NURSING MEDSUR2 HESI EXIT Questions with Answers Updated 2023,100% CORRECT

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NURSING MEDSUR2 HESI EXIT Questions with Answers Updated 2023 1.An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued bec... ause the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide. a. Remind the client that feeling better is the therapeutic effect of the medication. b. Inform the client that gradual tapering must be used to discontinue the medication. c. Tell the client to discuss the medication side effects with the HCP. d. Tell the client that the medication side effects will most likely dissipate over time. 3. The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching? a. robber free toys, such as wooden building blocks, are good choices for the child. b. Only foiled balloons will be used for the child’s birthday party. c. a diet of healthy fruits, such as bananas and kiwis, are best for the child. d. an epinephrine auto-injector will be on hand to treat allergic reactions. 4. a child is diagnosed with acquired aplastic anemia. The nurse knows that this child has the best prognosis with which treatment regimen? a. blood transfusion b. chemotherapy c. bone marrow transplantation d. immunosuppressive therapy 5. A client with bladder cancer had surgical placement of a ureteroileostomy (beal conduit) yesterday. Which postoperative assessment finding should the nurse report to the HCP immediately. a. red edematous stomach appearance b. liquid brown drainage from stoma c. stoma output of 40ml in the last hour d. mucous strings floating in the drainage. 7. The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request to this client? (Select all that apply) a. apple juice b. black coffee c. orange juice d. hot chocolate e. chicken broth 8. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client’s wrist restraints to the movable portion of the client’s bed frame. What action should the nurse take before leaving the room. a. Tie the knot with a double turn or square knot b. Ensure that the restraints are snug against the client’s wrists. c. Ensure that the knot can be quickly released. d. Move the ties so the restraints are secured to the side rails. 9. The nurse is preparing to send a client to the cardiac catheterization lab for an angioplasty. Which client report is most important for the nurse to explore further prior to the procedure? a. Experiences facial swelling after eating crab b. Reports left chest wall pain prior to the admission c. Verbalizes a fear of being in a confined space d. Drank a glass of water Q 10. The healthcare provider prescribes ceftazidime 1 gram every 8 hours. The label on the 1-gram vial reads, ‘’reconstitute with 100 ml sterile water’’ This dilution provides a concentration of how many mg/ml (enter numeric value only) 10mg/ml Q 11 When teaching a group of school-aged children how to reduce the risk for Lyme disease, which instruction should the camp nurse include? A) Wash hands frequently B) Avoid drinking lake water C) Wear long sleeves and pants D) Do not share personal products. Q 12 A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor? A) Serum calcium B) C) Erythrocyte sedimentation rate D) Osmolality. Q 13 An older woman who was recently diagnosed with end stage metastatic breast cancer is admitted because she is experiencing shortness of breath and confusion. The client refuses to eat and continuously asks to go home. Arterial blood gases indicate hypoxia. Which intervention is most important for the nurse to implement? A) Offer sips of favorite beverages B) Prepare for emergent oral intubation C) Initiate comfort measures D) Clarify end of life desires. Correct Answer 15. A client with chronic obstructive pulmonary disease (COPD) is experiencing worsening dyspnea and low oxygen levels. Vitals signs are temperature 99.6 F(37.5 C) heart rate 98 beat, respirations 28 breaths/minute, blood pressure 140/82 mmHg and oxygen saturation 88% ,which action should the nurse implement? A) Place the client in a forward-leaning position. B) Prepare client for endotracheal intubation C) Apply a non-rebreather mask at 100% oxygen D) Obtain a sputum sample for culture and sensitivity Q 16 A client with a history of upper respiratory symptoms is admitted with chest tightness, a productive cough, and difficulty breathing. The client arterial blood gasses (ABGS) indicate respiratory acidosis. An increase in laboratory tests support this finding. A) PaO2 B) PaCO2 C) Arterial pH D) HCO3 Q 17. The health care provider prescribed a low fiber diet for a client with ulcerative colitis, which food selection indicates to the nurse that the client understands the prescribed diet A) Roasted Turkey, Canned Vegetable. Correct answer B) Roast Pork, Fresh Strawberry C) Baked Potatoes with Skin, Raw Carrot D) Pancakes, Whole green cereals Q 18. Which instruction regarding skin care should the nurse provide to a client who is receiving radiation therapy for metastatic breast cancer? A) Use a sponge to de-breed the affected area B) Frequently apply moisturizer to prevent dry skin C) Protect the site from getting wet during bathing D) Gently path the skin after dry after rinsing with water Q 19. A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to not before administering the initial dose? A) Length of time of the exposure to tuberculosis B) Current diagnosis of hepatitis B C) History of intravenous drug abuse D) Conversion of the client PPD test from negative to positive Q 20. The charge nurse observes a new nurse preparing to insert intravenous (IV) catheter, the new nurse has gathered supplies including intravenous catheter and intravenous insertion kit, 4x4 sterile gauze dressing to cover and secure the insertion site. What action should the charge nurse take? A) Plan to observe the secured IV sit after the insertion procedure B) Confirm that the nurse has gathered the necessary supplies C) Instruct the nurse to use a transparent dressing over the site D) Remind the nurse to tape the gauze dressing securely in place Q 21. An adult client with severe depression was admitted to the psychiatric unit yesterday evening. Although the client ran a marathon one year ago, his spouse states that the client no longer runs, but sits and watches television most of the day. Which intervention is the most important for the nurse to include in this client’s plan of care for today? A) Help client to develop a list of daily affirmation B) Encourage client to participate for one hour in a team sport C) Assist client in identifying goals for the day D) Schedule client for a group that focus on self esteem Q 22. A client who is pregnant seems confused and presents with the onset of headache, polyuria, fatigue, and blurry vision. Which action should the nurse