[2018 HESI EXIT V6 and answers 100% verified]

2018 HESI EXIT V6 1. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts ...

2018 HESI EXIT V6 1. A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age? A) Death is personified as the bogeyman or devil B) Death is perceived as being irreversible C) The child feels guilty for the grandmother's death D) The child is worried that he, too, might die The correct answer is A: Death is personified as the bogeyman or devil 2. A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present A) Temperature of 37.5 degrees Celsius with painful urination B) An open wound on their heel C) Insomnia and daytime fatigue D) Nausea with 2 episodes of vomiting The correct answer is B: An open wound on their heel 3. The nurse admits an elderly Mexican-American migrant worker after an accident that occurred during work. To facilitate communication the nurse should initially A) Request a Spanish interpreter B) Speak through the family or co-workers C) Use pictures, letter boards, or monitoring D) Assess the client's ability to speak English The correct answer is D: Assess the client''s ability to speak English 4. In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings? A) Uterine atony B) Genital lacerations C) Retained placenta D) Clotting disorder The correct answer is B: Genital lacerations 5. The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change? A) Anticoagulant B) Liquid antacid C) Antihistamine D) Cardiac glycoside The correct answer is C: Antihistamine 6. The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client? A) Instruct the client to wear a high efficiency particulate air mask in public places. B) Ask a family member to supervise daily compliance C) Schedule weekly clinic visits for the client D) Ask the health care provider to change the regimen to fewer medications The correct answer is B: Ask a family member to supervise daily compliance 7. The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that "staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting." The nurse manager's leadership style is best described as A) Laissez-faire B) Autocratic C) Participative D) Group The correct answer is C: Participative 8. A nursing student asks the nurse manager to explain the forces that drive health care reform. The appropriate response by the nurse manager should include A) The escalation of fees with a decreased reimbursement percentage B) High costs of diagnostic and end-of-life treatment procedures C) Increased numbers of elderly and of the chronically ill of all ages D) A steep rise in health care provider fees and in insurance premiums The correct answer is A: The escalation of fees with a decreased reimbursement percentage 9. A client with hepatitis A (HAV) is newly admitted to the unit. Which action would be the priority to include in the plan of care within the initial 24 hours for this client? A) Wear masks with shields if potential splash B) Use disposable utensils and plates for meals C) Wear gown and gloves during client contact D) Provide soft easily digested food with frequent snacks The correct answer is C: Wear gown and gloves during client contact 10. A client has been taking alprazolam (Xanax) for 3 days. Nursing assessment should reveal which expected effect of the drug? A) Tranquilization, numbing of emotions B) Sedation, analgesia C) Relief of insomnia and phobias D) Diminished tachycardia and tremors associated with anxiety The correct answer is A: Tranquilization, numbing of emotions 11. The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is A) Advising client to restrict sodium intake B) Taking the blood pressure in the left arm C) Elevating her left arm above heart level D) Compressing the drainage device The correct answer is B: Taking the blood pressure in the left arm 12. A 70 year-old post-operative client has elevated serum BUN, Hct, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is: A) Impaired gas exchange B) Metabolic acidosis C) Renal insufficiency D) Fluid volume deficit The correct answer is D: Fluid volume deficit 13. The nurse is providing foot care instructions to a client with arterial insufficiency. The nurse would identify the need for additional teaching if the client stated A) "I can only wear cotton socks." B) "I cannot go barefoot around my house." C) "I will trim corns and calluses regularly." D) "I should ask a family member to inspect my feet daily." The correct answer is C: "I will trim corns and calluses regularly." 14. A woman who delivered 5 days ago and had been diagnosed with preeclampsia calls the hospital triage nurse hotline to ask for advice. She states “ I have had the worst headache for the past 2 days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps.” What should the nurse do next? A) Advise the client that the swings in her hormones may have that effect. However, suggest for her to call her health care provider within the next day. B) Advise the client to have someone bring her to the emergency room as soon as possible C) Ask the client to stay on the line, get the address and send an ambulance to the home D) Ask what the client has taken? How often? Ask about other specific complaints. The correct answer is C: Ask the client to stay on the line, get the address and send an ambulance to the home 15. The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is A) Drink 3000 to 4000 cc of fluid each day for one month B) Limit fluid intake to 1000 cc each day for one month C) Increase intake of citrus fruits to three servings per day D) Restrict milk and dairy products for one month The correct answer is A: Drink 3000 to 4000 cc of fluid each day for 1 month 16. A client on warfarin therapy following coronary artery stent placement calls the clinic to ask if he can take Alka-Seltzer for an upset stomach. What is the best response by the nurse? A) Avoid Alka-Seltzer because it contains aspirin B) Take Alka-Seltzer at a different time of day than the warfarin C) Select another antacid that does not inactivate warfarin D) Use on-half the recommended dose of Alka-Seltzer The correct answer is A: Avoid Alka-Seltzer because it contains aspirin 17. The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to A) Encourage the parents to enroll in cardiopulmonary resuscitation class B) Assist the parents to plan quiet play activities at home C) Stress to the parents that they will need relief care givers D) Instruct the parents to avoid contact with persons with infection The correct answer is A: Encourage the parents to enroll in cardiopulmonary resuscitation class 18. The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care? A) Risk for injury B) Self care deficit C) Alteration in comfort D) Alteration in mobility The correct answer is C: Alteration in comfort 19. An unlicensed assistive staff member asks the nurse manager to explain the beliefs of a Christian Scientist who refuses admission to the hospital after a motor vehicle accident. The best response of the nurse would be which of these statements? A) "Spiritual healing is emphasized and the mind contributes to the cure." B) "The primary belief is that dietary practices result in health or illness." C) "Fasting and prayer are initial actions to take in physical injury." D) "Meditation is intensive in the initial 48 hours and daily thereafter." The correct answer is A: "Spiritual healing is emphasized and the mind contributes to the cure." 20. In order to be effective in administering cardiopulmonary resuscitation to a 5 yearold, the nurse must A) Assess the brachial pulses B) Breathe once every 5 compressions C) Use both hands to apply chest pressure D) Compress 80-90 times per minute The correct answer is B: Breathe once every 5 compressions 21. The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care? A) Impaired skin integrity related to dependent edema B) Activity intolerance related to oxygen supply and demand imbalance C) Constipation related to immobility D) Risk for infection related to ineffective mobilization of secretions The correct answer is B: Activity Intolerance related to oxygen supply and demand imbalance . 