain more details of the client's claim of abuse D) Document the statement on the client's chart with a report to the manager A nurse from the maternity unit is floated to the critical care unit because of staff shortage on the evening shift. Which client would be appropriate to assign to this nurse? A client with A) A Dopamine drip IV with vital signs monitored every 5 minutes B) A myocardial infarction that is free from pain and dysrhythmias C) A tracheotomy of 24 hours in some respiratory distress D) A pacemaker inserted this morning with intermittent capture An unlicensed assistive personnel (UAP), who usually works on a surgical unit is assigned to float to a pediatric unit. Which question by the charge nurse would be most appropriate when making delegation decisions? A) "How long have you been a UAP and what units you have worked on?" B) "What type of care do you give on the surgical unit and what ages of clients?" C) "What is your comfort level in caring for children and at what ages?" D) "Have you reviewed the list of expected skills you might need on this unit?" A client frequently admitted to the locked psychiatric unit repeatedly compliments and invites one of the nurses to go out on a date. The nurse's response should be to A) Ask to not be assigned to this client or to work on another unit B) Tell the client that such behavior is inappropriate C) Inform the client that hospital policy prohibits staff to date clients D) Discuss the boundaries of the therapeutic relationship with the client A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)? A) To observe the type and amount of nasogastric tube drainage B) Monitor the client for nausea or other complications C) Irrigate the nasogastric tube with the ordered irrigate D) Perform nostril and mouth care The nurse is caring for a 69 year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)? A) Test blood sugar every 2 hours by accu check B) Review with family and client signs of hyperglycemia C) Monitor for mental status changes D) Check skin condition of lower extremities A nurse is working with one licensed practical nurse (PN), a student nurse and an unlicensed assistive personnel (UAP). Which newly admitted clients would be most appropriate to assign to the UAP? A) A 76-year-old client with severe depression B) A middle-aged client with an obsessive-compulsive disorder C) A adolescent with dehydration and anorexia D) A young adult who is a heroin addict in withdrawal with hallucinations The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees F for a post-surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP? A) Encourage oral fluids for the temperature elevation B) Check temperature 15 minutes after hot liquids are taken C) Ask the client to drink only cold water and juices D) Chart this temperature elevation on the flow sheet A client continuously calls out to the nursing staff when anyone passes the client's door and asks them to do something in the room. The best response by the charge nurse would be to A) Keep the client's room door cracked to minimize the distractions B) Assign 1 of the nursing staff to visit the client regularly C) Reassure the client that 1 staff person will check frequently if the client needs anything D) Arrange for each staff member to go into the client's room to check on needs every hour on the hour A client with a new diagnosis of diabetes mellitus is referred for home care. A family member present expresses concern that the client seems depressed. The nurse should initially focus assessment by using which approach? A) The results of a standardized tool that measures depression B) Observation of affect and behavior C) Inquiry about use of alcohol D) Family history of emotional problems or mental illness A mother with a Roman Catholic belief has given birth in an ambulance on the way to the hospital. The neonate is in very critical condition with little expectation of surviving the trip to the hospital. Which of these requests should the nurse in the ambulance anticipate and be prepared to do? A) The refusal of any treatment for self and the neonate until she talks to a reader B) The placement of a rosary necklace around the neonate's neck and not to remove it unless absolutely necessary C) Arrange for a church elder to be at the emergency department when the ambulance arrives so a "laying on hands" can be done D) Pour fluid over the forehead backwards towards the back of the head and say "I baptize you in the name of the father, the son and the holy spirit. Amen." An American Indian chief visit his newborn son and performs a traditional ceremony that involves feathers and chanting. The attending nurse tells a colleague "I wonder if he has any idea how ridiculous he looks -- he's a grown man!" The nurse's response is an example of A) Discrimination B) Stereotyping C) Ethnocentrism D) Prejudice A client expresses anger when the call light is not answered within 5 minutes. The client demanded a blanket. The best response for the nurse to make is A) "I apologize for the delay. I was