2019 PN Hesi Exit V1[160 questions and answers 100% verified graded A+

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2019 PN Hesi Exit V1 Question 1 A school-age client with diabetes is placed on an intermediateacting insulin and regular insulin before breakfast and before dinner. She will receive a snack of m... ilk and cereal at bedtime. What does the nurse tell the client the snack is intended to do? You Selected: • Prevent late night hypoglycemia. Correct response: • Prevent late night hypoglycemia. Question 2 A well-known public official of a small community is admitted to the emergency department following an episode of chest pain. Several nurses from the medical unit are aware of the admission and access the official’s electronic medical record to obtain a status update. What is the best response for the nurse manager to make to the nurses regarding this situation? You Selected: • “Assessing the official’s medical record is a breach of confidentiality.” Correct response: • “Assessing the official’s medical record is a breach of confidentiality.” Question 3 A four-year-old child is diagnosed as having acute lymphocytic leukemia. The white blood cell (WBC) count, especially the neutrophil count, is low. What is the most important intervention the nurse should teach the parents? You Selected: • Protect your child from infections because his resistance to infection is decreased Correct response: • Protect your child from infections because his resistance to infection is decreased Question 4 The nurse is caring for a client with influenza. The most effective way to decrease the spread of microorganisms is: You Selected: • placing the client in isolation. Correct response: • washing the hands frequently. Question 5 A client with a history of hypertension has been prescribed a new antihypertensive medication and is reporting dizziness. Which is the best way for the nurse to assess blood pressure? You Selected: • in the supine, sitting, and standing positions Correct response: • in the supine, sitting, and standing positions Question 6 A client has a soft wrist-safety device. Which assessment finding should the nurse investigate further? You Selected: • cool, pale fingers Correct response: • cool, pale fingers Question 7 A nurse is caring for a female client before surgery. The client states that she is glad that she will not be going through menopause as a result of her surgery and is only having her uterus removed. The nurse reviews the consent form and notes that the surgery is for a total abdominal hysterectomy with a salpingo-oophorectomy. What should the nurse do in this situation? You Selected: • Contact the surgeon to explain that the client needs further clarification regarding surgery. Correct response: • Contact the surgeon to explain that the client needs further clarification regarding surgery. Question 8 A young client diagnosed with schizophrenia is talking with the nurse and says, "You know, when I thought everyone was out to get me, I was staying in my apartment all the time. Now, I would like to get out and do things again." What is the best initial response by the nurse? You Selected: • "What activities did you enjoy in the past?" Correct response: • "What activities did you enjoy in the past?" Question 9 A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron deficiency anemia? You Selected: • nausea, vomiting, and anorexia Correct response: • dyspnea, tachycardia, and pallor Question 10 The nurse is discontinuing an intravenous catheter on a 10-year-old client with hemophilia. What would be the most important intervention for this client? You Selected: • Apply firm pressure on the site for 5 minutes after removal. Correct response: • Apply firm pressure on the site for 5 minutes after removal. Question 11 When a client returns from the recovery room postmastectomy, an initial postoperative assessment is performed by the nurse. What is the nurse’s priority assessment? You Selected: • checking the dressing, drain, and amount of drainage Correct response: • assessing the vital signs and oxygen saturation levels Question 12 A client with an uncomplicated term pregnancy arrives at the laborand-delivery unit in early labor saying that she thinks her water has broken. What is the nurse’s best action? You Selected: • Ask what time this happened and note the color, amount, and odor of the fluid. Correct response: • Ask what time this happened and note the color, amount, and odor of the fluid. Question 13 When documenting the care of a client, the nurse is aware of the need to use abbreviations conscientiously and safely. This includes You Selected: • ensuring the abbreviations are understandable to clients who may seek access to their health records Correct response: • limiting abbreviations to those approved for use by the institution Question 14 During routine prenatal screening, a nurse tells a client that her blood sample will be used for alpha fetoprotein (AFP) testing. Which statement best describes what AFP testing indicates? You Selected: • "This screening indicates if your baby's lungs are mature." Correct response: • "This test will screen for spina bifida, Down syndrome, or other genetic defects." Question 15 A client is recovering from an infected abdominal wound. Which foods should the nurse encourage the client to eat to support wound healing and recovery from the infection? You Selected: • chicken and orange slices Correct response: • chicken and orange slices Question 16 A nurse suspects that the laboring client may have been physically abused by her partner. What is the most appropriate intervention by the nurse? You Selected: • Collaborate with the interprofessional team to make a referral to social services. Correct response: • Collaborate with the interprofessional team to make a referral to social services. Question 17 A client is newly diagnosed with asthma. While learning to use a metered dose inhaler (MDI) for delivery of a short-term beta agonist, the client asks if a spacer is appropriate to use with this device. What is the nurse’s best response? You Selected: • “No, a spacer is not recommended because it can increase the risk of developing oropharyngeal candidiasis.” Correct response: • “Yes, a spacer is recommended because it increases the amount of medication that is delivered to the lungs.” Question 18 The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client’s pain, and the client refuses to get out of bed to ambulate as prescribed. The nurse contacts the health care provider (HCP), explains the situation, and provides information about drug dose, frequency of administration, the client’s vital signs, and the client’s score on the pain scale. The nurse requests a prescription for a different, or stronger, pain medication. The HCP tells the nurse that the current