22. For which of the following mother-baby pairs should the nurse review the Coomb's test in preparation for administering RhO (D) immune globulin within 72 hours of birth? A) Rh negative mother with Rh positive baby B) Rh negative mother with Rh negative baby C) Rh positive mother with Rh positive baby D) Rh positive mother with Rh negative baby The correct answer is A: Rh negative mother with Rh positive baby 23. An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first? A) Lung sounds B) Urine output C) Level of alertness D) Appetite The correct answer is C: Level of alertness ? 25. What is the major purpose of community health research? A) Describe the health conditions of populations B) Evaluate illness in the community C) Explain the health conditions of families D) Identify the health conditions of the environment The correct answer is A: Describe the health conditions of populations 26. The recent increase in the reported cases of active tuberculosis (TB) in the United States is attributed to which factor? A) The increased homeless population in major cities B) The rise in reported cases of positive HIV infections C) The migration patterns of people from foreign countries D) The aging of the population located in group homes The correct answer is B: The rise in reported cases of positive HIV infections 27. A 15 month-old child comes to the clinic for a follow-up visit after hospitalization for treatment of Kawasaki Disease. The nurse recognizes that which of the following scheduled immunizations will be delayed? A) MMR B) Hib C) IPV D) DtaP The correct answer is A: MMR 28. The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor? A) Sexually transmitted infection B) Exposure to teratogens C) Maternal hypertension D) Chromosomal abnormalities The correct answer is C: Maternal hypertension 29. After the shift report in a labor and delivery unit which of these clients would the nurse check first? A) A middle aged woman with asthma and diabetes mellitus Type 1 has a BP of 150/94 B) A middle aged woman with a history of two prior vaginal term births is 2 cm dilated C) A young woman is a grand multipara has cervical dilation of 4 cm and 50% effaced D) An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum The correct answer is D: An adolescent who is 18 weeks pregnant has a report of no fetal heart tones and coughing up frothy sputum 30. The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately? A) Fecal impaction B) Infrequent voiding C) Stress incontinence D) Burning with urination The correct answer is A: Fecal impaction 31. The nasogastric tube of a post-op gastrectomy client has stopped draining greenish liquid. The nurse should A) Irrigate it as ordered with distilled water B) Irrigate it as ordered with normal saline C) Place the end of the tube in water to see if the water bubbles D) Withdraw the tube several inches and reposition it The correct answer is B: Irrigate it as ordered with normal saline 32. The parents of a child who has recently been diagnosed with asthma ask the nurse to explain the condition to them. The best response is "Asthma causes… A) the airway to become narrow and obstructs airflow." B) air to be trapped in the lungs because the airways are dilated." C) the nerves that control respiration to become hyperactive." D) a decrease in the stress hormones which prevents the airways from opening." The correct answer is A: the airway to become narrow and obstructs airflow." 33. The nurse is assessing a child with suspected lead poisoning. Which of the following assessments is the nurse most likely to find? A) Complaints of numbness and tingling in feet B) Wheezing noted when lung sound auscultated C) Excessive perspiration D) Difficulty sleeping The correct answer is A: Complaints of numbness and tingling in feet 34. The nurse is caring for a client with end-stage heart failure. The family members are distressed about the client's impending death. What action should the nurse do first? A) Explain the stages of death and dying to the family B) Recommend an easy-to-read book on grief C) Assess the family's patterns for dealing with death D) Ask about their religious affiliations The correct answer is C: Assess the family''s patterns for dealing with death 35. The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in A) Calcium B) Fiber C) Sodium D) Carbohydrate The correct answer is C: Sodium 36. The nurse is teaching a mother who will breast feed for the first time. Which of the following is a priority? A) Show her films on the physiology of lactation B) Give the client several illustrated pamphlets C) Assist her to position the newborn at the breast D) Give her privacy for the initial feeding The correct answer is C: Assist her to position the newborn at the breast 37. The nurse is taking a health history from parents of a child admitted with possible Reye's Syndrome. Which recent illness would the nurse recognize as increasing the risk to develop Reye's Syndrome? A) Rubeola B) Meningitis C) Varicella D) Hepatitis The correct answer is C: Varicella 38. While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill? A) Stubborn behavior B) Rejection of parents C) Frustration with adults D) Assertion of control The correct answer is D: Assertion of control 39. A postpartum client admits to alcohol use throughout the pregnancy. Which of the following newborn assessments suggests to the nurse that the infant has fetal alcohol syndrome? A) Growth retardation is evident B) Multiple anomalies are identified C) Cranial facial abnormalities are noted D) Prune belly syndrome is suspected The correct answer is C: Cranial facial abnormalities are noted 40. The nurse is attending a workshop about caring for persons infected with Hepatitis. Which statement is correct when referring to the incidence rate for Hepatitis? A) The number of persons in a population who develop Hepatitis B during a specific period of time B) The total number of persons in a population who have Hepatitis B at a particular time C) The percentage of deaths resulting from Hepatitis B during a specific time D) The occurrence of Hepatitis