implement? A) Palpate bladder for urinary retention B) Assess client for signs of vertigo C) Take serial blood pressure readings D) Determine serum potassium level Q 23. The nurse knows that several complications can occur with the administration of blood, which finding is an indication of an air emboli? A) Nausea and vomiting B) Chills and tremors C) Increased blood pressure D) Difficult breathing 24. The nurse caring for a client with chronic obstructive pulmonary disease (COPD) who is unable to effectively cough up thick mucus. When the nurse prepares to suction the airway using a yankauer suction catheter, which action should the nurse include? A) Instill 3ml of normal saline before suction B) Wear protective goggles while performing the procedure C) Apply a water-soluble lubricant to the catheter D) Instruct the client to cough as the suction tip is removed 25. a nurse determines that more than 25% of the students at middle school are overweight. The nurse presents the information at a parent-teacher meeting. What action is most important for the nurse to include in the meeting? a. distribute a shopping list of suggested healthy snacks item. b. have several teachers talk about health risk associated with obesity c. provide information on ways to increase activity for the family d. determine the parents’ degree of concern about their children’s weight 27. When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take? a. encourage the client to implement relaxation techniques b. refer client to the social worker for support therapy c. explain that insulin is a life-saving drug for the client d. leave the client’s room and return later in the day. 29. The mother of a 12-month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experienced a loss of appetite. Which instructions should the nurse provide? a. perform CPT after meals to increase appetite and improve food intake. b. stop using CPT during the daytime until the child has regained an appetite c. perform CPT only in the morning, but increase frequency when appetite improves d. CPT should be performed more frequently, but at least an hour b4 meals 30. an ambulatory client with a saline lock wants to take a shower. Which action should the nurse take? a. protect the iv site with a gauze dressing b. advise the client to take a sponge bath c. remove the saline lock while the client showers d. tape a plastic bag over the iv site 31. A 15-years old male client is currently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. What nursing intervention is best for the nurse to implement ? A Recommend that he avoid fast food restaurant until he is familiar with his prescribed diet B Assist him in identifying popular fast foods that are within his meal plan for diabetes C encourage him to find activities to do with his friends that do not involve eating D advise him to take his own food with him when going to fast food restaurant with his friend 32. When the parents of a 6 years old boy with a brain tumor are told that his condition is terminal . The mother shouted at the father . This is all your fault. It never would have happened if we had sought treatment earlier. Which intervention is best for the nurse to implement? A. Assure the parents that a terminal diagnosis was inevitable. B. reference the parent to the chaplain to provide grief counseling C. explain to the parents that anger is a common response to grief D. tell the parents blaming each other will not change the situation 33. In preparing a diabetes education program which goal should the nurse identify as the primary emphasis for a class on diabetes self- management? A. reduce healthcare costs related to diabetes complications. B. enable client to become active participants in controlling the disease process C. prepare clients to independently treat their disease process. D increase clients knowledge of the diabetes disease process and treatment option 34. A client received a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement? A. obtain a specimen from culture and Sensitivity analysis. B. assess for fatty yellow streaks in client stool C. Observe the stool for a clay colored appearance. ;D send a stool sample to the lab for a guaiac test 35 While making rounds, the charge nurse notices a young adult asthma who was admitted yesterday is on the side of the bed and leaning over receiving oxygen at 2 via nasal cannula. The client is wheezing and is using pursed- breathing. Which intervention should the nurse implement? A. increase oxygen to 6 liters/ minute B. assist the client to lie back in bed C. administer a nebulizer treatment D. call for an ambu resuscitation 37. After placement of a left subclavian central venous catheter (CVC), the nurse receives a report of the X-ray findings that indicate the CVC tip is the client's superior vena cava. Which action should the nurse implement? A. secure the catheter using aseptic technique B. remove the catheter and apply direct pressure for 5 minutes C. initiate intravenous fluids as prescribed. D. notify the healthcare provider of the need to reposition the catheter 38The nurse is assessing a 4-year-old child with eczema.The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child? А Bathe the child daily with bath oil. B. Allow the child to wear only 100 % cotton clothing C. Apply baby lotion to the skin twice daily D. Keep the nails trimmed short . 39. The headcare provider changes the client medication prescription from IV To PO Administration and doubles the dose. The nurse Notes in the drug guide that the prescription medication, when given orally , has a high fast pass effect and reduces bio-availability . What action should the nurse implement? A. continue to administer the medication VIA the IV route B. give half the prescribed oral dose until the provider is consulted C. administer the medication via the oral route as prescribed D. consult with the pharmacist regarding the error in prescription 40. The home care nurse provided self care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction should the nurse include in the client's discharge teaching plan? (Select all that apply) А. Continue wearing compression stockings B. Maintain the bed flat while sleeping C. Use recliner for long periods of sitting D. Cross legs at knee but not at ankle E. Avoid prolonged standing or sitting 41. A mother brings her child who has a history of asthma to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic , and has labored respirations. Which assessment is most important for the nurse to obtain? A. Type of inhaler the child typically uses on a regular basis B. Frequency that the child uses a rescue inhaler during the week C. Type allergen exposure or trigger for the current episode D. Last dose and the type of rescue inhaler used by the child 42. A client