prescription for pain medication is sufficient for this client and that the client will feel better in several days. What should the nurse do next? You Selected: • Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. Correct response: • Explain to the HCP that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as prescribed. Question 19 The nurse is making a room assignment for a client whose laboratory test result indicate pancytopenia. Which client should the nurse put into the same room with the client with pancytopenia? You Selected: • a client with digoxin toxicity Correct response: • a client with digoxin toxicity Question 20 A community health nurse provides a client with information about a local support group for those with multiple sclerosis. Providing this information is an example of which of the following? You Selected: • A referral. Correct response: • A referral. Question 21 A nurse working on a neurologic floor has received reports on four clients. After identifying priority assessment data for each client, which client should the nurse investigate first? You Selected: • the client admitted after a head injury in a motor vehicle who reports nausea Correct response: • the client admitted after a head injury in a motor vehicle who reports nausea Question 22 The mother of an adolescent client who is diagnosed with oppositional defiant disorder tells the nurse that she has read extensively on this disorder and does not believe the diagnosis is correct for her daughter. Which response by the nurse is appropriate? You Selected: • “Tell me what you’ve found in your reading that’s leading you to that conclusion.” Correct response: • “Tell me what you’ve found in your reading that’s leading you to that conclusion.” Question 23 A nurse prepares a client's medication by reconstituting a multi-dose vial of medication. What other nursing interventions should the nurse take? Select all that apply. You Selected: • Label the vial with the strength of the medication. • Store the multi-dose vial in a secure place. • Initial the vial as the person reconstituting the medication. Correct response: • Label the vial with the strength of the medication. • Store the multi-dose vial in a secure place. • Initial the vial as the person reconstituting the medication. Question 24 Because of religious beliefs, a client, who is an Orthodox Jew, refuses to eat hospital food. Hospital policy discourages food from outside the hospital. The nurse should next: You Selected: • discuss the situation and possible courses of action with the dietitian and the client. Correct response: • discuss the situation and possible courses of action with the dietitian and the client. Question 25 After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the mother agrees to seek medical advice if the child experiences which symptom? You Selected: • fussiness and reports that the cast is heavy Correct response: • inability to extend the fingers on the right hand Question 26 While shopping, a nurse meets a neighbor who asks about a friend receiving treatment at the nurse's clinic. What is the nurse's most appropriate response? You Selected: • "I'm sorry, I can't disclose client information." Correct response: • "I'm sorry, I can't disclose client information." Question 27 When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication? You Selected: • urinary retention Correct response: • urinary retention Question 28 Which situation demonstrates correct principles of confidentiality? You Selected: • Two nurses alone in an elevator are discussing a client's status. Correct response: • An emergency department nurse reports suspected child abuse. Question 29 The nurse in a psychiatric unit has formed a therapeutic relationship with a client with a borderline personality disorder. When the client is readmitted to the unit for a suicide attempt, the nurse exclaims to another staff nurse, “Why? Everything was going well. How could they do this to me?” What response by the staff nurse reflects an understanding of the client’s borderline disorder? You Selected: • “Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety.” Correct response: • “Clients with borderline disorder act out to relieve anxiety, and something must have provoked a great deal of anxiety.” Question 30 A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is: You Selected: • monitoring the blood glucose level closely. Correct response: • monitoring the blood glucose level closely. Question 31 A 9-year-old client is brought to the emergency department with a sutured wound with purulent drainage. The area around the wound is red and warm to the touch, and the child is febrile. The parents want to know the significance of the purulent drainage. What is the best response by the nurse? You Selected: • “The drainage is an indication that the sutures were not tight enough.” Correct response: • “If a wound heals on the surface but infection remains, it will open and drain.” Question 32 A 19-year-old primigravid client at 38 weeks' gestation is 7 cm dilated, and the presenting part is at +1 station. The client tells the nurse, "I need to push!" What should the nurse do next? You Selected: • Instruct the client to use a pant-blow pattern of breathing. Correct response: • Instruct the client to use a pant-blow pattern of breathing. Question 33 A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it You Selected: • may induce bronchospasm. Correct response: • may induce bronchospasm. Question 34 Bone resorption is a possible complication of Cushing’s disease. To help the client prevent this complication, what should the nurse recommend to the client? You Selected: • Maintain a regular program of weight-bearing exercise. Correct response: • Maintain a regular program of weight-bearing exercise. Question 35 A client rates the pain level of a migraine an 8 on a scale of 1-10. How would the nurse administer the medication to give the client the quickest relief? You Selected: • intravenous (IV) Correct response: • intravenous (IV) Question 36 A client with Parkinson’s disease who is scheduled for physiotherapy is experiencing nausea and weakness. What is the mostappropriate action by the nurse? You Selected: • Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment. Correct response: • Assess the nausea and weakness and call physiotherapy to cancel or reschedule the appointment. Question 37 Which intervention should the nurse include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals? You Selected: • Offer the client nutritious finger foods. Correct response: • Offer the client nutritious finger foods. Question 38 Which activity should the nurse recommend to the client on an inpatient unit when thoughts of suicide occur? You Selected: • playing a card game with other clients Correct response: • talking with the