B in the population at a particular time The correct answer is A: The number of persons in a population who develop Hepatitis B during a specific period of time 41. A 36 year-old female client has a hemoglobin level of 14 g/dl and a hematocrit of 42% following a D&C. Which of the following would the nurse expect to find when assessing this client? A) Capillary refill less than 3 seconds B) Pale mucous membranes C) Respirations 36 breaths per minute D) Complaints of fatigue when ambulating The correct answer is A: Capillary refill less than 3 seconds 42. The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? The nurse is caring for a client suspected to have Tuberculosis (TB). Which of the following diagnostic tests is essential for determining the presence of active TB? A) Tuberculin skin testing B) Sputum culture C) White blood cell count D) Chest x-ray The correct answer is B: Sputum culture 43. The nurse has been teaching an apprehensive primipara who has difficulty in initial nursing of the newborn. What observation at the time of discharge suggests that initial breast feeding is effective? A) The mother feels calmer and talks to the baby while nursing B) The mother awakens the newborn to feed whenever it falls asleep C) The newborn falls asleep after 3 minutes at the breast D) The newborn refuses the supplemental bottle of glucose water The correct answer is A: The mother feels calmer and talks to the baby while nursing 44. The mother of a burned child asks the nurse to clarify what is meant by a third degree burn. The best response by the nurse is A) "The top layer of the skin is destroyed." B) "The skin layers are swollen and reddened." C) "All layers of the skin were destroyed in the burn." D) "Muscle, tissue and bone have been injured." The correct answer is C: "All layers of the skin were destroyed in the burn." 45. The nurse is taking a health history from a Native American client. It is critical that the nurse must remember that eye contact with such clients is considered A) Expected B) Rude C) Professional D) Enjoyable The correct answer is B: Rude 46. A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child? A) Riding in a car B) Falling off a bed C) Electrical outlets D) Eating peanuts The correct answer is D: Eating peanuts 47. When teaching parents about sickle cell disease, the nurse should tell them that their child's anemia is caused by A) Reduced oxygen capacity of cells due to lack of iron B) An imbalance between red cell destruction and production C) Depression of red and white cells and platelets D) Inability of sickle shaped cells to regenerate The correct answer is B: An imbalance between red cell destruction and production 48. The nurse is assessing a newborn delivered at home by an admitted heroin addict. Which of the following would the nurse expect to observe? A) Hypertonic neuro reflex B) Immediate CNS depression C) Lethargy and sleepiness D) Jitteriness at 24-48 hours The correct answer is D: Jitteriness at 24-48 hours 49. The nurse is caring for a client with congestive heart failure. Which finding requires the nurse's immediate attention? A) Pulse oximetry of 85% B) Nocturia C) Crackles in lungs D) Diaphoresis The correct answer is A: Pulse oximetry of 85% 50. The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body? A) Inspect the skin B) Auscultate breath sounds C) Evaluate muscle strength D) Investigate elimination patterns The correct answer is A: Inspect the skin 51. Which action is most likely to ensure the safety of the nurse while making a home visit? A) Observation during the visit of no evidence of weapons in the home B) Prior to the visit, review client's record for any previous entries about violence C) Remain alert at all times and leave if cues suggest the home is not safe D) Carry a cell phone, pager and/or hand held alarm for emergencies The correct answer is C: Staying alert at all times and leaving if cues suggest the home is not safe 52. An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by A) Tachypnea B) Acidic byproducts C) Vomiting and dehydration D) Hyperpyrexia The correct answer is A: Tachypnea 53. The nurse discovers that the parents of a 2 year-old child continue to use an apnea monitor each night. The parents state: “We are concerned about the possible occurrence of sudden infant death syndrome (SIDS).” In order to take appropriate action, the nurse must understand that A) The child is within the age group most susceptible to SIDS B) The peak age for occurrence of SIDS is 8 to 12 months of age C) The apnea monitor is not effective on a child in this age group D) 95% of SIDS cases occur before 6 months of age The correct answer is D: 95% percent of all SIDS cases occur before 6 months 54. As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid A) Surfing B) Scuba diving C) Parasailing D) Swimming Review Information: The correct answer is B: Scuba diving 55. The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be A) High calorie, low fat, low sodium B) High protein, low fat, low carbohydrate C) High protein, high calorie, unrestricted fat D) High carbohydrate, low protein, moderate fat The correct answer is C: High protein, high calorie, unrestricted fat 56. A client had arrived in the USA from a developing country 1 week prior. The client is to be admitted to the medical surgical unit with a diagnosis of AIDS with a history of unintended weight loss, drug abuse, night sweats, productive cough and a "feeling of being hot all the time." The nurse should assign the client to share a room with a client with the diagnosis of A) Acute tuberculosis with a productive cough of discolored sputum for over three months B) Lupus and vesicles on one side of the middle trunk from the back to the abdomen C) Pseudomembranous colitis and C. difficile. D) Exacerbation of polyarthritis with severe pain The correct answer is A: Acute tuberculosis with a productive cough of discolored sputum for over three months 57. A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client? A) Moist mucous membranes B) Urinary frequency C) Poor skin turgor D) Increased blood pressure The correct answer is C: Poor skin turgor 58. Parents are concerned that their 11 year-old child is a very picky eater. The nurse suggests which of the following as the best initial approach? A) Consider a liquid supplement to increase calories B) Discuss consequences of an unbalanced diet with the child C) Provide fruit, vegetable and protein snacks D) Encourage the child to keep a daily log of foods eaten The correct answer is B: Discuss consequences of an unbalanced diet with the child 59. At a community health fair the blood pressure of a 62 year-old client is 160/96. The client states “My blood pressure is usually much lower.” The nurse should tell the client to A) go get a blood pressure check within the next 48 to 72 hours B) check blood pressure again in 2 months C) see the health care provider immediately D) visit the health care provider within 1 week for a BP check The correct answer is A: go get a blood pressure check within the next 48 to 72 hours 