HESI LPN PRACTICE EXAM Currently Updated

HESI LPN PRACTICE EXAM 01. The nurse is planning care for a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priori ...

HESI LPN PRACTICE EXAM 01. The nurse is planning care for a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority for this client? A. Administer prescribed stool softener B. Administer prescribed PRN sleep medications C. Encourage breastfeeding to promote uterine involution D. Encourage use of prescribed analgesic perineal sprays 02. The nurse is palpating the right upper hypochondriac region of the abdomen of a client. What organ lies underneath this area? A . D u o d e n u m B . G a s t r i c p y l o r u s C . L i v e r D . S p l e e n 03. A client comes to the antepartal clinic and tells the nurse that she is 6 weeks pregnant. Which sign is she most likely to report? A . D e c r e a s e d s e x u a l l i b i d o B . A m e n o r r h e a C . Q u i c k e n i n g D . N o c t u r i a 04. A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make? A.Ask for a description of what happened during the night B.Tell the daughter to talk to the unit's nurse manager C.Reassure the daughter that the mother will get better care D. Explain that all the staff are doing the best they can05. A hospitalized toddler who is recovering from a sickle cell crisis holds a toy and say's "Mine". According to Erikson's theory of psychosocial development, this child's behavior is a demonstration of which developmental stage? A.Autonomy vs. Shame and Doubt B . I n d u s t r y v s . I n f e r i o r i t y C . I n i t i a t i v e v s . G u i l t D . T r u s t v s . M i s t r u s t 06. Which action should the nurse implement in caring for a client following an electroencephalogram (EEG)? A.Monitor the client's vital signs q4h B.Assess for sensation in the client's lower extremities C.Instruct the client to maintain bed rest for eight hours D.Wash any paste from the client's hair and scalp 07. The nurse is caring for a 75-year-old male client who is beginning to form a decubitus ulcer at the coccyx. Which intervention will be most helpful in preventing further development of the decubitus? A.Encourage the client to eat foods high in protein B.Assess the client with daily range of motion exercises C.Teach the family how to perform sterile wound care D.Ensure the IV fluids are administered as prescribed 08. What is the homeostatic cellular transport mechanism that moves water from a hypotonic to a hypertonic fluid space? A . F i l t r a t i o n B . D i f f u s i o n C . O s m o s i s D . A c t i v e t r a n s p o r t 09. The nurse is taking blood pressure of a client admitted with a possible myocardial infarction. When taking the client's BP at the brachial artery, the nurse should place the client's arm in which position?A.Slightly above the level of the heart B . A t t h e l e v e l o f t h e h e a r t C.At a level of comfort for the client D.Below the level of the heart 10. What are the final parameters that produce blood pressure? (Select all that apply) A . H e a r t r a t e B . S t r o k e v o l u m e C . P e r i p h e r a l r e s i s t a n c e D . N e u r o e n d o c r i n e h o r mo n e s E . M u s c l e t o n e 11. A client begins taking an antidepressant drug during the second day of hospitalization. Which assessment is most important for the nurse to include in this client's plan of care while the client is taking the antidepressant? A . A p p e t i t e B . M o o d C.Withdrawal D.Energy level 12. Based on the documentation in the medical record, which action should the nurse implement next? (Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client's medical record.) A.Give the rubella vaccine subcutaneously B.Observe the mother breastfeeding her infant C.Call the nursery for the infant's blood type result D.Administer Vicodin one tablet for pain 13. A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the nurse implement to prevent complications associated with Pneumonia?A.Encourage mobilization and ambulation B.Encourage energy conservation with complete bed rest C.Provide humidified oxygen per nasal cannula D.Restrict PO and intravenous fluids 14. The practical nurse is preparing to administer a prescription for cefazolin (Kefzol) 600 mg IM every six hours. The available vial is labeled, "Cefazolin (Kefzol) 1gram," and the instructions for reconstitution state, "For IM use add 2ml sterile water for injection. Total volume after reconstitution = 2.5 ml." When reconstituted, how many milligrams are in each mil of solution? (Enter numeric value only) 400 15. Which Nursing activity is within the scope of practice for the practical nurse? A.Complete an admission assessment in the normal newborn nursery B.Discontinue a central venous catheter that has become dislodged C.Observe a client rotate the subcutaneous site for an insulin pump D.Monitor a continuous narcotic epidural for a postoperative client16. After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel? A.Identify the need for additional supplies to provide an extra dressing change B.Provide perianal care and collect clean linens for the dressing change C.Document the diarrhea that necessitates an additional dressing change D.Position the client for access to the decubiti sites and remove dressings 17. The nurse is planning to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration in the order from fastest to slowest rate of absorption. Intravenous, sublingual, intramuscular, subcutaneous, oral 18. A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-hour post dilation and curettage (D&C), the nurse assesses vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene? A.Offer to call the social worker to discuss the possibility of adoption B.Reassure the client that the infertility specialist can help C.Express sorrow for the client's grief and offer to sit with her D.Chart the vital signs and amount of vaginal bleeding 19. A terminally ill male client and his family are requesting hospice care after discharge from the hospital and ask the nurse to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care? A.Enhance symptom management to improve end of life qualityB.Facilitates assisted suicide with the client's consent C.Offers ways to postpone the death experience at home D.Provide training for family members to care for the client 20. The nurse observes a wife shaving her husband’s beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth. What action should the nurse take? A.Advise the wife to shave against the hair growth B.Teach the wife to keep the skin loose to avoid cuts C.Encourage the wife to continue shaving her husband D.Demonstrate the correct procedure to the wife 21. To assess pedal pulse, what arterial sites should the nurse palpate? (Select all that apply) A.Posterior tibialis artery B . P o p l i t e a l a r t e r y C . E x t e r n a l f e m o r a l a r t e r y D . D o r s a l i s p e d i s a r t e r y E . R a d i a l a r t e r y 22. The nurse is admitting a client who is diagnosed with Angina Pectoris. Which precipitating factor in this client's history is likely to be related to the anginal pain? A.Smokes one pack of cigarettes daily B . D r i n k s t w o b e e r s d a i l y C.Works in a job that requires exposure to the sun D . E a t s w h i l e l y i n g i n b e d 23. The nurse is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catheterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take?A.Stand the client to void and run tap water within hearing distance before catheterizing the client B.Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter C.Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period D.Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. inflate the balloon 24. A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushinoid side effects? A.Moon face, slow wound healing, muscle wasting sodium and water retention B.Tachycardia hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor C.Bradycardia, weight gain, cold intolerance, myxedema facies and periorbital edema D.Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension 25. The cervix is the opening into the uterine cavity. What is its function in reproduction? A.Accepts and interprets signals of sexual stimuli B.Secretes mucus to facilitate sperm transport C.Serves as the site for union of ovum and sperm D.Receives the penis during intercourse 26. The nurse is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection? A.17-year-old who is sexually active simultaneously with numerous partners B.34-year-old homosexual who is in a monogamous relationship C.30-year-old cocaine user who inhales and smokes drugsD.45-year-old who has received two blood transfusions in the past 6 months 27. The nurse is administering amiodarone (Cordarone) to a client who has been admitted with Atrial Fibrillation(AFIB). What therapeutic response should the nurse anticipate? A.Conversion of irregular heart rate to regular heart rhythm B.Pulse oximetry readings within normal range during activity C.Peripheral pulse points with adequate capillary refill D.Increase exercise tolerance without shortness of breath 28. An elderly male client is planning to vacation with a group of senior citizens. He is concerned about developing constipation during the airplane flight. He shares this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide? A.Use an over the counter stool softener when needed B . E a t a h i g h p r o t e i n d i e t C.Increase the fluid intake in your diet D.Decrease the fat conten t in your diet 29. The nurse is assessing a client with dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client? A.Abnormal skin color changes in a client with dark skin cannot be determined B.Blanching the soles of the feet in a client with dark skin reveals cyanosis C.The lips and mucus membranes of a client with dark skin are dusky in color D.Cyanosis in a client with dark skin is seen in the sclera 30. When inserting an indwelling urinary catheter (Foley) in a female client, the nurse observes urine flow into the tubing. What action is taken next?A.Document the color and clarity of the urine B.Insert the catheter an additional inch C.Ask the client to breathe deeply and slowly exhale D.Inflate the balloon with 5 mL of sterile water 31. A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a Lumbar Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality? A.Mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain B.Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus C.An infusion of medication in the spinal canal will block pain perception D.The discharge of electricity will distract the client's focus on the pain 32. Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority? A.Application of topical antibacterial cream B.Use of careful hand washing technique C.Administration of plasma expanders D.Limiting visitors to the burned client 33. The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder. Which assessment finding is the most significant indicator of possible child abuse? A.The child looks at the floor when answering the nurse's questions B.The mother's version of the injury is different from the child's version C.The child has several abrasions on the chest and legs D.The mother refuses to answer questions about family history34. A client has a prescription for enteric-coated (EC) aspirin 325mg PO daily. The medication drawer contains one 325mg aspirin. What action should the nurse take? A.Contact the pharmacy and request the prescribed form of aspirin B.Instruct the client about the effects when given the medication C.Administer the aspirin with a full glass of water or a small snack D.Withhold the aspirin until consulting with the healthcare provider 35. The nurse explains the 2-week dosage prescription of prednisone (Deltasone) to a client who has poison ivy over multiple skin surfaces. What should the nurse emphasize about the dosing schedule? A.Decrease dosage daily as prescribed B.Monitor oral temperature daily C.Take the prednisone with meals D.Return for blood glucose monitoring in one week 36. The nurse is preparing to administer a 1.2mL injection to a 4-yearold. Which are the best sites to administeran IM injection? Select all that apply. A . V a s t u s L a t e r a l i s B . V e n t r o g l u t e a l C . D o r s o g l u t e a l D . R e c t u s f e m o r i s E . D e l t o i d 37. Which nonfood item is the most common cause of respiratory arrest in young children? A . B r o k e n r a t t l e s B . B u t t o n s C . P a c i f i e r s D . L a t e x b a l l o o n s38. A new mother is at the clinic with her 4-week-old for a well baby check up. The nurse should tell the mother to anticipate that the infant will demonstrate which millstone by 2-months of age. A.Turns from side to back and returns B.Consistently returns smiles to mother C.Finds hands and plays with fingers D.Holds head up and supports weight with arms 39. The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding? A.The solution's rate is too rapid B . T h e c l i e n t h a s p h l e b i t i s C.The infusion site is infected D.The infusion is infiltrated 40. The nurse observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement? A.Raise the bed to ensure the drainage bag remains off the floor B.Attach the drainage bag to the side rail instead of the bed frame C.Observe the appearance of the urine in the drainage tubing D.Secure the tubing to the client's gown instead of his abdomen 41. In assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next? A.Advise the client that suctioning will be used to obtain another specimen B.Re-instruct the client in coughing techniques to obtain another specimenC.Provide the client a glass of water and mouthwash to rinse the mouth D.Label the container and place the container in a biohazard transport bag 42. After report, the nurse receives the laboratory values for 4 clients. Which client requires the nurse’s immediate intervention? The client who is… A.Short of breath after a shower and has a hemoglobin of 8 grams B.Bleeding from a finger stick and has a prothrombin time of 30 seconds C.Febrile and has a WBC count of 14,000/mm3 D.Trembling and has a glucose level of 50 mg/dL 43. 