involved in an emergency." B) "Let's talk. Why are you upset about this?" C) "I am surprised that you are upset. The request could have waited a few more minutes." D) "I see this is frustrating for you. I have a few minutes so let's talk." An elderly client who lives in a retirement community is admitted with these behaviors as reported by the daughter: absence in the daily senior group activity, missing the weekly card games, a change in calling the daughter from daily to once a week, and the client's tomato garden is overgrown with weeds. The nurse should assign this client to a room with which one of these clients? A) An adolescent who was admitted the day before with acute situational depression B) A middle aged person who has been on the unit for 72 hours with a dysthymia C) An elderly person who was admitted 3 hours ago with cycothymia D) A young adult who was admitted 24 hours ago for detoxification A client diagnosed with anorexia nervosa states after lunch, "I shouldn't have eaten all of that sandwich, I don't know why I ate it, I wasn't hungry." The client's comments indicate that the client is likely experiencing A) Guilt B) Bloating C) Anxiety D) Fear A 65-year-old Catholic Hispanic-Latino client with prostate cancer adamantly refuses pain medication because the client believes that suffering is part of life. The client states "everyone's life is in God's hands." The next action for the nurse to take is to A) Report the situation to the health care provider B) Discuss the situation with the client's family C) Ask the client if talking with a priest would be desired D) Document the situation on the notes A teenage female is admitted with the diagnosis of anorexia nervosa. Upon admission, the nurse finds a bottle of assorted pills in the client's drawer. The client tells the nurse that they are antacids for stomach pains. The best response by the nurse would be A) "These pills aren't antacids since they are all different." B) "Some teenagers use pills to lose weight." C) "Tell me about your week prior to being admitted." D) "Are you taking pills to change your weight?" A client who has a belief based in Hinduism is nearing death. The nurse should plan for which action? A) After death a Hindu priest will pour water into the mouth of the client and tie a thread around the client's wrist B) The elders may be with the client during the process of the client dying and no last rites are given C) The family must be with the client during the process of dying and be the only ones to wash the body after death D) The body is ritually cleansed and burial is to be as soon as possible after the death Occurs An explosion has occurred at a high school for children with special needs and severe developmental delays. One of the students accompanied with a parent is seen at a community health center a day later. After the initial assessment the nurse concludes that the student appears to be in a crisis state. Which of these interventions based on crisis intervention principles is appropriate to do next? A) Help the student to identify a specific problem B) Ask the parent to identify the major problem C) Ask the student to think of different alternatives D) Examine with the parent a variety of options Which statement made by a client to the admitting nurse suggests that the client is experiencing a manic episode? A) "I think all children should have their heads shaved." B) "I have been restricted in thought and harmed." C) "I have powers to get you whatever you wish, no matter the cost." D) "I think all of my contacts last week have attempted to poison me." A client says, "It's raining outside and it's raining in my heart. Did you know that St. Patrick drove the snakes out of Ireland? I've never been to Ireland." The nurse would document this behavior as A) Perseveration B) Circumstantiality C) Neologisms D) Flight of ideas During the change-of-shift report the assigned nurse notes a Catholic client is scheduled to be admitted for the delivery of a ninth child. Which comment stated angrily to a colleague by this nurse indicates an attitude of prejudice? A) "I wonder who is paying for this trip to the hospital?" B) "I think she needs to go to the city hospital." C) "All those people indulge in large families!" D) "Doesn't she know there's such a thing as birth control?" Which of these statements by the nurse reflects the best use of therapeutic interaction techniques? A) "You look upset. Would you like to talk about it?" B) "I'd like to know more about your family. Tell me about them." C) "I understand that you lost your partner. I don't think I could go on if that happened to me." D) "You look very sad. How long have you been this way?" A nurse in the emergency department suspects domestic violence as the cause of a client's injuries. What action should the nurse take first? A) Ask client if there are any old injuries also present B) Interview the client without the persons who came with the client C) Gain client's trust by not being hurried during the intake process D) Photograph the specific