with acute renal injury (AKI) has been taking hemodialysis treatments at home. Which laboratory value indicates to the nurse that the hemodialysis treatment is effective? А. Decreasing creatinine B. Lowered hemoglobin . C.Elevating potassium D. Decreased calcium 43. Which conditions are most likely to respond to treatment with antihistamines? ( select all that apply) A. allergic rhinitis B. contact dermatitis C. otitis D. myocarditis E. bronchitis 44. The nurse identifies an electrolyte imbalance, an elevated pulse rate, and an elevated blood pressure for a client with chronic kidney disease. Which is the most important for the nurse to take? A. record usual eating patterns B. monitor daily sodium intake C. measure ankle circumference D. auscultate for irregular heart rate 45. A client with chronic renal insufficiency is preparing for discharge from the hospital. which information for the nurse to include in this client `s discharge teaching? A. use a topical applications to manage pruritus strategies to promote independent selfcare B. instructions regarding a restricted protein diet C. need for maintaining good oral hygiene 46: The nurse is preparing a client with an acoustic neuroma for an MRI: Which client complains is life threatening and should be reported to the healthcare provider immediately? A: intensifying headache B: right ear hearing loss C: difficulty with balance D: Facial numbness 47: A client with hemorrhoids asks for information about a high fiber diet? Which should the nurse suggest> Select all that apply A: Bowl of oatmeal B Bacon slice C: cup of raspberries D: scrambled eggs E: Raisin bran muffin 48: The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement? A: Prepare client for spinal anesthesia B: prepare the coach to accompany the client to delivery C: empty the client bladder using a straight catheter D: Convey to the client that birth is imminent 49: A 3 year old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment the moter ask why her child is at the 5th percentile for weight and height A: Does you child seem mentally slower than his peers also B: His smaller size is probably due to the heart disease C: You should not worry about the growth table. They are only average for children D: Haven't you been feeding him according to the recommended daily allowance for children? 50: While caring for a client who is being mechanically ventilated the nurse responds to a high pressure alarm on the ventilator. Which assessment finding warrants immediate intervention? A: Endotracheal cuff pressure greater than 25 cm H2O B: Decreased lung compliance during ventilation C: restless client who is biting the endotracheal tube D: Bilateral crackles with increased secretion 51. A 17-year old adolescent is brought to the emergency Department by both parents because the adolescent has been coughing and running a fever with flu-like symptoms for the past 24 hours. Which intervention should the nurse implement first? A. Place a mask on the client’s face. B. Obtain a chest x-ray per protocol. C. Determine the client’s blood pressure D. Assess the client’s temperature 52. A client is recovering in the outpatient surgical unit after an endoscopic carpal tunnel release. The nurse assesses the client’s vital signs, pain level, and dressing. Before discharging the client, which intervention should the nurse implement? A. Administer a nonsteroidal antiinflammatory drug for pain. B. Position the arm in a sling for discharge C. Check neurovascular status of the distal digits D. Change the dressing if drainage increases 53. 53. 54. During discharge teaching, an overweight client with heart failure (HF) is asked to make a grocery list for the nurse to review. Which food choices included on the client’s list should the nurse encourage? (Select all that applies). A. Cheddar cheese cubes B. Natural whole almonds C. Plain, air-popped popcorn D. Canned fruit in heavy syrup E. Lightly salted potato chips 55. A client with metastatic cancer who was taking hydromorphone by mouth at home is now receiving the medication intravenously while in the hospital. To evaluate if the client is receiving an equianalgesic dose of the hydromorphone, which assessment should the nurse complete? A. Pain scale B. Respiratory rate C. Level of consciousness D. Blood pressure 56. 56. 57. 57. 58. A client admitted to the hospital with a suspected ruptured diverticulum develops signs and symptoms of septic shock. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse to include in the plan of care? A. Maintain strict intake and output B. Monitor blood glucose level C. Keep head of the bed raised 45 degrees D. Assess warmth of extremities 59. An older adult client is receiving a second unit of blood when the nurse enters the room and finds the client sitting up in the bed. The client is dyspneic and seems confused. Lung auscultation reveals crackles in the base of both lungs. Vital sign measurement reveals a rapid, bounding pulse and elevated blood pressure. After discontinuing the transfusion, which intervention should the nurse implement? A. Monitor the hives and pruritus B. Obtain a urine specimen C. Keep the IV access line intact for diuretic administration D. Send the blood bag and blood tubing to the blood bank 60. The nurse is preparing to give fentanyl 0.075 mg intramuscularly to a client who is scheduled for a colonoscopy. The medication is labeled, 50 mcg/mL. How many mL should the nurse administer? (Enter numeric value only, if rounding is required, round to the nearest tenth). 0.075 mg *1000= 75 mcg so, 75mcg/50 mcg =1.5 mL 61. At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, “I just know I can’t handle all the pain.” Which is the priority nursing problem for this client? A. Pain (acute) B. Anticipatory grieving C. Anxiety D. Knowledge deficit 62. While administering a continuous insulin infusion to a client with diabetic ketoacidosis, it is essential for the nurse to monitor which serum lab values? A. Calcium B. Potassium C. Hemoglobin D. Protein 63. A client arrives at the clinic experiencing shortness of breath with a possible right spontaneous pneumothorax. Which lung sounds should the nurse expect to auscultate? A. Diminished to absent breath sounds from the apex to the base of the right lung fields B. Adventitious popping sounds or crackles that occur on inspiration or expiration C. High- pitched harsh crowing sound or stridor heard during inspiration D. High pitched wheezing with a musical quality on inspiration and expiration 64. An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription? A. 0800, 1200, 1600, 2000 B. 1000, 1600, 2200, 0400 C. Administer with meals and a bedtime snack D. Give in equally divided doses during waking hours 65. when the nurse is planning an educational session for new parents on ways to prevent sudden infant death syndrome(SidS). Which information is most important to provide parents of newborns and infants. A. keep a bulb syringe accessible for use for an infant. C. position the infant in a supine position while sleeping D. remove pillows and soft toys from the crib at bedtime 66. A client with peptic ulcer disease receives a prescription for intermittent suction via a Salem sump nasogastric tube(NGT)… obtaining coffee-ground gastric contents, the nurse clamps the NGT because the client must leave the unit for diagnostic studies. Upon return to the unit the client complains of nausea. Which action should the nurse implement first? A. Provide oral suction using a Yankauer tip. B. Administer a prescribed antiemetic agent. C. Irrigate the NGT with sterile normal saline. D. Connect the NGT to low intermittent suction. 