4 hours after administration of 20U of regular insulin, the client becomes shake and diaphoretic. What action should the nurse take? A.Encourage the client to exerc ise B.Administer a PRN dose of 10U of regular insulin C.Give the client crackers and milk D.Record the client's reaction on the diabetic flow sheet 44. The nurse is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage? A.Place a 4x4 wick in the stoma opening B.Apply a layer of zinc oxide ointment to the perimeter of the stoma C.Cut the bag opening to the measurement of the stoma size D.Administer a PRN antidiarrheal agent 45. Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?A . T e mp e r a t u r e o f 1 0 0 . 8 F B.A pulse rate of 150 beats per minute C.A respiratory rate of 10 breaths per minute D.A blood pressure of 180/110 46. Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. Which intervention should the nurse implement? A.Assess the client's hemoglobin to determine if the client is in shock B.Call the surgeon and prepare to take the client back to the operating room C.Outline the area with ink and check it q15 minutes to see if the area has increased D.No action is required since postoperative bleeding can be expected 47. The nurse is with a client when the healthcare provider explains that the biopsy classifies the results as aT1N0M0 tumor. Later in the morning, the client asks the nurse, "What do these letters T1N0M0, stand for?" Which response should the nurse provide first? A.“The letters are used to predict the prognosis of the cancer or tumor.” B.“The letters stand for tumor size, node involvement and metastasis.” C.“Let me refer you to the charge nurse.” D.“Are you confused? Would you like to talk?” 48. The nurse plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding? What information should the nurse provide this client? A.The client should bottle feed and pump her breast for 3 days following immunization B.The vaccine is given to produce maternal antibodies before lactation occursC.The infant will receive immunization through the mother's breast milk D.The client should not get pregnant for 3 months after immunization 49. In counting a client's radial pulse, the nurse notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse take? A.Recheck the radial pulse in thirty minutes B.Palpate the radial pulse for thirty seconds and double the rate C.Count the apical pulse rate for sixty seconds D.Compare the radial pulse rate bilaterally and record the higher rate 50. Which structures are located in the subcutaneous layer of the skin? A.Sebaceous and sweat glands B . M e l a n i n a n d k e r a t i n C.Sensory receptors and hair follicles D.Adipose cells and blood vessels 51. The nurse is in charge of a Nursing unit in a long term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients? A.Measure the amount of a client's residual urine after voiding B.Cleanse the perineal area of a client with urinary incontinence C.Insert a straight catheter to obtain a urine specimen for culture D.Provide catheter care for a client with a suprapubic catheter 52. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape in which direction to anchor the shield most effectively? A.Across the eye from the bridge of the nose to the right templeB.Longitudinally from the right forehead to the right cheek C.From the mid-forehead over to the right zygomatic process D.From the right lateral forehead surface to the medial nasal crease 53. 36 hours after delivery, the nurse determines a client's fundus is just above the umbilicus and displaced to the right of midline. What action should the nurse take first? A.Palpate the bladder for distension B.Ask the client when her last bowel movement occurred C.Catheterize the client and record the amount D . A s s e s s t h e a mo u n t o f l o c h i a 54. A client presents in the clinic because of generalized swelling after a bee sting. What intervention should the nurse implement first? A.Assess site of sting and remove stinger if present B.Perform mini-mental status exam to assess level of consciousness C.Determine respiratory status and apply a pulse oximeter D.Attach electrodes to monitor cardiac rhythm 55. The nurse is administering multiple medications to a 78-year-old client because of problems related topolypharmacy. At this client's age, which assessment is most important for the nurse to make? A.Cumulative serum drug levels and toxicity B.Synergistic actions due to simultaneous administration C.Tolerance to drugs that has been taken for long periods of time D.Antagonist actions of multiple medications 56. In obtaining an orthostatic vital sign measurement, what action should the nurse take first? A.Count the client's radial pulse B . A p p l y a b l o o d p r e s s u r e c u f f C.Instruct the client to lie supine D.Assist the client to stand upright57. A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What intervention should the nurse expect to implement to establish hydration in the immediate postoperative period? A.Diaper weights and urine specific gravity B.Gastronomy feedings in supine position C.Nipple feedings with glucose water D.Gavage feedings with 15 mL of formula 58. A urinary catheter (Foley) with a 5mL inflated balloon is being removed by the nurse. After withdrawing 5mLof fluid from the balloon, the nurse begins to withdraw the catheter while the client is in a Semi-Fowler's position. However, the nurse meets resistance and the client voices discomfort. What action should the nurse take next? A.Attempt to withdraw additional fluid from the balloon B.Assist the client in taking a series of deep breaths C.Lower the head of the client's bed so the client is supine D.Allow the client to rest before continuing to remove the catheter 59. The home health nurse observes an elderly male client attempt to open a child-proof medication container. When he is unsuccessful in opening the container, he throws it across the room and curses loudly. What action should the nurse implement? A.Transfer the medications to another bottle that is easier to open B.Leave the client's home immediately and plan to return later C.Ignore the outburst and demonstrate how to open the bottle D.Describe other types of medication containers that are available 60. At 7AM, a Diabetic client is conscious with a serum glucose level of 50mg/dL. To manage this client's care effectively, what should the nurse administer? A . O r a n g e j u i c eB . G l u c a g o n C . 