nurse Question 39 A nurse is teaching a client with multiple sclerosis (MS). When teaching the client how to reduce fatigue, the nurse should tell the client to You Selected: • rest in an air-conditioned room. Correct response: • rest in an air-conditioned room. Question 40 An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? You Selected: • a 10-year-old with a simple fracture of the humerus who is in severe pain Correct response: • a middle-aged man with no injuries who has rapid respirations and coughs Question 41 A 26-year-old primigravida visiting the prenatal clinic for her regular visit at 34 weeks’ gestation tells the nurse that she takes mineral oil for occasional constipation. What should the nurse should instruct the client to do? You Selected: • Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Correct response: • Avoid mineral oil because it interferes with the absorption of fat-soluble vitamins. Question 42 A client is receiving chemotherapy that has the potential to cause pulmonary toxicity. Which signs or symptoms indicates a toxic response to the chemotherapy? You Selected: • cough and shortness of breath Correct response: • cough and shortness of breath Question 43 A nurse observes a physician providing care to an infectious client without the use of personal protective equipment. What should the nurse do first? You Selected: • Notify the unit manager. Correct response: • Discuss the breach of practice with the physician. Question 44 The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital? You Selected: • Decrease the client's feelings of isolation and loneliness. Correct response: • Decrease the client's feelings of isolation and loneliness. Question 45 A nurse, a licensed practical nurse (LPN), and a nursing assistant are caring for a group of clients. The nurse asks the nursing assistant to check the pulse oximetry level of a client who underwent laminectomy. The nursing assistant reports that the pulse oximetry reading is 89%. The client Kardex contains an order for oxygen application at 2 L/min should the pulse oximetry level fall below 92%. The nurse is currently assessing a postoperative client who just returned from the postanesthesia care unit. How should the nurse proceed? You Selected: • Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Correct response: • Ask the LPN to obtain vital signs and administer oxygen at 2 L/min to the client who underwent laminectomy. Question 46 A physician orders a stool culture to help diagnose a client with prolonged diarrhea. The nurse who obtains the stool specimen should You Selected: • collect the specimen in a sterile container. Correct response: • collect the specimen in a sterile container. Question 47 A client returns to the nursing division after a procedure. The client tells the nurse that the client was awake during the procedure and recalls certain events. What is the nurse’s priorityintervention? You Selected: • Ask for additional information from the client. Correct response: • Ask for additional information from the client. Question 48 The nurse is observing an unlicensed assistive personnel (UAP) give care to a client after gynecologic surgery. The nurse should intervene if the UAP: You Selected: • ambulates the client. Correct response: • massages the client’s legs. Question 49 For a client with Graves' disease, which nursing intervention promotes comfort? You Selected: • maintaining room temperature in the low-normal range Correct response: • maintaining room temperature in the low-normal range Question 50 A client is admitted to the hospital because of threatening, aggressive behavior toward his family. In the first group meeting after the client is admitted, another client sits near the nurse and says loudly, "I'm sitting here because I'm afraid of Ted. He's so big, and I heard him talk about hitting people." The nurse should say to the client: You Selected: • "Everyone is here for different problems. You know you don't have to worry." Correct response: • "It's frightening to have new people on the unit. We're here to talk about things like being afraid." Question 51 A nurse is preparing to administer an I.V. containing dextrose 10% in ¼ normal saline solution to a 6-month-old infant. The nurse should select which tubing to safely administer the solution? You Selected: • I.V. tubing with a macrodrip chamber Correct response: • I.V. tubing with a volume-control chamber Question 52 What is the priority nursing intervention in the postictal phase of a seizure? You Selected: • Assess the client's breathing pattern. Correct response: • Assess the client's breathing pattern. Question 53 The fire alarm sounds on the maternal-neonatal unit at 0200. How can a nurse best care for the unit's clients during a fire alarm? You Selected: • Immediately evacuate the unit. Correct response: • Close all of the doors on the unit. Question 54 The nurse is suctioning a client’s tracheostomy. For what reason during the procedure does the nurse complete the above action? You Selected: • to lubricate the outside of the suction catheter Correct response: • to clear secretions from the tubing Question 55 A primiparous client is on a regular diet 24 hours postpartum. The client’s mother asks the nurse if she can bring her daughter some “special foods from home.” The nurse responds, based on the understanding about which principle? You Selected: • The client’s health care provider (HCP) needs to give permission for the foods. Correct response: • The mother can bring the daughter any foods that she desires. Question 56 A parent brings a 5-year-old child to a weekend vaccination clinic to prepare for school entry. The nurse notes that the child has not had any vaccinations since 4 months of age. What is the best way for the nurse to determine how to catch-up the child’s vaccinations? You Selected: • Contact the child’s health care provider (HCP) during office hours. Correct response: • Review nationally published immunization guidelines. Question 57 A client is admitted to the labor and delivery unit in labor with blood flowing down her legs. What would be the priority nursing intervention? You Selected: • Monitor fetal heart tones. Correct response: • Monitor fetal heart tones. Question 58 A nurse administers incorrect medication to a client. After assessing the client, and completing an incident report, which is the priority action by the nurse? You Selected: • Complete an adverse drug reaction (ADR) report. Correct response: • Report the incident to risk management. Question 59 A multipara at 16 weeks’ gestation is diagnosed as having a fetus with probable anencephaly. The client is from a conservative faith and has decided to continue the pregnancy and donate the neonatal organs after the death of the neonate. What should the nurse do? You Selected: • Explore