67. The nurse is admitting a client from the postanesthesia unit to the postoperative surgical care unit. Which prescription should the nurse implement first? A. Cefazolin 1 gram IVPB q8 hours B. Complete blood cell count (CBC) in Am C. Straight catheterization if unable to void correct D. Advance from clear liquids as tolerated. 68. The healthcare provider prescribes acarbose, an alpha-glucosidase inhibitor, for a client with type 2 diabetes mellitus. Which information provides the best indicator of the drug’s effectiveness? A. Body mass index (BMI) between 20 and 24 B. Body pressure readings less than 120/80 mm Hg C. Self-reported glucose levels 120 to 150 mg/dL (6.7 mmol/L to 8.3 mmol/L D. Hemoglobin A1c (HbA1c) readings less than 7% 69. The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first? A. A client diagnosed with depression who is experiencing sexual dysfunction. B. A young man with schizophrenia who wants to stop taking his kedio. C. The mother of a child who was involved in a physical fight at school today D. A family member of a client with dementia who has been missing for five hours. 70. The nurse is assessing a client with pulmonary edema who is reporting two pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies crackles in all lung fields and use of accessory muscles. Which action should the nurse include in the client’s plan of care? A. Arrange a prescribed electrophysiology study(EPS) for the client. B. Address the client’s commitment to their daily exercise regimen. C. Administer the prescribed amiodarone immediately. D. Institute a daily fluid restriction while the client is in the hospital. 71. A. Client with delusions tells the nurse. You aren’t doing your job. Go get those people over there and shoot them before they get me. Which statement is the nurse's best response? A. What would you like to see me do to protect you? B. There is no one who will hurt you C. You are in a safe place. No one can get to you here. D. You seem quite frightened right now. 72. Oral antibiotics are prescribed for an 18-month old toddler with severe otitis media. An antipyrine and benzocaine-otic is also prescribed for pain and inflammation. Which instruction should the nurse emphasize concerning the instillation of the antipyrine/benzocaine otic solution? A. Keep the medication registered between administrations. B. Warm the medication in the microwave for 10 seconds before instilling C. Have the child lie with the ear up for one to two minutes after instillation D. Place the dropper on the upper outer ear canal and instill the medication slowly 73. The school nurse is preparing a presentation for elementary school teachers to inform them about when a child should be referred to the school clinic for further follow-up. The teachers should be instructed to report which situations to the school nurse? ( select all that apply) A. Refuses to complete written homework assignments B. Bruises on both knees after the weekend C. Shaking changes the child’s handwriting legibly. D. Thirst and frequent requests for bathroom breaks E. Sunburn with blisters on the face, arms, and hands. 74. The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contained water. The nurse should emphasize the need to report the onset of the problem. A. Low grade fever B. Bruising of the skin C. Abdominal cramping D. Body emesis 75. A client with a history of alcohol addiction says, my body feels fine when I abstain from alcohol consumption. But I miss my late.night glasses of wine, which concept should the nurse discuss with the client. A. Craving not sure B. Tolerance C. Denial D. Withdrawal 76. A client who fell 20 feet from the roof of his home has multiple injuries, including a right pneumothorax. Chest tubes were inserted in the emergency department prior to his transfer to intensive care unit (ICU). The nurse observes that the suction control chamber is bubbling at the -10cm H20 mark with fluctuation in the water seal, and over the past hour 75 mL of bright red blood is measured in the collection chamber. Which intervention should the nurse implement? A. Give blood from the collection chamber as autotransfusion. B. Manipulate blood in tubing to drain into the chamber. C. Add sterile water to the suction control chamber D. Increase wall suction to eliminate fluctuation in water seal. 77. A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect? A. Herpes simplex virus B. Toxic shock syndrome C. Syphilis D. Mononucleosis 78. The nurse is explaining the need to reduce salt intake to a client with primary hypertension. Which explanation should the nurse provide? A. High salt can damage the lining of the blood vessels B. Excessive salt can cause blood vessels to constrict C. Too much salt can cause the kidneys to retain fluid D. Salt can cause inflammation inside the blood vessels. 79. A client with multiple sclerosis is experiencing scotomas(blind spots). Which are limiting peripheral vision. What intervention should the nurse include in this client’s plan of care? A. Practice visual exercises that focus on a still object B. Encourage the use of corrective lenses during the day C. Alternative an eye patch from eye to eye every 2 hours D. Teach techniques for scanning the environment. 