1 0 u n i t s o f r e g u l a r i n s u l i n D.IV of 5% glucose in water at 100 mL/hr 61. A nurse is caring for a client with Multiple Sclerosis (MS) who is receiving an immunosuppressant. Which action is most important for the nurse to implement to evaluate for adverse effects from this particular medication? A.Observe the client's skin for bruising B.Auscultate the client's bowel sounds C.Monitor the client's intake and output D.Note changes the client's weight 62. A male client with Hypercholesterolemia is being discharged with a new prescription for simvastatin (Zocor).The client tells the nurse that he understands it is important to have liver tests performed periodically. How should the nurse respond? A.Instruct the client that the only regular testing needed is to monitor his cholesterol level B.Teach the client that liver tests are usually only done if the client reports symptoms C.Review with the client that renal function tests are needed, rather than liver tests D.Confirm that the client correctly understands the need to monitor liver function regularly 63. An obese female client with a high serum cholesterol level comes to the clinic for a follow-up evaluation. She tells the nurse that she is now walking 30 minutes three times per week and is eating a carbohydrate free, high protein diet in order to lose weight. What response is best for the nurse to provide? A.Explain to the client that her diet choice is not helpful in lowering cholesterol levels B.Discuss the importance of maintaining a target heart rate during each exercise period C.Teach the client additional ways to lower cholesterol, including stress managementD.Praise the client for her exercise and dieting efforts and encourage her to continue with this program 64. A child with Chronic Asthma is scheduled for Chest Physiotherapy. When should the nurse administer themeter-dosed inhaler (MDI) puff of bronchodilator relative to postural drainage treatments? A . B e f o r e p o s t u r a l d r a i n a g e B . D u r i n g p o s t u r a l d r a i n a g e C. After postural drainage D . B e t w e e n t r e a t me n t s 65. A client has a prescription for lorazepam (Avitan) 1mg for anxiety. The medication is supplied as 0.5mgtablets. How many tablets should the client take? (Enter numeric value only) 1mg / 0.5mg = 2 tab 66. The nurse is caring for a middle-aged male client who had a Myocardial Infarction (MI) 3 days ago. Which finding is most important for the nurse to report? A . F r o t h y r e d - t i n g e d s p u t u m B . I r r e g u l a r h e a r t r a t e C . T w o p o u n d w e i g h t g a i n D . D e p e n d e n t e d e m a 67. A client is diagnosed with Clostridium Difficile (CDIFF). What action should the nurse implement to prevent the spread of the organism? A. Place a surgical mask on the client during transport B. Don non-sterile gloves when performing direct care C. Wear a particular respirator mask when in the room D. Keep the door closed to the client's room at all times 68. A 67-year-old woman who lives alone tripped on a rug in her home and fractured her right hip. The nurse knows that which predisposingfactor contributes to the occurrence of hip fractures among elderly women. A.Urinary retention resulting in renal calculi formation B.Failing eyesight resulting in an unsafe environment C.Osteoporosis resulting from hormonal changes D.Transient ischemic attacks (TIAs) which impair mental acuity 69. An elderly client is admitted for evaluation of Alzheimer's disease. At 2AM, the nurse finds the client trying to open the emergency door. What is the most appropriate response for the nurse to make in this situation? A.“This is the emergency door. Are you looking for the bathroom?” B.“You look confused. Would you like to talk about your feelings?” C.“Let's go back to your room. Your doctor does not want you to be walking alone.” D.”You want to go outside at this time me of night? It's dangerous out there.” 70. Which nurse's behavior is a breach of client confidentiality according to the Health Insurance PortableAccountability Act (HIPPA) regulations? A.A daily report sheet with the information of the team's clients is taken home B.Privileged health information (PH) is mailed through the US postal service C.A client is called by both the first and last name in a public waiting room. D.The ambulance health care provider is given information about the client's history 71. A client is returning to the surgical unit after a total right knee replacement. Which assessment findings are most important for the nurse to include in this client's record?A.Pedal pulses, pallor, pain, paresthesia or paralysis B.Level of consciousness, lung sounds, and bladder tone C.Swallow reflex, nausea, and vomiting and IV infusion site. D.Call bell side rails, bed in position, and ambulation aids 72. The nurse is standing at the clinic desk when a mother and preschool child approach. The mother tells the nurse that her child has a fever and rash. What action should the nurse take? A.Take the child immediately to a different part of the clinic B.Have them wait in the waiting area away from the other children C.Tell the mother to return to the clinic when the rash subsides D.Place them firs on the list to see the healthcare practitioner 73. A nurse is contributing to a care plan for an adolescent female client with Anorexia Nervosa. Which outcome statement or goal would be most appropriate for this client? A.She will participate in a daily aerobic exercise program B.She will consume at least 50 percent of all meals C.Her laboratory values will remain within normal limits D.She will develop a positive body image and self-identity 74. A female client with no family history of Breast Cancer (BA) asks the nurse how often she should obtain a Mammogram. Which additional client information should the nurse obtain before answering this client's question? A . C u r r e n t a g e B . B r e a s t s i z e C . B r e a s t f e e d i n g h i s t o r y D . M e n o p a u s a l s t a t u s 75. the practical nurse working on the postpartum unit is assisting a new mother with her newborn’s diaper change. The mother state that the infant fed well and completed the while bottle of formula. Whataction should the PN implement first when the infant begins to spit up during the diaper change? A.Bubble or burp the infant by patting the infant's back B.Encourage the mother to avoid over feeding the infant C.Turn the newborn and bulb suction the mouth and nose D.Wipe away the secretions and finish the diaper change 76. An older male client tells the nurse that his religion does not permit him to bathe daily. How should the nurse respond? A.Review the importance of hygienic measures for improved health B.State that the healthcare provider has prescribed a bath today C.Offer the client several choices of times to bathe during the day D. Request that the client clarify his religious beliefs about bathing 77. A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the PN provide? A. Possible exposure to an environmental staphylococcus infection can infect the newborn's eyes and cause visualdeficits