60. A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client’s temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is A) Maintain fluid and electrolyte balance B) Control nausea C) Manage pain D) Prevent urinary tract infection The correct answer is C: Manage pain The immediate goal of therapy is to alleviate the client’s pain. 61. An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN? A) A middle-aged client who says "I took too many diet pills" and "my heart feels like it is racing out of my chest." B) A young adult who says "I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?" * C)An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 D) An elderly client who reports having taken a "large crack hit" 10 minutes prior to walking into the emergency room The correct answer is c: An adolescent who has been on pain medications for terminal cancer with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10 62. While planning care for a toddler, the nurse teaches the parents about the expected developmental changes for this age. Which statement by the mother shows that she understands the child's developmental needs? A) "I want to protect my child from any falls." B) "I will set limits on exploring the house." C) "I understand the need to use those new skills." D) "I intend to keep control over our child." The correct answer is C: "I understand the need to use those new skills." 63. A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year old twins at home and a miscarriage 10 years ago at 12 weeks gestation. How would the nurse accurately document this information? A) Gravida 4 para 2 B) Gravida 2 para 1 C) Gravida 3 para 1 D) Gravida 3 para 2 The correct answer is C: Gravida 3 para 1 64. A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the nurse do first? A) Gastric lavage PRN B) Acetylcysteine (mucomyst) for age per pharmacy C) Start an IV Dextrose 5% with 0.33% normal saline to keep vein open D) Activated charcoal per pharmacy The correct answer is A: Gastric lavage PRN 65. The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is A) Verify correct placement of the tube B) Check that the feeding solution matches the dietary order C) Aspirate abdominal contents to determine the amount of last feeding remaining in stomach D) Ensure that feeding solution is at room temperature The correct answer is A: Verify correct placement of the tube 66. The nurse anticipates that for a family who practices Chinese medicine the priority goal would be to A) Achieve harmony B) Maintain a balance of energy C) Respect life D) Restore yin and yang The correct answer is D: Restore yin and yang 67. Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure? A) angina at rest B) thrombus formation C) dizziness D) falling blood pressure The correct answer is B: thrombus formation 68. A nurse prepares to care for a 4 year-old newly admitted for rhabdomyosarcoma. The nurse should alert the staff to pay more attention to the function of which area of the body? A) The muscles B) The cerebellum C) The kidneys D) The leg bones The correct answer is A: All striated muscles 69. A client comes to the clinic for treatment of recurrent pelvic inflammatory disease. The nurse recognizes that this condition most frequently follows which type of infection? A) Trichomoniasis B) Chlamydia C) Staphylococcus D) Streptococcus The correct answer is B: Chlamydia 70. During the evaluation of the quality of home care for a client with Alzheimer's disease, the priority for the nurse is to reinforce which statement by a family member? A) At least 2 full meals a day is eaten. B) We go to a group discussion every week at our community center. C) We have safety bars installed in the bathroom and have 24 hour alarms on the doors. D) The medication is not a problem to have it taken 3 times a day. The correct answer is C: We have safety bars installed in the bathroom and have 24 hour alarms on the doors. 71. The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing? A) Apply dressing using sterile technique B) Improve the client's nutrition status C) Initiate limb compression therapy D) Begin proteolytic debridement The correct answer is B: Improve the client''s nutrition status 72. During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to A) Increase fluids that are high in protein B) Restrict fluids C) Force fluids and reassess blood pressure D) Limit fluids to non-caffeine beverages The correct answer is C: Force fluids and reassess blood pressure 73. Which individual is at greatest risk for developing hypertension? A) 45 year-old African American attorney B) 60 year-old Asian American shop owner C) 40 year-old Caucasian nurse D) 55 year-old Hispanic teacher The correct answer is A: 45 year-old African American attorney 74. The nurse is caring for a client with a serum potassium level of 3.5 mEq/L. The client is placed on a cardiac monitor and receives 40 mEq KCL in 1000 ml of 5% dextrose in water IV. Which of the following EKG patterns indicates to the nurse that the infusions should be discontinued? A) Narrowed QRS complex B) Shortened "PR" interval C) Tall peaked T waves D) Prominent "U" waves The correct answer is C: Tall peaked T waves 75. A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication? A) Weight gain of 5 pounds B) Edema of the ankles C) Gastric irritability D) Decreased appetite The correct answer is D: Decreased appetite 76. Which of these statements best describes the characteristic of an effective rewardfeedback system? A) Specific feedback is given as close to the event as possible B) Staff are given feedback in equal amounts over time C) Positive statements are to precede a negative statement D) Performance goals should be higher than what is attainable The correct answer is A: Specific feedback is given as close to the event as possible 77. The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to A) Excessive fetal weight B) Low blood sugar levels C) Depletion of subcutaneous fat D) Progressive placental insufficiency The correct answer is D: Progressive placental insufficiency 78. A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A) Positive sweat test B) Bulky greasy stools C) Moist, productive cough D) Meconium ileus The correct answer is C:Moist, productive cough 79. Which of the following should the nurse implement to prepare a client for a KUB (Kidney, Ureter, Bladder) radiograph test? A) Client must be NPO before the examination B) Enema to be administered prior to the examination C) Medicate client with Lasix 20 mg IV 30 minutes prior to the examination D) No special orders are necessary for this examination The correct answer is D: No special orders are necessary for this examination 80. The hospital has sounded the call for a disaster drill on the evening shift. Which of these clients would the nurse put first on the list to be discharged in order to make a room available for a new admission? A)A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago B) A young adult with diabetes mellitus Type 2 for over 10 years and admitted with antibiotic induced diarrhea 24 hours ago C) An elderly client with a history of hypertension, hypercholesterolemia