80: In monitoring tissue perfusion in a client following an above the knee amputation, which action should the nurse include in the plan of care? A: Evaluate closest proximal pulse B: Note amount and color of wound drainage C: Assess skin elasticity of the stump D: Observe for swelling around the stump 81: The nurse is caring for a postpartum client with a firm midline uterus one finger breath below the umbilicus and has continuous bleeding from the vagina the nurse recognizes the client is exhibiting symptoms of which complication? Cervical Laceration 82: A client with Cellulitis of the right great toe has been taking an antibiotic for seven days which assessment should the nurse complete to determine effectiveness of the medication? A: observe for signs of inflammation on and surrounding the toe B: Determine the length of the capillary refill time of the toe C: Compare the pedal pulse volume of the right and left feet D: Note any thickening scarring or ridgeline present on the toe 83: A client with acute renal failure is admitted for uncontrolled type 1 diabetes mellitus and hypokalemia the nurse administers an IV dose of regular insulin per sliding scale. Which intervention is most important for the nurse to include in the client plan of care? Monitor the client cardiac activity via telemetry 85: The health care provider prescribe a low dose heparin protocol at 18 unit/kg/ hour for a client with a possible pulmonary embolism. The client weight 144 pound. The available solution is labeled heparin sodium 25000 units in 5% dextrose injection 250 mL. The nurse should program the pump to deliver how many mL/ hour 12 mL/hr 86: The nurse instructs the UAP to turn and immobilize all the clients with an indwelling urinary catheter every two hours. What additional action should the nurse instruct the uap to take each time the client is turned? Offer the client oral fluid 87: A mother runs into the emergency department with a toddler in her arms and tells the nurse that her child got into some cleaning products. The child smells of chemicals on the hands, face, and on the front of the child’s clothes. After ensuring the airway is patent, what action should the nurse implement first? Determine type of chemical exposure 88: An adult male reported that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mmHg. Which risk factors should the nurse explore further with the client (SATA) Family health history and history of hypertension 89: The nurse assesses the client's fluid intake at breakfast which consists of oatmeal, a cup of milk and 12 ounces of coffee. How many milliliters should the nurse document in the client record? 600 mL 90: A client with an asymptomatic abdominal aneurysm visits the health clinic for a routine visit. Which action is most important for the nurse to include in assessing the client? Auscultate bowel sounds 91) A client is admitted with a severe asthma attack. For the last 3hours the client has experienced increasing SOB . Arterial blood gas results are:ph 7; 22, PaCo2 55mmHg, Hco3 25 mEq/L (25 mmol/L). Which interventions should the nurse implement? a) Administer PRN dose of albuterol. b) position client for maximum comfort c) space care to provide periods of rest d) instruct client to purse lip breathe 92) The nurse administers the osmotic diuretic mannitol to a client who has a closed head injury. Which assessment finding indicates an immediate response to administration of the mannitol? a) A decrease in skin turgor b) An increase in serum osmolarity values c) an increase in serum sodium d) a decrease in intracranial pressure ( not sure) 93) A female client who has a borderline personality disorder is being discharged today . When the nurse makes morning rounds, the client begins the interaction by complaining about the aloofness of the night shift nurse and expresses joy to see that, “ My favorite nurse is on duty now”. Which response is best for the nurse to provide to this client's dichotomous tendency? a) I am happy that you are getting better and will be able to go home b) I am glad you like me. Which nurse was acting aloof to you? c) What did the night nurse do that makes you think she is aloof? d) Tomorrow I will talk to that nurse about how you were treated last night 94) The nurse who is working on a surgical unit receives a change of shift report for a group of clients for the upcoming shift. A client with which condition requires immediate attention by the nurse? a) Gunshot wound 3 hours ago with dark drainage of 2 cm noted on the dressing b) Mastectomy 2 days ago with 50 mL bloody drainage noted in the Jackson Pratt drain c) Collapsed lung after a fall 8 hrs ago with 100 mL blood in the chest tube collection container d) Abdominal-perineal resection 2 days ago with no drainage on dressing who has fever and chills 95) A male client with a fracture of the left femur has skeletal traction in place while waiting for surgery. The client is restless and tells the nurse that he needs to urgently urinate. What intervention should the nurse implement a) log roll and place adult disposable briefs b) maintain traction while client uses the urinal ( not sure) c) release traction so d) client can use bedpan e) insert an indwelling urinary catheter 96) The nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bed pan. Which action should the nurse take? a) Evaluate the effectiveness of this measure to stimulate client voiding b) Recommend a complete bath to cleanse perineal area more fully c) Instruct the PN that this technique promotes infection in elderly females. d) Suggest contacting the health care provider for a prescription for catheter insertion 97) In assessing a client at 34 weeks gestation, the nurse notes that she has a slightly elevated total T4 with a slightly enlarged thyroid, a hematocrit of 28 % , a heart rate of 92 BPM, and a systolic murmur. Which finding requires follow up? a) Heart rate of 92 beats per minute b) systolic murmur c) elevated thyroid hormone level d) hematocrit of 28 % ( 0.28 volume fraction) 98) An older client who lives with a granddaughter was brought to the clinic for an appointment and the granddaughter remains in the examination room with the client. When interviewing the client, who is normally alert and oriented, the nurse observes slow responses to questions,little eye contact, and slurred speech. Which action should the nurse take next? a) ask the client if an assisted living facility has been considered b) Interview the client privately without the family member present. c) request social services to make a home visit d) complete a neurological and musculoskeletal assessment 99) After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? SATA( select all that apply) a) Take out dentures and place in a labeled cup b) apply a body shroud c) gentle close the eyes d) place a small pillow under the head e) remove resuscitation equipment from the room 100) The nurse is assessing a male client with a history of Addisons disease. The client has flu-like symptoms and nausea with vomiting over the past week. The client's spouse reports that he acted confused and was extremely weak when he awoke this morning. The client is febrile and has tachycardia. The healthcare provider diagnosis acute adrenal insufficiency. Which medications will most likely be prescribed? a) Hydrocortisone 100 mg IV every 6 hrs until systolic BP reaches 110 mmHG. b) Regular insulin drip to keep blood glucose around 100 mg/dL (5.55 mmol/L) c) Potassium chloride 20 mEq IV to