Nursing_knowledge_Assessment_Practice_Exam RN EXIT COMPREHENSIVE PROCTORED EXAM COMBINED 2019 2020 2021 | VALUE PACK

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HESI RN EXIT COMPREHENSIVE PROCTORED EXAM COMBINED 2019 2020 2021 | VALUE PACK After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. W... hat should the nurse to first? Correct Answer: Assist the client out of bed and involve in activity. A client with dementia uses the defense mechanism of confabulation. What is the reasoning? Correct Answer: To decrease anxiety. A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx? Correct Answer: Disturbed thought process. A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response? Correct Answer: When you interrupt, I cannot explain what to do to the group. When performing a MSE on a client which assessment intervention would best assist the nurse? Correct Answer: Ask the client to interpret the proverb a stitch in time saves nine. A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give first? Correct Answer: Magnesium. A woman is just told of her husband's dx of terminal cancer. What would the nurse offer for the spouse (wife)? Correct Answer: How would you like to be involved with your husband's care? A nurse is to remove staples from an abdominal incision, the client is very anxious. What is the most important intervention? Correct Answer: Attempt to distract the client with general conversation. A man who was stranded on the roof of his house for two days after a natural disaster, months later ... Correct Answer: Implement anxiety control strategies. A man dx with bipolar disorder states, "I don't understand, I believe in God and have not done anything to deserve this". What is the nurse's best response? Correct Answer: You didn't do anything wrong. You have a chemical imbalance in your brain. A client becomes upset when the nurse he requests is not assigned to him, what is the nurse's best response? Correct Answer: Advise the client that nursing assignments are not based on client requests. A client needs to wash her hands for two hours before able to go on with her morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism? Correct Answer: Compulsion. A client in group is talking about her prostitution, the nurse asks her if she was abused by her parents. She states "my mother ran my father out when I was young". What defense mechanism was used? Correct Answer: Repression. A woman calls the crisis hotline and says she has a loaded gun and is going to kill herself. To maintain patient confidentiality what would the nurse do? Correct Answer: Contact the person the client chooses to go to the home and remove the weapon. A client with anger management issues uses belt making and bangs the leather heavily. What defense mechanisms is being used? Correct Answer: Sublimation. A bipolar client comes into the clinic and tells the nurse that the next time she sees her sister I'm going to kill her. What should the nurse do? Correct Answer: Inform the sister. What would be the nurse's highest priority for a newly admitted depressed client upon admission? Correct Answer: The nurse should go through the client's belongings. Who is most prone to being abused (elder abuse)? Correct Answer: Females over 75 living with their families. or mentally or physically handicapped A client in the dayroom had tripped over a table and is escalating and has picked up a chair which he is threatening to throw at another client. What should the nurse do first? Correct Answer: Go and get more staff assistance. A woman who is psychotic is carrying all of her belongings around with her because she is afraid that someone will steal it. What is the best way to establish trust? Correct Answer: Make brief contact with the client throughout the day. In adolescent group discussing a handout on anger management, a client is becoming increasingly interruptive and talking about his home and pets. What is the nurse's most appropriate response? Correct Answer: Redirect the the handout. What is the most important intervention for a client with bulimia? Correct Answer: Plan scheduled meals. A client comes into the ED with DTs. What should the nurse do first? Correct Answer: Administer Ativan. What are the side effects of Risperdal? Correct Answer: Fever, tachycardia, and sweating. A client who is refusing to take his medication is wandering on the unit and going in and out of resident's rooms. What is the priority? Correct Answer: Safety* deal with the wandering in and out of other client's rooms. A nurse observes a client in the dayroom talking to himself. What should the nurse do first? Correct Answer: Ask the client if they are currently hearing voices? A client comes to the nurses' station and told the nurse that her roommate had cut her wrists in the bathroom. After assessing and dressing the wounds, what should the nurse do next? Correct Answer: Move the client to a private room by the nurse's station. A man comes into the ER after being in a car accident with a blood alcohol level greater than 2.0, what should the nurse prepare to administer? Correct Answer: Ativan or Librium per facility policy What would be proper teaching for a client who is to start taking Antabuse? Correct Answer: Has not had anything alcoholic to drink for the last 48 hours. Alzheimer's patient-nurse goes to do dressing change and the client refuses. What should the nurse do? Correct Answer: Leave and come back 30 minutes later. A client is confused in an acute care hospital setting. What would support the dx of delirium instead of dementia? Correct Answer: Delerium: Started in hospital. An elderly woman is brought to the ER with multiple stages of healing bruises. What should the nurse do? Correct Answer: Take the woman aside and ask her about abuse. A business man is stressed