B. The newborn is at risk for blindness from a corneal syphilitic infection acquired from a mother's infected vagina C. Treatment prevents tear duct obstruction with harmful exudate from a vaginal birth that can lead to dry eyesin the newborn D. State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection 78. The scope of practice for the practical nurse includes which client assessment? A. An agitated client with bilateral wrist restraints B. New admission of a client with deep vein thrombosis C. Return of a postanesthesia client following a colon resectionD. Transfer of a client with sepsis from a long-term care facility 79. What skin care measure should the nurse implement for a client who underwent an external radiation treatment the previous day? A. Cleanse the radiated area with water and pat the skin dry B. Lightly massage the radiated skin with a lanolin-based lotion C. Rinse the site with normal saline and cover with a sterile towel D. Use a soft washcloth to gently remove the skin markings 80. Which organ lays retroperitoeally? A . K i d n e y s B . T e s t i c l e s C . U r i n a r y b l a d d e r D . P a n c r e a s 81. The nurse is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedulephysical exercises with the physical therapy department? A . B e f o r e b e d t i me , a t 2 0 0 0 B . A f t e r b r e a k f a s t C . B e f o r e t h e e v e n i n g me a l D . A f t e r l u n c h 82. The nurse is planning to ambulate a client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first? A. Place non-skid shoes on the client B. Show the client how to use the call light C. Use a gait belt to support the client D.Assist the client to a bedside sitting position 83. A client is admitted to the hospital with second and third degree burns to the face and neck. How should thenurse best position theclient to maximize function of the neck and face and prevent contracture? A.The neck extended backward using a rolled towel behind the neck B.Prone position using pillows to support both arms outward from the torso C.Side-lying position using pillows to support the abdomen and back D.The neck forward using pillows under the head and sandbags on both sides 84. A client receives a new prescription for the angiotensin II receptor antagonist losartan (Cozaar). Which client instruction should the nurse encourage this client to follow? A.Move slowly when getting up to prevent sudden dizziness B.Take this medication with or after meals C.Do not stop this medication until all of the tablets are gone D.Keep the dietary log during initial therapy 85. The healthcare provider prescribes erythromycin (Ilosone) 300 mg PO QID. The medication label reads,"Ilosone 100mg/5mL." How many mL should the nurse administer at each dose? (Enter the numeric value only) 300mg/100mg = 3mg X 5mL = 15mL 86. The nurse is monitoring a client with an IV infusion in the left antecubital fossae. The infusion pump is functioning without alarms at the prescribed rate of 100 mL/hour. The site is warm, red and without swelling. What conclusion should these findings indicate to the nurse? A.The IV fluids are infusing into the subcutaneous tissues and the pump should be stopped B.The infusion pump is functioning properly and the IV site is healthy C.The insertion date should be verified and the IV discontinuedD.The site is inflamed and should be reported to the RN for placement in another site 87. The nurse reviews the laboratory notiresults of a client whose serum pH is 7.38. On the pH scale, what does this value imply about the client's homeostasis? A . A l k a l o s i s B . A c i d o s i s C . N o r m a l s e r u m p H D . I n c o mp a t i b l e w i t h l i f e 88. The nurse plans to assess a newborn and to check the infant's Moro reflex. In assessing this reflex, the nurse is evaluating which parameter? A.Neurological integrity B . R e n a l f u n c t i o n i n g C . T h e r mo g e n i c r e g u l a t i o n D . R e s p i r a t o r y a d e q u a c y 89. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. To ensure that the task is safely delegated what action should the nurse implement? A.Inform the UAP that the suction is available at the bedside B.Instruct the UAP to notify the PN if the client begins to choke C.Observe the UAP's ability to implement precautions during feeding D.Ask the UAP about previous experience performing this skill 90. The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take? A.Ask the client why the bath was refused B.Ask family members to encourage the client to bathe C.Explain the importance of good hygiene to the client D.Reschedule the bath for the fo llowing day91. An adult female client is admitted to the psychiatric unit with a diagnosis of major depression. After 2 weeks of antidepressant medication therapy, the nurse notices the client has more energy, is giving her belongings away to her visitors, and is in an overall better mood. Which intervention is best for the nurse to implement? A.Tell the client to keep her belongings because she will need them at discharge B.Ask the client if she has had any recent thoughts of harming herself C.Reassure the client that the antidepressant drugs are apparently effective D.Support the client by telling her what wonderful progress she is making 92. In assisting a client perform pursed lip breathing, the nurse should ensure that the client performs which action? A. Inhale through the nose with the mouth shut and exhales through pursed lips B.Inhale through pursed lips then exhale with the mouth held open C.Inhale though pursed lips and then exhale through the nose with the mouth closed D.Inhale through the mouth puff the cheeks and exhale through pursed lips 93. A 3-year-old admitted with fever of unknown origin (FUO) has begun vomiting in the past half hour. The child's temperature is 101.8o F, and the last dose of antipyretic medication was given 5 hours ago. The child has prescriptions of acetaminophen (Tylenol) 160 mg per 5 mL elixir or 160 mg suppositories PRN fever or pain. What action should the nurse take at this time? A.Make the child NPO and hold all medications until the vomiting has stoppedB.Give acetaminophen elixir to ensure the child's cooperation with swallowing C.Notify the healthcare provider that the child's fever has become dangerously high D.Use an acetaminophen suppository for the fever since the child is vomiting 94. A client is having Radical Mastectomy. What is the position of choice during the immediate postoperative period? A.Side-lying on the operative side with the bed flat B.Supine with the arm on the operative side in a dependent position C.Semi-Fowler's position with the arm on the operative side elevated D.Sim's position with the arm on the operative side in a dependent position 95. The nurse assesses the perineum of a client 12 hours after a normal vaginal delivery and finds that she has Perineal Hematomas. The nurse should prepare for which treatment? A.Heat lamp three times per day B.Insertion of a vaginal packing C.Cold packs to the perineum D.Operative excision of the hematomas 96. A client at 28-weeks gestation is admitted to the antepartum unit and is being treated for preterm labor. She has a prescription for brethine (Terbutaline) 250 micrograms subcutaneously q4h. The medication is available for injection in 1 mg per mL vials. How many mL should the nurse administer? A . 