infuse over 2 hrs until confusion resolves d) hypotonic saline solution at 100 mL/hr until all edema disappears 101) The nurse is performing an admission assessment for a newborn who has asymmetrical buttocks. Which assessment test results should the nurse report to the health care provider? a) Ortolani maneuver causing a click at the hip joint b) moro test precipitating a startle response c) babinski test that reveals fanning out of toes d) plumb line test indicates fetal position curvature 102) A family member accompanies a client with schizophrenia to the mental health unit. The family member describes to the nurse the client experienced a prolonged psychotic episode that lasted for 3 days. Which action should the nurse implement first? a) Review the list of medications taken at home b) assess if warning signs were observed c) explore possible triggers to the episode d) verify nutrition and hydration status 103) The nurse is assessing a client with closed head injury sustained in a motor vehicle collision. Which finding indicates the lowest level of neurologic functioning? a) Localization of a tactile stimulus b) withdrawal from painful stimuli c) decerebrate posturing during position changes d) decorticate posturing during tracheal suctioning 104) The nurse is caring for a client who is receiving continuous ambulatory peritoneal dialysis (CAPD) and notes that the output flow is 100 mL less than the input flow. Which actions should the nurse implement first? a) Continue to monitor intake and output with next exchange b) Check the clients BP and serum bicarbonate c) change the clients position d) Irrigate the dialysis catheter 105. After receiving report, the nurse can most safely plan to access which clients last? A. an adult client with no postoperative drainage in the Jackson Pratt drain with the bulb compressed B. an older client with dark red drainage on postoperative dressing, but no drainage in the Hemovac. C. And older clients with distended abdomen and no drainage from the nasogastric tube D. an adult client with rectal tube draining clear, PALE red liquid drainage The answer: A 106. The nurse is preparing the community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? A. Minimize heavy lifting and bending B. reduce intake of foods high in vitamin D C. recommend weight bearing physical activity. D. decrease intake of foods high in fats The answer: C 107. In 1615 prior to ambulating or postoperative clients for the first time, the nurse reviewed the client's medical record. Based on the data contained in the record, what action should the nurse take before assisting the client with ambulation? ( Click on each chart tab for additional information. Please be sure to scroll the bottom right corner for each tab to view all information contained in the client's medical record) A. apply PRN oxygen per nasal cannula B. administer a PRN dose of an anti pyretic C. reinforced the surgical wound dressing D. remove sequential compression devices The answer: D 108. An older male client is admitted to the mental health unit with the sudden onset of global disorientation and is continuously converging with his mother who died 50 years ago. The nurse reviews the multiple prescriptions for the client and assesses his urine specimen. Which is cloudy dark yellow and has a foul odor. These findings suggest that the client is experiencing which condition? A. Psychosis episodes B. delirium C. dépression D. dementia The answer: B 109. The nurse determines that 850 ml of serosanguinous drainage is in the pleura vac chest drainage system of a client who is 12 hours post operative for the removal of long term are. Which location on the chest collection unit indicates this finding? ( Click the chosen location period to change period click on the new location) There is a picture 110) Is missing 111. An unresponsive male victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save his life. The client is accompanied by a close. But no family members are available. What action should the nurse take first? A. Continue to provide life support until a third ward search for guardian is completed B. ask the man's friend to sign the informed consent since the client is unresponsive C. notify the unit manager that and an emergency court order is needed to allow surgery D. carry on with surgical preparation of the client without assigned confirmed consent The answer: D 112. An older client is admitted to the cardiac stepdown unit following coronary artery bypass surgery(CABG) . Which postoperative nursing intervention is most beneficial to prevent respiratory complications? A. Provide ice or liquid's win declines passes flatus B. note areas of atelectasis on the delete chest X rays C. promote full diaphragmatic excursion by messaging the back D. assist to a chair the day after surgery when condition is stable The answer: C 113. The mother brings her four month old son into the clinic with a quarter taped over his umbilicus. And tells the nurse the color is supposed to fix her child's hernia. Which explanation should the nurse provide? A. The quarter should be secured with an elastic bandage wrap B. the hernia is normal variation that resolves without treatment C. restrictive clothing will be adequate to help the hernia go away D. and abdominal binder can be worn daily to reduce the protrusion The answer: B 114. The charge nurse in the critical care unit is reviewing clients' conditions to determine who is stable enough to be transferred. Which client status reports indicate readiness for transfer from the critical care unit to a medical unit? A. Myocardial infarction with signs bradycardia and multiple ectopic beats B. pulmonary embolism with the and intravenous heparin infusion and new onset he hematuria C. adult respiratory distress syndrome with pulse oximetry of 88 percent saturation D. chronic liver failure with a hemoglobin of 10.1 g/dL (101 g/L) and a slight bilirubin elevation The answer: D 115. The unlicensed assistive personnel ( UAP) reported that a client's blood pressure cannot be measured because the client has cast on both arms and is unstable to be turned to the prone position for blood pressure measurements in the legs. Which action should the nurse implement? A. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed B. add device that you a P to document the last blood pressure obtained on the client's graphic sheet C. document wide the blood pressure cannot be accurately measured at the present time D. estimate the blood pressure by assessing the pause volume of the clients radial pulses The answer: A 116) ?? 