and lupus, and was admitted with Stevens- Johnson syndrome that morning D) An adolescent with a positive HIV test and admitted for acute cellulitus of the lower leg 48 hours ago The correct answer is A: A middle aged client with a history of being ventilator dependent for over 7 years and admitted with bacterial pneumonia five days ago 81. A triage nurse has these 4 clients arrive in the emergency department within 15 minutes. Which client should the triage nurse send back to be seen first? A) A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying B) A teenager who got a singed beard while camping C) An elderly client with complaints of frequent liquid brown colored stools D) A middle aged client with intermittent pain behind the right scapula The correct answer is B: A teenager who got singed a singed beard while camping 82. A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider? A) Blood pressure 94/60 B) Heart rate 76 C) Urine output 50 ml/hour D) Respiratory rate 16 The correct answer is A: Blood pressure 94/60 83. A nurse enters a client's room to discover that the client has no pulse or respirations. After calling for help, the first action the nurse should take is A) Start a peripheral IV B) Initiate closed-chest massage C) Establish an airway D) Obtain the crash cart The correct answer is C: Establish an airway 84. A 3 year-old child comes to the pediatric clinic after the sudden onset of findings that include irritability, thick muffled voice, croaking on inspiration, hot to touch, sit leaning forward, tongue protruding, drooling and suprasternal retractions. What should the nurse do first? A) Prepare the child for x-ray of upper airways B) Examine the child's throat C) Collect a sputum specimen D) Notify the healthcare provider of the child's status The correct answer is D: Notify the health care provider of the child''s status 85. A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 mg, and promethizine hydrochloride (Phenergan) 50 mg IM to a preoperative client. Which action should the nurse take first? A) Raise the side rails on the bed B) Place the call bell within reach C) Instruct the client to remain in bed D) Have the client empty bladder The correct answer is D: Have the client empty bladder 86. In children suspected to have a diagnosis of diabetes, which one of the following complaints would be most likely to prompt parents to take their school age child for evaluation? A) Polyphagia B) Dehydration C) Bed wetting D) Weight loss The correct answer is C: Bed wetting 87. A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication: A) Should be taken in the morning B) May decrease the client's energy level C) Must be stored in a dark container D) Will decrease the client's heart rate The correct answer is A: Should be taken in the morning 88. A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure A) Right heart function B) Left heart function C) Renal tubule function D) Carotid artery function The correct answer is B: Left heart function 89. Which of these findings indicate that a pump to deliver a basal rate of 10 ml per hour plus PRN for pain break through for morphine drip is not working? A) The client complains of discomfort at the IV insertion site B) The client states "I just can't get relief from my pain." C) The level of drug is 100 ml at 8 AM and is 80 ml at noon D) The level of the drug is 100 ml at 8 AM and is 50 ml at noon The correct answer is C: The level of drug is 100 ml at 8 AM and is 80 ml at noon 90. The nurse is performing a neurological assessment on a client post right CVA. Which finding, if observed by the nurse, would warrant immediate attention? A) Decrease in level of consciousness B) Loss of bladder control C) Altered sensation to stimuli D) Emotional lability The correct answer is A: Decrease in level of consciousness 91. When teaching a client with coronary artery disease about nutrition, the nurse should emphasize A) Eating 3 balanced meals a day B) Adding complex carbohydrates C) Avoiding very heavy meals D) Limiting sodium to 7 gms per day The correct answer is C: Avoiding very heavy meals 92. The nurse is speaking at a community meeting about personal responsibility for health promotion. A participant asks about chiropractic treatment for illnesses. What should be the focus of the nurse’s response? A) Electrical energy fields B) Spinal column manipulation C) Mind-body balance D) Exercise of joints The correct answer is B: Spinal column manipulation 93. The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs 2 hours ago. The nurse should A) Place a call to the client's health care provider for instructions B) Send him to the emergency room for evaluation C) Reassure the client's wife that the symptoms are transient D) Instruct the client's wife to call the doctor if his symptoms become worse The correct answer is B: Send him to the emergency room for evaluation 94. While assessing a 1 month-old infant, which finding should the nurse report immediately? A) Abdominal respirations B) Irregular breathing rate C) Inspiratory grunt D) Increased heart rate with crying Review Information: The correct answer is C: Inspiratory grunt 95. A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which A) Increase the heart rate B) Lead to dehydration C) Are considered aerobic D) May be competitive The correct answer is B: Lead to dehydration 96. The nurse is caring for a client who had a total hip replacement 4 days ago. Which assessment requires the nurse’s immediate attention? A) I have bad muscle spasms in my lower leg of the affected extremity. B) "I just can't 'catch my breath' over the past few minutes and I think I am in grave danger." C) "I have to use the bedpan to pass my water at least every 1 to 2 hours." D) "It seems that the pain medication is not working as well today." The correct answer is B: "I just can''t ''catch my breath'' over the past few minutes and I think I am in grave danger." 97. The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question? A) "You need to regain your strength before attempting such exertion." B) "When you can climb 2 flights of stairs without problems, it is generally safe." C) "Have a glass of wine to relax you, then you can try to have sex." D) "If you can maintain an active walking program, you will have less risk." The correct answer is B: "When you can climb 2 flights of stairs without problems, it is generally safe." 98. What would the nurse expect to see while assessing the growth of children during their school age years? A) Decreasing amounts of body fat and muscle mass B) Little change in body appearance from year to year C) Progressive height increase of 4 inches each year D) Yearly weight gain of about 5.5 pounds per year The correct answer is D: Yearly weight gain of about 5.5 pounds per year 99. The nurse is assigned to care for a client who has a leaking intracranial aneurysm. To minimize the risk of rebleeding , the nurse should plan to A) Restrict visitors to immediate family B) Avoid arousal of the client except for family visits C) Keep client's hips flexed at no less than 90 degrees D) Apply a