0 . 0 2 5 B . 0 . 0 0 2 5 C . 0 . 2 5 D . 2 5 . 097. A school-aged child with AIDS is exposed to an active case of Varicella. The nurse should recommend that the family take which action? A.Obtain penicillin G 1000Uweekly B.Obtain the Varicella vaccine C.Enroll in a home school program D.Obtain the Varicella zoster immune globulin School child got the disease. Select all that applly. 98. The principle of client advocacy is best demonstrated when the nurse exhibits which behaviors on behalf of the client? A.Nurse who contracts child protective services to report a mother's decision to refuse vaccination for herfirstborn infant B.Nurse refusing to care for a convicted rapist stating that personal discomfort would inhibit provision of qualitycare C.Nurse who translates complaints for a Spanish-speaking client to the healthcare provider during rounds D.Nurse sharing information about life after death with a grieving family who just lost a loved one 99. The nurse is preparing a client for an Intravenous Pyelogram (IVP) scheduled for the following morning. What action is most important for the nurse to implement? A.Determine if the client has any allergies to shellfish B.Inform client that an IV dye will be administered before the IVP C. Explain that dizziness may occur when the dye is given D.Administer a bowel prep the evening before the procedure 100. A nurse refuses to perform a procedure because it is beyond the scope of practice for practical nurses. Which resource best defines the nurse’s legal responsibility in regard to scope of practice?A.Nursing Practice Standards for Licensed Practical/Vocational Nurses B.State Nurse Practice Act C.Code of Ethics for Licensed Practical/Vocational Nurses D . P a t i e n t ' s B i l l o f R i g h t s 101. While making the bed of a female client who is sitting in the bedside chair, the nurse observes the client seems anxious. To encourage verbalization by the client, what action should the nurse take? A.Continue to make the bed while conversing with the client B.Sit next to the client at a slight angle to continue the conversation C.Remain standing close enough to the client to hold her hand D.Bring a chair face-to-face with the client for further discussion 102. A client is admitted for observation after experiencing a Transient Ischemic Attack (TIA). The nurse anticipates implementing care for which client problem? A . H i g h r i s k f o r i n j u r y B.Altered breathing patterns C.Ineffective airway clearance D . H i g h r i s k i n f e c t i o n 103. An elderly postoperative client has the Nursing diagnosis, "Impaired mobility related to fear of falling." Which desired outcome best directs Nursing actions for this client? A.The physical therapist will instruct the client in the use of a walker B.The nurse will place a gait belt on the client prior to ambulation C.The client will ambulate with assistance q4h D.The client will use self-affirmation statements to decrease fear104. A female client complains to the nurse about being admitted to a semi-private room and expresses her displeasure because she requested a private room prior to admission. What response is best for the nurse to provide this client? A.Room assignments are based on client's acuity level, not necessarily by request B. I will place your name on the room request list for the next available private room C.Your healthcare provider must provide a written request to get you a private room D.There are no private rooms available, so you will have to stay her for the time being 105. During preoperative preparation, the nurse should offer the client which explanation about why deep breathing exercising with an incentive spirometer are necessary after surgery? A."Deep breathing exercises using the spirometer will help prevent postoperative complications." B."Failure to keep your lungs working may result in pneumonia and death." C."Incentive spirometry is uncomfortable but necessary for you postoperative care." D."You will use the spirometer for the first postoperative day only." 106. The nurse is caring for a client who had a total Laryngectomy, Left Radical Neck Dissection, and tracheostomy. The client is receiving Nasogastric (NG) tube feedings via an enteral pump. Today the rate of the feeding was increased from 50 mL/hr to 75mL/hr. What parameter should the nurse use to evaluate the client's the client's tolerance to the rate of the feeding? A . B o w e l s o u n d s B . U r i n a r y a n d s t o o l o u t p u t C.Gastric residual volumes D . D a i l y w e i g h t107. A client is admitted with a fever of undermined origin (FUO). During rounds, the nurse finds the client diaphoretic, and the linens are damp. What should the nurse do first? A.Change the bed linen to prevent chilling B.Check the client's vital signs and pain scale C.Assess the client for urinary incontinence D.Determine fluid intake for the past 8 hours 108. Which client should the nurse assign to an unlicensed assistive personnel (UAP)? A. An older male client with melena who is complaining of abdominal pain and needs a guaic test of a stool sample B.A young adult experiencing flank pain and hematuria who needs all urine strained for stones C.A client who has a regular heart rate after a pacemaker replacement and now needs to ambulate D. An elderly client with Right-Sided Hemiplegia and Receptive Aphasia who needs to be transferred to the wheelchair 109. The nurse is administering the shingles vaccine to an older male client who asks why he should receive the immunization. Which information should the nurse provide? A.A history of chickenpox indicates that he harbors the dormant virus B. The client's last dose of adult immunizations was 10 years ago C.A recent outbreak of fever blisters indicates reactivation of the virus D.Multiple stressful personal experiences increase his risk of shingles 110. In preparing a client for a lumbar puncture, what action should the nurse implement? A.Assist the client to the bathroom to voidB.Apply a pulse oxi meter to the client 's finger C.Teach the client to cough and deep breathing exercises D.Ensure that the client has been NPO for six hours 111. A client who had a Lobectomy two days ago has 2 chest tubes, each attached to a water-sealed drainage system, Pleur-Evac. The nurse observes that in the last 8 hours the serosanguineous fluid has diminished to output in the drainage chamber. What is the most likely outcome of this observation? A.Removal of the lower chest tube, if a chest x-ray reveals no pleural accumulations