his or her own feelings about the issues of anencephaly and organ donation. Correct response: • Explore his or her own feelings about the issues of anencephaly and organ donation. Question 60 A client who is to have a vaginal radium implant tells the nurse she is concerned about being radioactive. The nurse should tell the client: You Selected: • “The radiation is necessary to treat your tumor.” Correct response: • ”The radioactive material is controlled and stays with the source; once the material is removed, no radioactivity will remain.” Question 61 An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting You Selected: • 18 to 20 g of a simple carbohydrate. Correct response: • 15 g of a simple carbohydrate. Question 62 A competent client in a long-term care facility refuses to take oral diuretic medication. The nurse informs the client that if the medication isn’t taken, restraints will be applied, and the medication will be given by injection. Which legal tort best describes this nurse’s statement? You Selected: • negligence Correct response: • assault Question 63 A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? You Selected: • lung auscultation and measurement of vital capacity and tidal volume Correct response: • lung auscultation and measurement of vital capacity and tidal volume Question 64 Which client should the nurse assess first? You Selected: • a client with chronic hypertension whose blood pressure today is 182/98 mm Hg Correct response: • a client being treated for chronic stable angina who reports a recent increase in chest pain frequency Question 65 A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain from her episiotomy. What should the nurse instruct the woman to do? You Selected: • Take a sitz bath. Correct response: • Apply an ice pack to her perineum. Question 66 The nurse is admitting a hospital client who does not speak English and who is accompanied by the client's school-aged child. The client appears to be in pain, but the nurse is unable to assess the character or history of the client's pain. How should the nurse best communicate with the client? You Selected: • Have a hospital interpreter come to the assessment; defer the assessment if none is available. Correct response: • Enlist the help of a hospital interpreter; ask the son to translate if none is readily available. Question 67 A client who has just been diagnosed with mixed muscular dystrophy asks the nurse about the usual course of this disease. How should the nurse respond? You Selected: • "You should ask your physician about that." Correct response: • "You may experience progressive deterioration in all voluntary muscles." Question 68 The nurse is caring for a client with type 2 diabetes who has been admitted with hyperglycemia. What is the most important consideration when developing a teaching plan for this client? You Selected: • Assess what the client already knows, then identify learning needs. Correct response: • Assess what the client already knows, then identify learning needs. Question 69 A nurse is teaching a pregnant client how to distinguish false labor contractions from true labor contractions. Which statement by the client indicates an understanding of this concept? You Selected: • "False labor contractions start in the back and radiate to the abdomen." Correct response: • "False labor contractions are usually felt in the abdomen." Question 70 A client has been taking fluoxetine, 40 mg daily at 0900 for 1 week. The client states he feels nervous and has had diarrhea. What interpretation does the nurse make about the client’s symptoms? You Selected: • important, probably suggesting a decrease in dosage or change to another medication Correct response: • important, probably suggesting a decrease in dosage or change to another medication Question 71 Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"? You Selected: • "Test your blood glucose every 4 hours." Correct response: • "Test your blood glucose every 4 hours." Question 72 In which maternal locations would the nurse place the ultrasound transducer of the external electronic fetal heart rate monitor if a fetus at 34 weeks' gestation is in the left occipitoanterior (LOA) position? You Selected: • near the symphysis pubis Correct response: • below the umbilicus on the left side Question 73 The client with a cervical spinal cord injury is admitted to the rehabilitation unit with skeletal traction (Gardner-Wells Traction). What nursing actions are a priority when caring for the client? Select all that apply. You Selected: • Assess the client’s skin integrity. • Maintain active range of motion. • Maintain proper body alignment. Correct response: • Assess the client’s skin integrity. • Maintain proper body alignment. • Assess client’s neurological function. Question 74 An older client with diabetes who has been maintained on metformin has been scheduled for a cardiac catheterization. The nurse should verify that the health care provider (HCP) has written which prescription for taking the metformin before the procedure? You Selected: • Withhold the metformin. Correct response: • Withhold the metformin. Question 75 A client tells the nurse that she doesn't have funds to buy diapers and formula. The nurse should refer this client to a You Selected: • social worker. Correct response: • social worker. Question 76 A voluntary client in a facility decides to leave the unit before treatment is complete. To detain the client, the nurse refuses to return the client's personal effects. This action is an example of: You Selected: • slander. Correct response: • false imprisonment. Question 77 A postpartum multiparous client diagnosed with endometritis is to receive intravenous antibiotic therapy with ampicillin. Before administering this drug, the nurse must take which action? You Selected: • Ask the client if she has any drug allergies. Correct response: • Ask the client if she has any drug allergies. Question 78 A 2-year-old is being seen in the outpatient department for a minor injury. The nurse places the child on the examining table, and the child begins to scream and cry. No attempts to comfort the toddler are effective. Which is the nurse's best action? You Selected: • Allow the parents to hold the child in their lap for the assessment. Correct response: • Allow the parents to hold the child in their lap for the assessment. Question 79 The nurse is teaching an adolescent how to self-administer insulin. Which of the following is a priority for the nurse to emphasize about insulin administration? You Selected: • Insulin injections are administered in subcutaneous tissue. Correct response: • Insulin injections are administered in subcutaneous tissue. Question 80 A 2 1/2-year-old child and his 2-month-old sibling are brought to the clinic by their father, who explains