117) The nurse is planning the preoperative teaching plan for a 12 year old child who is scheduled for surgery. to help reduce the child’s anxiety which action is best for the nurse to implement a) give the child syringes or hospital mask to play with at home prior to hospitalization b) provide dolls and equipment to re-enact feelings associated with painful procedures c) provide a family tour of the preoperative unit one week before the surgery is scheduled d) include the child in play therapy with children who are hospitalized for similar surgery 118) A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. which intervention should the nurse implement (select all that apply) a) report serum albumin and globulin levels b) provide diet low in phosphorus c) monitor abnormal girth d) increase oral fluid intake to 1,500 ml, daily e) note signs of swelling and edema 119) the wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complementary medical therapies might cure the disease. which response should the nurse provide a) encourage the wife to ventilate her feelings about having a husband with Parkinson’s disease b) Compile a list of alternative medication that are effective in curing Parkinson’s disease c) Explain that there are no known conventional , alternative or complementary therapies that cure Parkinson’s disease d) Tell the wife that her husband’s neurologist would know more about alternative treatments to cure Parkinsonism 120) An older adult client is admitted to the stroke unit after recovery from the acute phase of an ischemic cerebral vascular accident (CVA). which interventions should the nurse include in the plan of care during convalescence and rehabilitation ( select all that apply) a) Measure neurological vital signs every 4 hours b) suction oral cavity every 4 hours c) encourage family to participate in the client’s care d) place a bedside commode next to bed e) play classical music in room while client is awake 121) the nurse is providing breastfeeding teaching to a new mother. which infant action should the nurse emphasize indicates readiness to feed a) crying when undisturbed b) showing hand to mouth movements ( NOT SURE) c) following movements with eyes d) spitting up clear mucus 122) the nurse includes assessment for fat embolism syndrome (FES) in the plan of care for a client with a fractured femur. which finding should the nurse include that are often the earliest indication of a FES. a) Petechial rash b) Pulmonary crackles c) Tachycardia, fever d) Confusion, restlessness 123) A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. which intervention should the nurse implement while administering this medication a) measure urinary output every hour b) monitor serum potassium frequently c) initiate seizure precautions d) assess pupillary response to light hourly 124) The husband of an older woman, diagnosed with pernicious anemia, calls the clinic to report that his wife still has memory loss and some confusion since she received the first dose of nasal cyanocobalamin two days ago. he tell the nurse that she may be getting alzheimer’s disease. what action should the nurse take a) explain that memory loss and confusion are common with vit B12 deficiency b) determine if the client is taking iron and folic acid supplement c) encourage the husband to bring the client to the clinic for a complete blood count d) ask if the client is experiencing any change in bowel habits 125) An older adult male who is in his early 70’s is admitted to the emergency department because of COPD exacerbation. The client is struggling to breathe and the healthcare team is preparing for endotracheal intubation. The spouse’s wife, who is 30 years younger than the client, asks the nurse to stop the procedure and provide the nurse with a copy of the living will. which action should the nurse take a) Facilitate a family meeting with the palliative care team b) place a certified copy of the living will in the client’s record c) alert the nursing staff of the client’s do not resuscitate status d) Notify the healthcare provider of the client’s wishes 126) A female client is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. the client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication a) Apical heart rate 72 beats/minute b) .Blood pressure 90/76 mm Hg c) Hypertension d) muscle weakness 127) A female adult who is undergoing chemotherapy tells the nurse that she plans to volunteer at the elementary school this winter. which questions is best for the nurse to ask this client a) are you aware that you do not have a fully functioning immune system b) have you considered that you are putting yourself at risk for developing infections c) is it possible that you will be in direct contact with the children at the school d) do you realized that you will be exposed to many different kinds of germs 128) when caring for a client with full-thickness burns to both lower extremities, which assessment finding warrants immediate intervention (select all that apply) a) weeping serosanguinous fluids from wounds b) sloughing tissue around wound edges c) change in the quality of the peripheral pulses d) complaint of increase pain and pressure e) loss of sensation to the left lower extremity 129) missing 130. missing 131) A client develops urticaria on the trunk and neck shortly after a secondary infusion of piperacillin is initiated. In what order should the nurse implement these interventions? (Arrange in order of priority, highest priority first) THESE ARE IN ORDER- Seen on Quizlet A) Stop the infusion B) Assess vital signs C) Contact the healthcare provider D) Document reaction to the drug E) Initiate an adverse event report 132) Which assessment finding is most important when planning to provide a complete bed bath to a bedfast client? Seen on Quizlet A) Orthopnea B) Pallor C) 2+ pitting edema of the feet D) Right-sided paralysis 133) An infant is unresponsive and gasping for breath. Prior to starting CPR, which should the nurse palpate for a pulse? A)The nurse should palpate the brachial pulse. So it will be the picture pointing to the arm. Google 134) missing 135) What is the priority nursing problem for a client with hypoparathyroidism? A) Risk for injury B) Imbalanced nutrition C) Deficient knowledge D) Anxiety 136) The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to withhold the next dose of the medications? QUIZLET A) Saturation of more than one pad an hour B) Hypertension C) Excessive lochia D) Difficulty locating the uterine fundus 137) The public health nurse receives funding to initiate a primary prevention program in the community. Which program best fits the nurse’s proposal? QUIZLET A) Case management and screening for clients with HIV B) Vitamin supplements for high-risk pregnant women C) Regional relocation center for earthquake D) Lead screening for children in low-income housing 138) The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol? A) Nausea, vomiting, diaphoresis, anxiety, tremors