warming blanket for temperatures of 98 degrees Fahrenheit or less The correct answer is A: Restrict visitors to immediate family 100. The nurse is performing a gestational age assessment on a newborn delivered 2 hours ago. When comparing findings to the Ballard scale, which situation may affect the score? A) Birth weight B) Racial differences C) Fetal distress in labor D) Birth trauma The correct answer is C: Fetal distress in labor 101. A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first? A) Place the child in the nearest bed B) Administer IV medication to slow down the seizure C) Place a padded tongue blade in the child's mouth D) Remove the child's toys from the immediate area The correct answer is D: Remove the child’’s toys from the immediate area 102. A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that remedies A) Destroy organisms causing disease B) Maintain fluid balance C) Boost the immune system D) Increase bodily energy The correct answer is C: Boost the immune system 103. The nurse is caring for a 2 year-old who is being treated with chelation therapy, calcium disodium edetate, for lead poisoning. The nurse should be alert for which of the following side effects? A) Neurotoxicity B) Hepatomegaly C) Nephrotoxicity D) Ototoxicity The correct answer is C: Nephrotoxicity 104. The nurse is caring for a 1 year-old child who has 6 teeth. What is the best way for the nurse to give mouth care to this child? A) Using a moist soft brush or cloth to clean teeth and gums B) Swabbing teeth and gums with flavored mouthwash C) Offering a bottle of water for the child to drink D) Brushing with toothpaste and flossing each tooth The correct answer is A: Using a moist soft brush or cloth to clean teeth and gums 105. At a senior citizens meeting a nurse talks with a client who has diabetes mellitus Type 1. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity? A) "I give my insulin to myself in my thighs." B) "Sometimes when I put my shoes on I don't know where my toes are." C) "Here are my up and down glucose readings that I wrote on my calendar." D) "If I bathe more than once a week my skin feels too dry." The correct answer is B: "Sometimes when I put my shoes on I don''t know where my toes are." 106. A couple trying to conceive asks the nurse when ovulation occurs. The woman reports a regular 32 day cycle. Which response by the nurse is correct? A) Days 7-10 B) Days 10-13 C) Days 14-16 D) Days 17-19 The correct answer is D: Days 17-19 107. Included in teaching the client with tuberculosis taking INH about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical? A) Liver function B) Kidney function C) Blood sugar D) Cardiac enzymes The correct answer is A: Liver function 108. A 78 year-old client with pneumonia has a productive cough but is confused. Safety protective devices (restraints) have been ordered for this client. How can the nurse prevent aspiration? A) Suction the client frequently while restrained B) Secure all 4 restraints to 1 side of bed C) Obtain a sitter for the client while restrained D) Request an order for a cough suppressant The correct answer is C: Obtain a sitter for the client while restrained 109. A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy? A) Check the skin on the sacrum for breakdown B) Inspect the pin site for signs of infection C) Auscultate the lungs for atelectasis D) Perform a neurovascular check for circulation The correct answer is D: Perform a neurovascular check for circulation 110. The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding? A) Bounding pulse B) Rapid respirations C) Oliguria D) Neck veins are distended The correct answer is C: Oliguria 111. When suctioning a client's tracheostomy, the nurse should instill saline in order to A) Decrease the client's discomfort B) Reduce viscosity of secretions C) Prevent client aspiration D) Remove a mucus plug The correct answer is D: Remove a mucus plug 112. A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms? A) Drink small amounts of liquids frequently B) Eat the evening meal just before retiring C) Take sodium bicarbonate after each meal D) Sleep with head propped on several pillows The correct answer is D: Sleep with head propped on several pillows 113. A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse’s immediate attention? A) Capillary refill of fingers on right hand is 3 seconds B) Skin warm to touch and normally colored C) Client reports prickling sensation in the right hand D) Slight swelling of fingers of right hand The correct answer is C: Client reports prickling sensation in the right hand 114. A newborn is having difficulty maintaining a temperature above 98 degrees Fahrenheit and has been placed in a warming isolate. Which action is a nursing priority? A) Protect the eyes of the neonate from the heat lamp B) Monitor the neonate’s temperature C) Warm all medications and liquids before giving D) Avoid touching the neonate with cold hands The correct answer is B: Monitor the neonate’s temperature 115. The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action? A) Periorbital edema B) Dizziness spells C) Lethargy D) Shortness of breath The correct answer is B: Dizziness spells 116. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the health care provider ordering A) Pulmonary embolectomy B) Vena caval interruption C) Increasing the coumadin therapy to an INR of 3-4 D) Thrombolytic therapy The correct answer is B: Vena cava interruption 117. A 70 year-old woman is evaluated in the emergency department for a wrist fracture of unknown causes. During the process of taking client history, which of these items should the nurse identify as related to the client’s greatest risk factors for osteoporosis? A) Menopause at age 50 B) Has taken high doses of steroids for arthritis for many years C) Maintains an inactive lifestyle for the past 10 years D) Drinks 2 glasses of red wine each day for the past 30 years The correct answer is B: Takes steroids for arthritis 118. Decentralized scheduling is used on a nursing unit. A chief advantage of this management strategy is that it A) Considers client and staff needs B) Conserves time for planning C) Frees the nurse manager to handle other priorities D) Allows for requests about special privileges The correct answer is A: Considers client and staff needs 119. A newborn has hyperbilirubinemia and is undergoing phototherapy with a blanket. Which safety measure is most important during this process? A) Regulate the neonate’s temperature using a radiant heater B) Withhold feedings while under the phototherapy C) Provide water feedings at least every 2 hours D) Protect the eyes of neonate from the phototherapy lights The correct answer is C: Provide water feedings at least every 2 hours 120. The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information? A) "I usually avoid driving at night since lights sometimes seem to make things blur." B) "I take half of the usual dose for my sinuses to maintain my blood pressure." C) "I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem." D) "I take extra fiber and drink lots of water to avoid getting constipated." The correct answer is D: "I take extra fiber and drink lots of water to avoid getting constipated." 