B.Change the Pleur-Evac system and re-assess output in the empty chamber C.An increase in the prescribed suction force to facilitate drainage of serosanguineous fluids D.Advance the chest tube to ensure proper placement of the tip to enhance drainage 112. While caring for a client who has been vomiting, the nurse notes that the client's breath has developed a fruity odor. What assessment should the nurse perform first? A.Auscultate the client's bowel sounds B.Determine the client's capillary glucose C.Observe the color of the client's urine D.Measure the client's oxygen saturation 113. The nurse is preparing to assist an elderly client to the bathroom. The nurse knows that an elderly adult's center of gravity changes from the hips to another area of the body. Which area of the body is the center of gravity for the elderly client? A . U p p e r t o r s o B . H e a d C . F e e t D . U p p e r e x t r e m i t i e s114. A 60-year-old client with cancer of the liver is in a Hepatic Coma and unresponsive. What should the nurse say to family members who are inquiring about the condition of their loved one? A.“Your loved one's condition is very critical, and there has been no response in the last 24 hours.” B.“The nurses have not been able to arouse the client and the healthcare provider knows the outcome.” C.“You need to discuss the condition with the charge nurse in a family conference.” D.“The client's condition is extremely critical. Has your family made funeral arrangements?” 115. A client complains of kidney pain. The nurse understands that the kidneys are located where? A.On the retroperitoneal posterior abdominal wall at the costovertebral angle B.Within the curve of the duodenum, posterior to the spleen C.Lateral to the stomach in the hypochondriac region D.Superior aspect of the bladder in right and left iliac region 116. The nurse receives report on an adult client who has a central intravenous (IV) infusion. Where should the nurse observe when assessing the integrity of the access site? A.Umbilical area of the abdomen B.Antecubital fossae of the arm C.Chest wall below the clavicle D . D o r s a l s u r f a c e o f t h e h a n d 117. The healthcare provider prescribes an IV solution of clindamycin (Cleocin) 850mg in 75mL of D2W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/minute?(Enter numeric value only. If rounding is required round to the nearest whole number) 75mL X 15gtt/mL = 38mL118. The nurse is administering a subcutaneous injection of epoetin (Epogen) to a client with Chronic Kidney Disease (CKD). This medication is being administered to treat which manifestation of CKD? A . A n e m i a B . A n u r i a C . H y p e r t e n s i o n D . E d e m a 119. The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. Prior to administering medications to this resident, what is the best Nursing action? A.Confirm the room and bed numbers will those on the medication record B.Ask a regular staff member to confirm the resident’s identity C.Hold the medication until a family member arrives D.Re-orient the resident to name, place and situation 120. The nurse is assessing an older male client with Gastritis. He has been unable to eat for the past 48 hours and has been vomiting during this same period of time. Which finding can the nurse expect this client to exhibit? A.Edematous lower extremities and an increased temperature B.A decreased temperature and increased blood pressure C.Dry skin and an increased heart rate D.Diaphoresis and hypertension 121. An adult male client tells the nurse that he believes someone is trying to obtain his computer records, which his wife reports are recreational in nature. The client insists that an elaborate alarm system needs to be installed in his home. The nurse knows that this client is exhibiting which sign or symptom? A.Delusions of persecutionB . I d e a s o f r e f e r e n c e C . H a l l u c i n a t i o n s D . C o n f a b u l a t i o n 122. The nurse enters a client's room to perform a sterile dressing change. The nurse observes that the client is"gurgling" on oral secretions and coughing. Which action should the nurse first take? A . P o s i t i o n t h e c l i e n t s u p i n e B . F i n g e r s w e e p t h e o r a l c a v i t y C.Perform oral suctioning D . P r o v i d e mo u t h c a r e 123. What length of blood pressure cuff should the nurse use when obtaining a client's blood pressure? A.A cuff that is longer than the circumference of the extremity should be used B.The length of the blood pressure cuff does not make a difference C.The cuff and its bladder should nearly encircle the extremity's circumference D.At least two-thirds the circumference of the extremity should be covered 124. A nurse is assisting a client from the bathroom back to bed following a minor surgical procedure. The client, still not fully alert, reports feeling nauseated and begins to vomit. What is the first action the nurse should take? A.Place a cool rag on the client's head B.Suction the client's oral cavity C.Provide the client an emesis basin D.Place the client in a side-laying position 125.The nurse is caring for a 10-year-old child with Hemophilia who has recently been diagnosed as HIV positive. What precautions should the nurse take when interacting with the child and mother?A.No special precautions are needed B . W e a r g l o v e s o n l y C . W e a r g l o v e s a n d a ma s k D.Wear a mask, gloves and gown 126.A 26-year-old prima gravida who delivered a 7-pound male infant 26 hours ago tells the nurse that she is confused about when she and her husband can return to having sexual intercourse. What info should the nurse reinforce with this client? A.They can have intercourse when the episiotomy is healed and the lochial flow has stopped B.They should wait to resume sexual activities until the fatigue assorted with a new baby has passed C.They can resume sexual activity at 6 weeks postpartum D.It is best to wait until both parties feel up to having sexual intercourse 127. The healthcare provider tells the family of a 6-year-old child with a malignant brain tumor that the tumor is metastasizing and the child's condition is terminal. How can the nurse best help the family cope with this news? A.Refer the family to a support group to find answers to their questions B.Reinforce the stages of the grieving process C.Listen to the family's reactions and reflect on their fears and concerns D.Transfer the child to a private room 128.The nurse is implementing the plan of care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the client acting on these suicidal thoughts? A.Describes being very depressed B.Has little appetite and neglects personal hygiene C.Is not interested in the activities of family and friends D.Begins to show signs of improvement129.On a short-staffed unit of a long-term care facility, it is most important that the nurse assign the unlicensed assistive personnel (UAP) to complete morning care for the