B) Dilated pupils tachycardia, elevated blood pressure, elation C) Excessive eating, constipation, headache D) Mood lability, poor hand coordination fever, drowsiness 139) Dopamine 5mcg/kg/minute IV is prescribed for a client who weighs 132 pounds. The pharmacy dispenses a 500 ml IV solutions of 0.9% normal saline with dopamine 1600mg. The nurse should program the pump to deliver how many ml/hour? A)5.6ml/hr 140) MISSING 141) An older client with alzheimers disease is confused and asking the nurse to call their mother who is deceased. Which non pharmacological intervention should the nurse implement? A) Reduce the client’s interaction with others during day B) Awaken the client for reality checks every 4 hours at night C) Clarify reality with the client about delusional thoughts D) Use distraction and therapeutic communication skills 142) An older client comes to the clinic with a family member. When the nurse attempts to take the clients history, the client does not respond to questions in a clear manner. What action should the nurse implement first? a- Assess the surroundings for noise and distractions 143) MISSING 144) A client with SIADH is admitted with hyponatremia.Which intervention is most important for the nurse to include in the plan of care to protect the client from injury? a) limit oral water intake b) assess neurological status every 8 hrs c) administer a hypertonic iv fluids as prescribed d) initiate seizure precautions 145) A client admitted for an elective outpatient procedure has been npo since midnight except for medications.The client's spouse provides a list of home medications and confirms a history of hypertension and diabetes. In the preoperative assessment, the nurse observes the client to be slow in responding to questions. Which intervention should the nurse implement first? a) Check accuracy of medication list b) insert an indwelling foley catheter c) establish mental status baseline d) obtain a capillary blood glucose level 146) A young adult woman visits the clinic and learns that she is positive for BRCA1 gene mutation and asks the nurse what to expect next. How should the nurse respond? A) offer assurance that there are a variety of effective treatment for breast cancer B) explain that counselling will be provided to give her information about her cancer risk C) provide information about survival rates for women who have the genetic mutation. D) gather additional information about the client's daily history for all types of cancer. 147) a client with deep vein thrombosis (DVT) in the left leg is on heparin protocol. Which intervention is the most important for the nurse to include in this client's plan of care? a) measure each calf’s girth to evaluate edema in the affected leg. b) encourage mobilization to prevent pulmonary embolism. c) assess blood pressure and heart rate at least every 4 hours. d) observe for bleeding side effects related to heparin therapy 148) a client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care? a) analyze past hurts and resentments to identify the source b) relax and reduce the amount of effort to solve the program c) focus on small achievable tasks, not taxing problems d) concentrate on and ventilate emotions when distressed 149)?? 150)?? 151)?? 152) the nursing staff on a medical unit includes a registered nurse (RN), Practical nurse (PN), and unlicensed assistive personnel(UAP). Which task should the charge nurse assign to the RN:? a) supervise a newly hired graduate nurse during an admission assessment. b) transport a client who is receiving IV fluids to the radiology department. c) complete ongoing focussed assessments of a client with wrist restraints. d) Administer PRN oral analgesics to a client with a history of chronic pain. 153) identify the conductive structure that is visualized with an otoscope ( click the chosen location. to change , click on the new location) 154) the nurse is preparing to administer a suspension ampicillin labeled, 250mg/5ml, to a child with impetigo. The prescription is for 500mg four times a day. How many ml should the child receive per day? 40 ml 155) a gravida 2 para 1, at 38-weeks gestation, scheduled for a repeat cesarean section in one week, is brought to the labor and delivery unit complaining of contractions every 10 minutes. While assessing the client, the client’s mother enters the labor suite and says in a loud voice. ‘’ I've had 8 children and I know she is in labor. i want to have her cesarean section right now” which action should the nurse take? a) notify the charge nurse of the situation b) request security to remove her from the room c) request that the mother leaves the room d) tell the mother to stop speaking for the client. 156)?? 157) the nurse is preparing to administer an IV dose of ciprofloxacin to a client with urinary tract infection. Which client data requires the most immediate intervention by the nurse? a) white blood cell count of 12,000 mm (12 x 10) b) urine culture positive for MRSA c) serum sodium of 145 mEq/l d) serum creatine of 4.5 mg//dl 158)?? 159)?? 160) ?? new questions from today 1.A female child is brought to the emergency department after awakening with a bark like cough and stridor… answer is examine oropharyngeal area for foreign body 4. A multiparous client who delivered her infant three hours ago asks the nurse if she can take a warm sitz bath because it helped reduce a perineal pain after the last delivery. What action should the nurse implement? a) review the use of sitz bath equipment with the client 6. Which lab values are critical for the nurse to monitor for a client who is experiencing a thyrotoxic gal crisis a. blood and urine cultures b. renal and liver function tests c. electrolytes and hemoglobin d. glucose and calcium levels 7. An older client preparing to transition from every rehabilitation facility to home is receiving discharge instruction from the nurse which action should the nurse take while providing the discharge instruction A) stand behind the client to avoid intimidation B) turn on the overhead light while giving instruction C) provide handout written at a 12 grade reading level D) use background music to promote relaxation 8. An older male client is admitted with medical diagnosis of possible cerebral vascular… Ask the wife to stop 9. An older client is admitted in respiratory distress secondary to heart failure… everything except fluid deficit 10. the nurse is admitting a client from the postanesthesia surgical unit. Which prescription… straight catheterization if unable to void 11. an adult woman who was recently diagnosed with type 2 diabetes mellitus is seen in the clinic… reduce daily fat intake to 10 % of total calories, decrease processed…,increase dietary fiber [Show More]

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