121. On daily cleaning of a tracheostomy, the client coughs and displaces the tracheostomy tube. The nurse could have avoided this by A) placing an obturator at the client’s bedside B) having another nurse assist with the procedure C) fastening clean tracheostomy ties before removing old ties D) Withdraw catheter in a circular motion The correct answer is C: fastening clean tracheostomy ties before removing old ties 122. Which contraindication should the nurse assess for prior to giving a child immunizations? A) Mild cold symptoms B) Chronic asthma C) Depressed immune system D) Allergy to eggs The correct answer is C: Depressed immune system 123. The nurse is teaching home care to the parents of a child with acute spasmodic croup. The most important aspect of this care is A) Sedation as needed to prevent exhaustion B) Antibiotic therapy for 10 to 14 days C) Humidified air and increased oral fluids D) Antihistamines to decrease allergic response The correct answer is C: Humidified air and increased oral fluids 124. A newborn delivered at home without a birth attendant is admitted to the hospital for observation. The initial temperature is 35 degrees Celsius (95 degrees Fahrenheit) axillary. The nurse recognizes that cold stress may lead to what complication? A) Lowered BMR B) Reduced PaO2 C) Lethargy D) Metabolic alkalosis The correct answer is B: Reduced PaO2 125. In addition to standard precautions, a nurse should implement contact precautions for which client? A) 60 year-old with herpes simplex B) 6 year-old with mononucleosis C) 45 year-old with pneumonia D) 3 year-old with scarlet fever The correct answer is A: 60 year-old with herpes simplex 126. Which of the following situations is most likely to produce sepsis in the neonate? A) Maternal diabetes B) Prolonged rupture of membranes C) Cesarean delivery D) Precipitous vaginal birth The correct answer is B: Prolonged rupture of membranes 127. Which client is at highest risk for developing a pressure ulcer? A) 23 year-old in traction for fractured femur B) 72 year-old with peripheral vascular disease, who is unable to walk without assistance C) 75 year-old with left sided paresthesia and is incontinent of urine and stool D) 30 year-old who is comatose following a ruptured aneurysm The correct answer is C: 75 year-old client with left sided paresthesia and is incontinent of urine and stool 128. A new nurse manager is responsible for interviewing applicants for a staff nurse position. Which interview strategy would be the best approach? A) Vary the interview style for each candidate to learn different techniques B) Use simple questions requiring "yes" and "no" answers to gain definitive information * C) Obtain an interview guide from human resources for consistency inn interviewing each candidate D) Ask personal information of each applicant to assure meeting of job demands The correct answer is C: Obtain an interview guide from human resources for consistency in interviewing each candidate 129. A client who is 12 hour post-op becomes confused and says: “Giant sharks are swimming across the ceiling.” Which assessment is necessary to adequately identify the source of this client's behavior? A) Cardiac rhythm strip B) Pupillary response C) Pulse oximetry D) Peripheral glucose stick The correct answer is C: Pulse oximetry 130. A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take? A) Call the health care provider B) Access the site by cutting a window in the cast C) Record the findings in the nurse's notes only D) Outline the spot with a pencil and note the time and date on thecast The correct answer is D: Outline the spot with a pencil and note the time and date on the cast 131. A nurse assessing the newborn of a mother with diabetes understands that hypoglycemia is related to what pathophysiological process? A) Disruption of fetal glucose supply B) Pancreatic insufficiency C) Maternal insulin dependency D) Reduced glycogen reserves The correct answer is A: Disruption of fetal glucose supply 132. The nurse is teaching a parent about side effects of routine immunizations. Which of the following must be reported immediately? A) Irritability B) Slight edema at site C) Local tenderness D) Temperature of 102.5 F The correct answer is D: Temperature of 102.5 F 133. The parents of a toddler ask the nurse how long their child will have to sit in a car seat while in the automobile. What is the nurse’s best response to the parents? A) “Your child must use a care seat until he weighs at least 40 pounds." B) The child must be 5 years of age to use a regular seat belt. C) “Your child must reach a height of 50 inches to sit in a seat belt." D) “The child can use a regular seat belt when he can sit still." The correct answer is A: “Your child must use a care seat until he weighs at least 40 pounds." 134. A 16 year-old boy is admitted for Ewing's sarcoma of the tibia. In discussing his care with the parents, the nurse understands that the initial treatment most often includes A) Amputation just above the tumor B) Surgical excision of the mass C) Bone marrow graft in the affected leg D) Radiation and chemotherapy The correct answer is D: Radiation and chemotherapy 135. A client complains of some discomfort after a below the knee amputation. Which action by the nurse is appropriate to do initially? A) Conduct guided imagery or distraction B) Ensure that the stump is elevated for the initial day C) Wrap the stump snugly in an elastic bandage D) Administer opioid narcotics as ordered The correct answer is B: Ensure that the stump is elevated for the initial day 136. What is the best way that parents of pre-schoolers can begin teaching their child about injury prevention? A) Set good examples themselves B) Protect their child from outside influences C) Make sure their child understands all the safety rules D) Discuss the consequences of not wearing protective devices The correct answer is A: Set good examples themselves 137. Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client? A) Venturi mask B) Partial rebreather mask C) Non-rebreather mask D) Simple face mask The correct answer is C: Non-rebreather mask 138. The nurse is teaching the mother of a 5 month-old about nutrition for her baby. Which statement by the mother indicates the need for further teaching? A) "I'm going to try feeding my baby some rice cereal." B) "When he wakes at night for a bottle, I feed him." C) "I dip his pacifier in honey so he'll take it." D) "I keep formula in the refrigerator for 24 hours." The correct answer is C: "I dip his pacifier in honey so he''ll take it." 139. The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5. Which of the following would the nurse anticipate? A) Additional potassium will be given IV B) Blood for coagulation studies will be drawn C) Total parenteral nutrition (TPN) will be started D) Serum lipase levels will be evaluated The correct answer is C: Total parenteral nutrition (TPN) will be started 141. A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss? A) The newborn needs additional assessments B) The mother should breast feed more often C) A change to formula is indicated D) The loss is within normal limits The correct answer is D: The loss is within normal limits 142. During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse? A) The client's self-report is the most important consideration B) Cultural sensitivity is fundamental to pain management C) Clients have the right to have their pain relieved D) Nurses should not prejudge a client's pain using their own values The correct answer is A: The client''s self report is the most important consideration 143. A 35-year-old client of Puerto Rican-American descent is diagnosed with ovarian cancer. The client states “I refuse both radiation and chemotherapy because they are 'hot.'” The next action for the nurse to take is to A) Document the situation in the notes B) Report the situation to the health care provider C) Talk with the client's family about the situation D) Ask the client to talk about the concerns about the "hot"treatments The correct answer is D: Ask the client to talk about the concerns about the "hot" treatments 144. Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy? A) Benzodiazepines B) Chlorpromazine (Thorazine) * C) Succinylcholine (Anectine) D) Thiopental sodium (Pentothal Sodium) The correct answer is C: Succinylcholine (Anectine) 145. A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which changes would require the nurse's immediate attention? A) Increased restlessness B) Tachycardia C) Tracheal deviation D) Tachypnea The correct answer is C: Tracheal deviation 146. Which approach is a priority for the nurse who works with clients from many different cultures? A) Speak at least 2 other languages of clients in the neighborhood B) Learn about the cultures of clients who are most often encountered C) Have a list of persons for referral when interaction with these clients occur D) Recognize personal attitudes about cultural differences and real or expected biases The correct answer is D: Recognize personal attitudes about cultural differences and real or expected biases 147. A client with chronic obstructive pulmonary disease (COPD) and a history of coronary artery disease is receiving Aminophylline, 25mg/hour. Which one of the following findings by the nurse would require immediate intervention? A) Decreased blood pressure and respirations. B) Flushing and headache. C) Restlessness and palpitations. D) Increased heart rate and blood pressure. The correct answer is C: Restlessness and palpitations. 148. The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care? A) Encourage child to engage in activities in the playroom B) Promote independence in activities of daily living C) Talk with the child and allow him to express his opinions D) Provide frequent reassurance and cuddling The correct answer is A: Encourage child to engage in activities in the playroom . 149. A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these mediations would the nurse anticipate the health care provider ordering? A) Oral Coumadin therapy B) Heparin 5000 units subcutaneously b.i.d. C) Heparin infusion to maintain the PTT at 1.5-2.5 times the control value D) Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value The correct answer is D: Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value 150. The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience A) High fever B) Nausea C) Face and neck edema D) Night sweats The correct answer is B: Nausea 151. While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age? A) 1 year of age B) 2 years of age C) 3 years of age D) 4 years of age The correct answer is B: 2 years of age 152. Which of these clients, who all have the findings of a board-like abdomen, would the nurse suggest that the health care provider examine first? A) An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago." B) A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy C) A middle-aged client admitted with diverticulitis and has taken only clear liquids for the past week D) A teenager with a history of falling off a bicycle and did not hit the handle bars The correct answer is A: An elderly client who stated that "My awful pain in my right side suddenly stopped about 3 hours ago." 153. A client with a panic disorder has a new prescription for Xanax (Alprazolam). In teaching the client about the drug's actions and side effects, which of the following should the nurse emphasize? A) Short-term relief can be expected B) The medication acts as a stimulant C) Dosage will be increased as tolerated D) Initial side effects often continue The correct answer is A: Short-term relief can be expected 154. Which of these questions is priority when assessing a client with hypertension? A) "What over-the-counter medications do you take?" B) "Describe your usual exercise and activity patterns." C) "Tell me about your usual diet." D) "Describe your family's cardiovascular history." The correct answer is A: "What over-the-counter medications do you take?" 155. During a routine check-up, an insulin-dependent diabetic has his glycosylated hemoglobin checked. The results indicate a level of 11%. Based on this result, what teaching should the nurse emphasize? A) Rotation of injection sites B) Insulin mixing and preparation C) Daily blood sugar monitoring D) Regular high protein diet The correct answer is C: Daily blood sugar monitoring 156. Which of these clients would the nurse monitor for the complication of C. difficile diarrhea? A) An adolescent taking medications for acne B) An elderly client living in a retirement center taking prednisone C) A young adult at home taking a prescribed amino glycoside D) A hospitalized middle aged client receiving clindamycin The correct answer is D: A hospitalized middle aged client receiving clindamycin 157. The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse? A) Decreased breath sounds in right lower lobe B) Aspiration of a residual of 100cc of formula C) Decrease in bowel sounds D) Urine output of 250 cc in past 8 hours The correct answer is A: Decreased breath sounds in right lower lobe 158. The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse do first? A) Explain that the procedure will help him to get well B) Show a cartoon character with a blood pressure cuff C) Explain that the blood pressure checks the heart pump D) Permit handling the equipment before putting the cuff in place The correct answer is D: Permit handling the equipment before putting the cuff in place 159. A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client’s medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours? A) digoxin (Lanoxin) B) diltiazam (Cardizem) C) nitroglycerine ointment D) metoprolol (Toprol XL) The correct answer is A: digoxin (Lanoxin) 160. To prevent drug resistance common to tubercle bacilli, the nurse is aware that which of the following agents are usually added to drug therapy? A) Anti-inflammatory agent B) High doses of B complex vitamins C) Amino glycoside antibiotic D) Two anti-tuberculosis drugs The correct answer is D: Two anti-tuberculosis drugs