that the older child says “no” whenever asked to do something. The nurse should explain that the negativism demonstrated by toddlers is frequently an expression of which characteristic? You Selected: • pursuit of autonomy Correct response: • pursuit of autonomy Question 81 A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30 minutes before the bath? You Selected: • Administer an analgesic. Correct response: • Administer an analgesic. Question 82 The team leader has noticed a sharp increase in medication errors associated with IV antibiotic administration over the last 2 months. The group that could offer resources for tracking medication errors and improving care outcomes is the: You Selected: • Pharmacy and Products Office. Correct response: • Quality Improvement and Risk Management Department. Question 83 A physician orders digoxin elixir for a client with heart failure. Immediately before administering this drug, the nurse must check the client's You Selected: • apical pulse. Correct response: • apical pulse. Question 84 One of the myths about sexual abuse of young children is that it usually involves physically violent acts. Which behavior is more likely to be used by the abusers? You Selected: • tying the child down Correct response: • coercion as a result of the trusting relationship Question 85 While taking an admission history, a client tells a nurse that they were a former IV drug abuser. Which test would be most important for this client to undergo? You Selected: • hepatitis C virus test Correct response: • hepatitis C virus test Question 86 A 44-year-old client has been experiencing spotting, nausea, vomiting, and fatigue. A positive pregnancy test and an ultrasound confirm a 13 week gestation. The client had three prior miscarriages with no term births. What does the nurse recognize as the greatest risk factor for the client at this time? You Selected: • pregnancy loss Correct response: • pregnancy loss Question 87 The nurse is conducting a routine risk assessment at a prenatal visit. Which question would be the best to screen for intimate partner violence? You Selected: • “How safe do you feel in your home?” Correct response: • “How safe do you feel in your home?” Question 88 A child being treated for conduct disorder is the last person on the unit selected for an activity. The nurse should expect the client to demonstrate: You Selected: • withdrawal. Correct response: • aggression. Question 89 A client who is paralyzed after a spinal cord injury needs to be transferred to a stretcher. Which assistive device should the nurse use to facilitate this transfer? You Selected: • transfer board Correct response: • transfer board Question 90 A client with diabetes is taking insulin lispro injections. At what time should the nurse advise the client to eat? You Selected: • within 10 to 15 minutes after the injection. Correct response: • within 10 to 15 minutes after the injection. Question 91 Which of the following clients should the nurse assess first? You Selected: • the client who is a child with stridor and nasal flaring Correct response: • the client who is a child with stridor and nasal flaring Question 92 Which mediation can the nurse administer through a nasogastric (NG) tube? You Selected: • acetaminophen Correct response: • acetaminophen Question 93 A client has been prescribed corticosteroids. The nurse would also anticipate an order for You Selected: • blood glucose checks every 6 hours. Correct response: • blood glucose checks every 6 hours. Question 94 When preparing for a spiritual counselor to visit a hospitalized client, the nurse should You Selected: • take measures to ensure privacy during the counselor's visit. Correct response: • take measures to ensure privacy during the counselor's visit. Question 95 A client with pernicious anemia asks why she must take vitamin B12 injections forever. Which is the nurse's best response? You Selected: • "The reason for your vitamin deficiency is an increased requirement for the vitamin because of rapid red blood cell production." Correct response: • “The reason for your vitamin deficiency is an inability to absorb the vitamin because the stomach is not producing sufficient amounts of a factor that allows the vitamin to be absorbed.” Question 96 A client is admitted to the emergency department with a ruptured abdominal aortic aneurysm. No family members are present, and the surgeon instructs the nurse to take the client to the operating room immediately. Which action should the nurse take regarding informed consent? You Selected: • Take the client to the operating room for surgery without informed consent. Correct response: • Take the client to the operating room for surgery without informed consent. Question 97 A nurse coming onto the night shift assesses a client who gave birth vaginally that morning. The nurse finds that the client's vaginal bleeding has saturated two perineal pads within 30 minutes. What is the first action the nurse should take? You Selected: • Assess the fundus and massage it if it's boggy. Correct response: • Assess the fundus and massage it if it's boggy. Question 98 The nurse is caring for a client recently diagnosed with hepatitis C. In reviewing the client’s history, what information will be most helpful as the nurse develops a teaching plan? The client: You Selected: • traveled to Central America recently and ate uncooked vegetables. Correct response: • has a known history of sexually transmitted disease. Question 99 A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child’s arrival, what should the nurse do first? You Selected: • Institute droplet precautions. Correct response: • Institute droplet precautions. Question 100 The selection of a nursing care delivery system (NCDS) is critical to the success of client care in a nursing area. Which factor is essential to the evaluation of an NCDS? You Selected: • identifying who will be responsible for making client care decisions Correct response: • identifying who will be responsible for making client care decisions Question 101 Which of the following observations by the nurse would indicate that a client is unable to tolerate a continuation of a tube feeding? You Selected: • formula in the client’s mouth during the feeding, and increased cough Correct response: • formula in the client’s mouth during the feeding, and increased cough Question 102 A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: TIS, N0, M0. What does this classification mean? You Selected: • no evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis Correct response: • carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Question 103 A physician has ordered a heating pad for an elderly client's lower back pain. Which item would be most important for a nurse to assess before applying the heating pad? You