injuries in question Which of these findings would indicate that the nurse-client relationship has passed from the orientation phase to the working phase? The client A) Has revitalized a relationship with her family to help cope with the death of a daughter B) Had recognized regressive behavior as a defense mechanism C) Expresses a desire to be cared for and pampered D) Recognizes feelings with appropriate expression of feelings A client who is thought to be homeless is brought to the emergency department by police. The client is unkempt, has difficulty concentrating, is unable to sit still and speaks in a loud tone of voice. Which of these actions is the appropriate nursing intervention for the client at this time? A) Allow the client to randomly move about the holding area until a hospital room is available B) Engage the client in an activity that requires focus and individual effort C) Isolate the client in a secure room until control is regained by the client D) Locate a room that has minimal stimulation outside of it for admission process A 2-day-old child with spina bifida and meningomyelitis is in the intensive care unit after the initial surgery. As the nurse accompanies the grandparents for a first visit, which response should the nurse anticipate of the grandparents? A) Depression B) Anger C) Frustration D) Disbelief Which statement by the client during the initial assessment in the the emergency department is most indicative for suspected domestic violence? A) "I am determined to leave my house in a week." B) "No one else in the family has been treated like this." C) "I have only been married for 2 months." D) "I have tried leaving, but have always gone back." A nurse states: "I dislike caring for African-American clients because they are all so hostile." The nurse's statement is an example of A) Prejudice B) Discrimination C) Stereotyping D) Racism Which statement made by a nurse about the goal of total quality management or continuous quality improvement in a health care setting is correct? A) "It is to observe reactive service and product problem solving." B) Improvement of the processes in a proactive, preventive mode is paramount. C) A chart audits to finds common errors in practice and outcomes associated with goals. D) A flow chart to organize daily tasks is critical to the initial stages. The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of A) Anonymity B) Beneficence C) Justice D) Autonomy When teaching a client about the side effects of fluoxetine (Prozac), which of the following will be included? A) Tachycardia blurred vision, hypotension, anorexia B) Orthostatic hypotension, vertigo, reactions to tyramine rich foods C) Diarrhea, dry mouth, weight loss, reduced libido D) Photosensitivity, seizures, edema, hyperglycemia The nurse is performing an assessment of the motor function in a client with a head injury. The best technique is A) A firm touch to the trapezius muscle or arm B) Pinching any body part C) Sternal rub D) Gentle pressure on eye orbit The nurse is teaching about non-steroidal anti-inflammatory drugs to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions? A) Reporting joint stiffness in the morning B) Taking the medication 1 hour before or 2 hours after meals C) Using alcohol in moderation unless driving D) Continuing to take aspirin for short term relief A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these? A) Double vision and visual halos B) Extremity tingling and numbness C) Confusion and lightheadedness D) Sensitivity of sunlight The nurse admits a 2-year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure? A) "He has been taking long naps for a week." B) "He has had an ear infection for the past 2 days." C) "He has been eating more red meat lately." D) "He seems to be going to the bathroom more frequently." A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority? A) Check that the catheter tip is intact B) Apply a pressure dressing to the site C) Monitor respiratory status D) Assess for mental status changes An 18-month-old child is on peritoneal dialysis in preparation for a renal transplant in the near future. When the nurse obtains the child's health history, the mother indicates that the child has not had the first measles, mumps, rubella (MMR) immunization. The nurse understands that which of the following is true in regards to giving immunizations to this child? A) Live vaccines are withheld in children with renal chronic illness B) The MMR vaccine should be given now, prior to the transplant C) An inactivated form of the vaccine can be given at any time D) The risk of vaccine side effects precludes giving the vaccine The nurse is preparing to administer a tube feeding to a post-operative client. To accurately assess for a gastrostomy tube placement, the priority is to A) Auscultate the abdomen while instilling 10 cc of air into the tube B) Place the end of the tube in water to check for air bubbles C) Retract the tube several inches to check for resistance D) Measure the length of tubing from nose to epigastrium