about his finances, has anxiety and sleeplessness. Correct Answer: Limit intake of sugar and caffeine. A mother comes into the clinic with her son who is being accused of a crime. She is worried her son will go to jail. What should the nurse say to the mother? Correct Answer: Consequences of enabling behaviors. What is a common side effect of cocaine use. Correct Answer: Heart attack. A client on LSD comes into the ER. How do you approach the client? Correct Answer: Talk calmly and soothing to the client. A client taking Meth and Benzo's, what would the nurse prepare to do for overdose? Correct Answer: Give Narcan. An alcoholic father tells his wife and children to stay away from him. What is the most important nursing dx? Correct Answer: Risk for injury. What should you advise a patient on a MAOI not to eat? Correct Answer: Cheese, beer, and avocado. The parents of a teenager who has overdosed what is the first question to ask? Correct Answer: What drug did the client ingest? A client becomes agitated when the nurse is talking to his wife. He has not eaten in 3 days. What should the nurse do? Correct Answer: Take to quiet room and give PB crackers. When opening a mental health clinic... Correct Answer: American Nursing Association. A client with a hx of depression and abusing alcohol with their depression getting worse. What is the most important nursing dx? Correct Answer: Ineffective coping. A woman is being abused by her husband, the abuse is escalating. What would the nurse ask first? Correct Answer: Do you have a plan in place when you are not safe? (SAFETY!!!) A patient has stopped taking Depakote six months ago, what would the nurse assess? Correct Answer: Mood. A nurse visits a community half way house with one bathroom. The nurse notices urine all over the walls of the bathroom. The toilet is clogged with feces and paper towels. Correct Answer: Infection control. A client with Alzheimer's keeps asking for his mother. What is the nurses appropriate response? Correct Answer: Your mothers not here but you are safe. A client is told to come in by friends, clients complaints include losing his job, just got a divorce, single dad with two kids, what would be the best question for nurse to ask? Correct Answer: What is troubling you the most? What are the side effects of Lithium? Correct Answer: Dehydration, diarrhea, and thirstiness. PPD 10 mm or more is considered as _____ Correct Answer: positive 3 sputum cultures are negative Correct Answer: - Pt is considered noninfectious at this point - it is performed 2-4 weeks after TB therapy TB private room description Correct Answer: -at least 6 air exchange per hour -venting to the outside - have contravention lights installed Tracheostamy wall suction maintained between _________ mm hg of pressure Correct Answer: 120-180 (one question said 100-150) 80-100 for infants 100-120 for children Tracheostomy care Correct Answer: insert catheter until pt coughs or resistance is felt then withdraw 1 cm to move away from mucosa -hyperoxygenate the client before and after suctioning -use intermittent suction in the airway ( not constant) for 10-15 sec Bell of the stetoscope Correct Answer: should not be used in auscultating lung sounds chronic airflow limitation (cal) Correct Answer: -should alternate periods of activity with rest periods to conserve energy -sit when performing activities -limit activities that involve arm movements -avoid raising the arms above the head incentive spirometry Correct Answer: dont breath through nose Pleurisy Correct Answer: splint the chest during coughing and deep breathing to prevent atelectasis -lie on the affected side to minimize movement on the affected chest wall silicosis Correct Answer: avoid exposure to sands, quarzes, flints and many other stones.. also soaps, polishes and filters may contant silica CPT or chest physicay therapy Correct Answer: assist in mobilizing secretions to enhance more effective breathing -will indirectly assist the pt with coughing a client being weaned from a mechanical ventilator Correct Answer: antianxiety medications and opioid analgesics western blot Correct Answer: test to conform HIV psychosocial needs Correct Answer: helping the client deal with his or her own feelings client with endotracheal tube Correct Answer: cannot talk so use 'pictures or word board' to communicate peak flow meter for asthma Correct Answer: record the final position of the indicator wall sunction pressure : Adults children Correct Answer: adults: 80-120 children: 60-110 ... Correct Answer: always remove the oxygen just before the ABG levels are drawn pulmonary embolism symptoms Correct Answer: CHEST PAIN, dyspnea, tachypnea others: tachycardia, diaphoresis, cough, hemopytosis,fever, andsyncope WBC with a shift to the left Correct Answer: proliferation of WBCs complication of empysema Correct Answer: carbon monoxide narcosis: s/s occipital headache, drowsiness and inability to concentrate, bounding pulse, co2 of >75 mm hg, confusion, coma, asterixis flail chest Correct Answer: multiple chest fractures -apply firm but gentle pressure inward in inspiration, outward in expiration nasal polyp Correct Answer: nasal obstruction 1 toxoplasmosis 2 cryptosporydiosis 3 malignant lymphoma 4 pneumocystis pneumonia Correct Answer: 1 changes in mental status, neurological deficits, headaches, fever 2 mild diarrhea to cholera-like syndrome with body wasting and electrolyte imbalances (15-20 L/day) 3 weight loss, fever and night sweats 4 fungal infection of the lung (usually seen with HIV) fever, dyspnea, tachypnea, persistent dry cough, crackles drainage system bubbling Correct Answer: continous bubbling in the water seal chamber X suction control chamber spacer Correct Answer: -reduces the incidence of [Show More]

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