Selected: • Client's level of consciousness Correct response: • Client's level of consciousness Question 104 Which nifedipine-related side effect should the nurse be most concerned with when caring for a new stroke admission? You Selected: • hypotension Correct response: • hypotension Question 105 A client at 27 weeks gestation experiences uterine cramping and also secretes a small amount of bright red bleeding and mucus. The client calls her prenatal clinic nurse. Which of the following recommendations is most appropriate from the nurse? You Selected: • Instruct the client to go to an emergency room for an urgent assessment. Correct response: • Instruct the client to go to an emergency room for an urgent assessment. Question 106 A 16-year-old primiparous client has decided to place her baby for adoption. The adoptive parents are on their way to the hospital when the mother says, “I want to see the baby one last time.” What should the nurse do? You Selected: • Allow the client to see and hold the baby for as long as she desires. Correct response: • Allow the client to see and hold the baby for as long as she desires. Question 107 A 37-week gestation client is on bed rest for gestational hypertension. The nursing student and nurse are visiting the client in her home and need to perform external fetal monitoring (EFM). The student nurse asks the nurse if the student nurse is allowed to perform this skill. What is the nurse’s most appropriate response? You Selected: • "Yes, but only after you read about the procedure in the regional policy and procedure manual." Correct response: • "Yes, but I will demonstrate it once and then supervise you while you perform the procedure." Question 108 Parents tell a nurse that they have not met their goal of home management of their child with schizoaffective disorder. They report that the client poses a threat to their safety. Based on this information, what recommendation should the nurse make? You Selected: • Evaluate the client for voluntary admission to a mental health facility. Correct response: • Evaluate the client for voluntary admission to a mental health facility. Question 109 A client has been diagnosed with metabolic alkalosis. The nurse should anticipate what finding from the client's arterial blood gases? You Selected: • serum bicarbonate of 28 mEq/L Correct response: • serum bicarbonate of 28 mEq/L Question 110 A client on the adolescent psychiatric unit was admitted with a diagnosis of body dysmorphic disorder. The client has not been able to attend school or their part-time work over the past year as a result of certain body obsessions. Recently, the client shaved the hair all over their body, claiming, “It is all growing weird.” What component of therapy would be most important for the nurse to apply to this client? You Selected: • The client is at high risk for suicide. Correct response: • The client’s body image is real to the client. Question 111 A client comes to the emergency department complaining of chest pain. An electrocardiogram (ECG) reveals myocardial ischemia and an anterior-wall myocardial infarction (MI). Which ECG characteristic does the nurse expect to see? You Selected: • prolonged PR interval Correct response: • elevated ST segment Question 112 A nurse notices that a large number of clients who receive oxytocin to induce labor vomit as the infusion is started. The nurse assesses the situation further and discovers that these clients received no instruction before arriving on the unit and haven't fasted for 8 hours before induction. How should the nurse intervene? You Selected: • Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. Correct response: • Initiate a unit policy involving staff nurses, certified nurse-midwives, and physicians in teaching clients before labor induction. Question 113 A client comes to the clinic for evaluation. The client tells the nurse, “I have been having headaches and dizziness. I looked it up on the Internet, and I think I might have a brain tumor.” The client hands the nurse a printout of what the client found. Which response by the nurse would be mostappropriate? You Selected: • “Tell me more about where you found this information that you gave me.” Correct response: • “Tell me more about where you found this information that you gave me.” Question 114 During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been experiencing breast engorgement. To relieve engorgement, the nurse teaches the client to use which intervention before nursing her baby? You Selected: • Apply an ice cube to the nipples. Correct response: • Express a small amount of breast milk. Question 115 The nurse instructs the client on health maintenance activities to help control symptoms from a hiatal hernia. Which statement would indicate that the client has understood the instructions? You Selected: • "I will avoid lying down after a meal." Correct response: • "I will avoid lying down after a meal." Question 116 The parent asks the nurse about a 9-year-old child’s apparent need for between-meal snacks, especially after school. What information should the nurse include in the teaching plan? You Selected: • The child should eat the snacks the mother thinks are appropriate. Correct response: • The child should help with preparing the snacks. Question 117 A client with rheumatoid arthritis tells the nurse, “I know it’s important to exercise my joints so that I won’t lose mobility, but my joints are so stiff and painful that exercising is difficult.” Which response by the nurse would be most appropriate? You Selected: • "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." Correct response: • "Take a warm tub bath or shower before exercising. This may help with your discomfort." Question 118 The nurse assesses a child after heart surgery to correct tetralogy of Fallot. Which finding would the nurse report to the health care provider as an indication that the client has low cardiac output? You Selected: • altered level of consciousness and thready pulse Correct response: • altered level of consciousness and thready pulse Question 119 A client who is positive for human immunodeficiency virus (HIV) tells the nurse that the client's significant other is the only family member who knows the client's health status. What should the nurse do to keep the client's health status confidential? Select all that apply. You Selected: • Ask all family members, except the client's significant other, to wait outside when she's educating the client. • Use the hospital code for HIV when documenting care. Correct response: • Use the hospital code for HIV when documenting care. • Ask all family members, except the client's significant other, to wait outside when she's educating the client. Question 120 What should the nurse do when the client with a diagnosis of schizophrenia walks into group naked? You Selected: • Lead the client to his room and help him dress if he needs assistance. Correct response: • Lead the client to his room and help him dress if he needs assistance. Question 121 Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration? You Selected: • The cells in the alveoli are so damaged by the client’s long history of respiratory problems that increased oxygen levels and reduced carbon dioxide levels likely will cause the cells to burst. Correct response: • The client’s respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. Question 122 A client begins clozapine therapy after several other antipsychotic agents fail to relieve psychotic symptoms. The nurse instructs the client to return for weekly white blood cell (WBC) counts to assess for which adverse reaction? You Selected: • infection Correct response: • granulocytopenia Question 123 A client states, "I have abdominal pain." Which assessment question would best determine the client's need for pain medication? You Selected: • "What does the pain feel like?" Correct response: • "What does the pain feel like?" Question 124 When developing the preoperative teaching plan for a 14- month-old child with an undescended testis who is scheduled to have surgery, which method is most appropriate? You Selected: • Explain to the parents how the defect will be corrected. Correct response: • Explain to the parents how the defect will be corrected. Question 125 The nurse plans to place graduated compression stockings on a client in the preoperative setting. List in order the steps the nurse will follow. All options must be used. You Selected: • Review medical record and medical orders for graduated compression stockings. • Identify the client and explain procedure. • Place the client in supine position. • Apply powder or lotion to legs. • Smoothly pull the stocking over the ankle and calf. • Turn the stocking inside out and ease the stocking over the foot and heel. Correct response: • Review medical record and medical orders for graduated compression stockings. • Identify the client and explain procedure. • Place the client in supine position. • Apply powder or lotion to legs. • Turn the stocking inside out and ease the stocking over the foot and heel. • Smoothly pull the stocking over the ankle and calf. Question 126 A client with depression states, “I’m still feeling nauseous after I take venlafaxine. Maybe I need something else.” What should the nurse should tell the client to do? You Selected: • Take venlafaxine only in the morning. Correct response: • Take the medication at mealtime. Question 127 Which information should the nurse include in the teaching plan for a primiparous client who asks about weaning her neonate? You Selected: • “Eliminate the baby’s favorite feeding times first.” Correct response: • “Gradually eliminate one feeding at a time.” Question 128 A grandson calls the crisis center expressing concern about his grandmother, who lost her husband a month ago. He states, “She’s been in bed for a week and is not eating or showering. She told me that she didn’t want to kill herself, but it’s not like her to do nothing for herself. She won’t even talk to me when I visit her.” The nurse encourages the grandson to bring his grandmother to the center for evaluation based on which reason? You Selected: • The behaviors may reflect passive suicidal thoughts. Correct response: • The behaviors may reflect passive suicidal thoughts. Question 129 When caring for a client receiving haloperidol, the nurse should assess for which problem? You Selected: • extrapyramidal symptoms Correct response: • extrapyramidal symptoms Question 130 A nurse is administering daunorubicin through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication? You Selected: • thrombosis Correct response: • extravasation Question 131 Which nursing intervention is essential in caring for a client with compartment syndrome? You Selected: • wrapping the affected extremity with a compression dressing to help decrease the swelling Correct response: • removing all external sources of pressure, such as clothing and jewelry Question 132 A primigravid client visits the clinic for a routine examination at 35 weeks’ gestation. The client’s blood pressure is near the baseline of 120/74 mm Hg with no proteinuria or evidence of facial edema. The client asks the nurse, “What should I take if I get an occasional headache after looking at my computer at work all day?” Which over-the-counter medicine does the nurse consider to be safest for occasional use by a pregnant client with no known risks? You Selected: • acetaminophen Correct response: • acetaminophen Question 133 A depressed client in the psychiatric unit hasn't been getting adequate rest and sleep. To encourage restful sleep at night, the nurse should: You Selected: • encourage environmental stimulation during the evening. Correct response: • gently but firmly set limits on how much time the client spends in bed during the day. Question 134 A client has several patches of vesicles over both arms. Which care should the nurse provide to this client? You Selected: • Instruct on the application of an antiparasitic agent. Correct response: • Cover the draining areas with sterile gauze. Question 135 A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program? You Selected: • assessing present voiding patterns Correct response: • assessing present voiding patterns Question 136 A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which "related-to" phrase should the nurse add to complete the nursing diagnosis statement? You Selected: • Related to visual field deficits Correct response: • Related to impaired balance Question 137 A nurse suspects that a child, age 4, is being neglected. Which question should the nurse ask the parents to best assess the child's nutritional status? You Selected: • "What did your child eat for breakfast?" Correct response: • "What did your child eat for breakfast?" Question 138 A medication nurse is preparing to administer 0900 medications to a client with liver cancer. Which consideration is the nurse’s highest priority? You Selected: • purpose of the medication Correct response: • metabolism of the medication Question 139 After an intravenous pyelogram (IVP), the nurse should include which measure in the client's plan of care? You Selected: • Encourage adequate fluid intake. Correct response: • Encourage adequate fluid intake. Question 140 The nurse receives the preoperative blood work report for a client who is scheduled to undergo surgery. Which laboratory finding should the nurse report to the surgeon and anesthesiologist? You Selected: • blood urea nitrogen, 15 mg/dL (5.4 mmol/L) Correct response: • creatinine, 2.6 mg/dL (230 µmol/L) Question 141 For the child experiencing excessive vomiting secondary to pyloric stenosis, the nurse should assess the child for which acid-base imbalance? You Selected: • metabolic alkalosis Correct response: • metabolic alkalosis Question 142 Which indicator is the best for determining whether a client with Addison's disease is receiving the correct amount of glucocorticoid replacement? You Selected: • daily weight Correct response: • daily weight Question 143 The client with recurring depression will be discharged from the psychiatric unit. Which suggestion to the family is most important to include in the plan of care? You Selected: • Provide for a schedule of activities outside the home. Correct response: • Involve the client in usual at-home activities. Question 144 During the initial assessment, the nurse notes that the neonate’s hands and feet appear blue while the neonate’s torso appears pale pink. What should the nurse do next? You Selected: • Keep the neonate in an isolation incubator for at least 2 hours. Correct response: • Place the infant skin to skin with the mother. Question 145 Which finding is normal for a client during the icteric phase of hepatitis A? You Selected: • yellowed sclera Correct response: • yellowed sclera Question 146 A nurse is working on a surgical floor. The nurse must logroll a client following a You Selected: • cystectomy. Correct response: • laminectomy. Question 147 After receiving a report, the nurse is making out assignments. Which client would be appropriate to assign to unlicensed assistive personnel? You Selected: • an 8-month-old with pneumonia who will be discharged today Correct response: • an 8-month-old with pneumonia who will be discharged today Question 148 A client, with heart failure, is receiving furosemide, 40 mg IV. The provider orders 40 mEq of potassium chloride in 100 ml of dextrose 5% in water, to infuse over four hours. The client’s most recent serum potassium level is 3.0 mEq/L. At which infusion rate should the nurse set the IV pump? Record your answer using a whole number. Your Response: • 67 Correct response: • 25 Question 149 A client has expressed her desire to give birth with minimal intervention. She is now moving into the active phase of labor. What intervention by the nurse would be the priority of care? You Selected: • watching for rupture of the membranes Correct response: • offering support by reviewing the short-pant form of breathing Question 150 A 35-year-old client who is 28 weeks pregnant is admitted for testing. After reading the nursing notes, which rationale best explains why a pregnant client would lie on her left side when resting or sleeping in the later stages of pregnancy? You Selected: • to prevent compression of the vena cava Correct response: • to prevent compression of the vena cava Question 151 The laboratory comes to draw an Hgb AIc. The client asks the nurse what this test represents. Which statement would be correct? You Selected: • “This test reflects the average blood glucose over a period of approximately 2-3 months.” Correct response: • “This test reflects the average blood glucose over a period of approximately 2-3 months.” Question 152 A client who recently had a stroke requires a cane to ambulate. When teaching about cane use, the nurse should explain that the reason for holding a cane on the uninvolved side is to You Selected: • distribute weight away from the involved side. Correct response: • distribute weight away from the involved side. Question 153 A 7-year-old has had an appendectomy on November 12. He has had pain for the last 24 hours. There is a prescription to administer acetaminophen with codeine every 3 to 4 hours as needed. The nurse is beginning the shift, and the child is requesting pain medication. The nurse reviews the chart below for pain history. Based on the information in the medical record, what should the nurse do next? You Selected: • Instruct the child to take deep breaths and blow his pain away. Correct response: • Administer the acetaminophen with codeine. Question 154 A nurse is conducting an educational program about advanced directives for a group of adults at a local community center. The nurse explains what the directives entail and how they are used. After explaining this topic, the nurse determines that the teaching was successful based on which statement by the group? You Selected: • “The document allows us to choose what we want to have happen.” Correct response: • “The document allows us to choose what we want to have happen.” Question 155 A nurse is caring for a full-term pregnant client in active labor. The electronic fetal monitor reveals a fetal heart rate (FHR) of less than 70 beats for 1 minute. What is the nurse’s priority intervention? You Selected: • Place the client on her left side and apply oxygen. Correct response: • Place the client on her left side and apply oxygen. Question 156 The nurse is assessing a client with thigh high antiembolism stockings. Assessment findings include redness, swelling, and pain in the left calf. What is the priority action by the nurse? You Selected: • Notify the healthcare provider. Correct response: • Notify the healthcare provider. Question 157 Which client statement indicates an understanding of the risk of alcohol relapse? You Selected: • "I know I can stay dry if my wife keeps alcohol out of the house." Correct response: • “Stopping support groups and not expressing feelings can lead to relapse.” Question 158 A nurse is caring for a client who has end-stage chronic obstructive pulmonary disease receiving I.V. push morphine for pain management. During rounds, the nurse discusses with the physician the need to start the client on a continuous morphine infusion. The nurse bases this request on the fact that: You Selected: • serving as a client advocate is an important role. Correct response: • serving as a client advocate is an important role. Question 159 A client with posttraumatic stress disorder states, “You don’t know what I’ve been through. What can you do?” The nurse should respond: You Selected: • “I haven’t been through what you have, but I’ll be better able to understand if you tell me more about it.” Correct response: • “I haven’t been through what you have, but I’ll be better able to understand if you tell me more about it.” Question 160 A client was hospitalized for 1 week with major depression with suicidal ideation. He is taking venlafaxine 75 mg three times a day and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, “I hardly think about it anymore and wouldn’t do anything to hurt myself.” The nurse should make which judgment about the client? You Selected: • The depression is improving, and the suicidal ideation is lessening. Correct response: • The depression is improving, and the suicidal ideation is lessening. [Show More]

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