resident with which problem first? A.Dyspnea who uses oxygen continuously B.Straight catheterization to be performed q6h C.Frequent episodes of fecal incontinence D.Bolus feedings via PEG tube to be performed q4h 130.The nurse assesses a client receiving a hypertonic full strength tube feeding that is infusing continuous at 50mL/hr. Which finding is most important for the nurse to report to the charge nurse? A . D r y m u c o u s me mb r a n e s B . G a s t r i c r e s i d u a l o f 5 0 mL C.Report of increased hunger D . H y p e r a c t i v e b o w e l s o u n d s 131.A male client who was admitted with Gangrene of the right lower extremity (RLE) is confused, and his wife refuses to sign the operative permit for an above the knee amputation. What action should the nurse take next? A.Explain the consequences of Sepsis if the amputation is delayed B.Notify the RN that the client's wife needs further explanation about the procedure C.Document on the client record the refusal for surgical treatment D.Encourage the client's wife to express concerns about making the decision 134.A male client attends a community support program for mentally impaired and chemically abusive clients. The client tells the nurse that his drugs of choice are cocaine and heroin. What is the greatest health risk for this client?A . H e p a t i t i s B . H y p e r t e n s i o n C . D i a b e t e s D . G l a u c o m a 135. The nurse is caring for a group of clients on a postpartum unit. After shift report, which client should the nurse assess first? A.Gravida 6 Para 4 who delivered vaginally 24 hours ago B.Gravida 1 Para 0 who is not having contractions C.Gravida 3 Para 3 who delivered vaginally 2 hours ago D.Gravida 1 Para 2 who is preparing for discharge 136.A client returns to the unit following a cardiac catheterization with a Femoral Artery Access. Which objective criteria is most important for the nurse to obtain immediately upon the clients return? A . P u p i l r e s p o n s e s t o l i g h t B . P e d a l p u l s e s C . R e s p i r a t o r y r a t e D . P e r i p h e r a l m o b i l i t y 137.An elderly female client tells the nurse that she does not do regular Breast Self Examination (BSE) because she is too old. The nurse’s response to the client is based on what information? A.The incidence of breast cancer increases with age B.The client should have a health care provider do a breast exam at least once a year C.After age 70, breast cancer is less likely to occur D.The history of breast cancer in a family member is indicative of the need for BSE 138. A client with Meningitis is in a coma and Nursing care includes seizure precautions. To help prevent seizure activity, what intervention should the nurse implement? A.Maintain an oral airway suction equipment and oxygen at the bedsideB.Provide respiratory isolation precautions for visitors and staff C.Provide emergency anti convulsant medication at the bedside D.Maintain a quiet calm darkened environment 139. The nurse is assisting a female client to obtain a voided specimen for urine culture. After the client cleanses the meatus, which intervention is performed next? A . I n i t i a t e t h e u r i n e s t r e a m B . S e p a r a t e t h e l a b i a C.Position the collection cup D . O b s e r v e t h e u r i n e 140. A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse identifies that an unlicensed assistive personnel (UAP) has omitted a vital component of the protocol. After implementing the missing component, what should the nurse take? A. Report the UAP's omission to the charge nurse B.Complete an unusual occurrence report C.Supervise the UAP after reviewing the protocol D.Assign the UAP to more stable clients the next day 141. What is the best intervention for the nurse to implement when providing morning care for an ambulatory client with an indwelling catheter (Foley)? A.Keep the catheter intact while assisting the client with a shower B.Remove the catheter while the client takes a shower C.Provide the client with a sponge bath in a chair or the bed D.Assist the client with a tub with the catheter clamped 142. Based on the Nursing diagnosis of, "Risk for Infection," which intervention should the nurse implement when providing care for an elderly client with Urinary Incontinence? A.Maintain standard precautionsB.Utilize an antibacterial perineal wash C.Insert an indwelling urinary cath eter D.Initiate contact isolation precautions 143. The charge nurse brings a #18fr urinary catheter (Foley) with a 30mL balloon to the nurse who is preparing to insert a catheter in a female client who weighs 50 kg. What action should the nurse take first? A.Ask the client if she has previously been catheterized B.Position the client and observe the urinary meatus C.Obtain a 30 ml syringe and a vial of sterile water D.Consult with the charge nurse about the catheter 144. An 82-year-old client is admitted to the hospital with a fractured right hip. Following surgical repair, a footboard is placed at the client's feet. What is the reason the nurse will offer concerning the footboard? The footboard is used to… A . p r e v e n t f o o t d r o p B . p r e v e n t h i p d i s l o c a t i o n C . p r o mo t e mo v i n g i n b e d D.promote early ambulation 145. Following a left leg above the knee amputation (AKA), a client voices several complaints. Which statement should be reported to the charge nurse immediately? A . M y l e f t f o o t i s s o p a i n f u l B . M y i n c i s i o n i s s o d r y C.I've been feeling so light headed D.I'm tired of turning so much 146. In caring for a client following a below the knee amputation (BKA) which task is best for the nurse to delegate to the unlicensed assistive personnel (UAP) who is assisting with the care of this client? A.Empty and measure the drainage in the suction drainage deviceB.Reassure the client that phantom limb pain is genuine pain C.Review the client's vital signs for indications of infection D.Observe and mark the amount of drainage on the dressing 147. 2 days after an abdominal hysterectomy, an elderly client with Diabetes Mellitus Type II has a syncopal episode. Her vital signs are within normal limits, but her sugar is 325 mg/dL. What intervention should the nurse implement first? A.Give the client 4 ounces of orange juice B.Administer next scheduled dose of metformin (Glucophage) C.Cancel the client's dinner tray D.Administer regular insulin per sliding scale 148. A client returns to the postoperative unit following an open reduction and internal fixation of a hip fracture. The practical nurse applies the prescribed sequential compression device (SCD) to both lower extremities. (BLE).What action is important when turning the client to a lateral position? A.Decrease the amount of pressure exerted on both legs while turning the client B.Replace the SCDs with antiembolic stockings while using an abduction pillow C.Remove both of the SCDs while the client is turned to the lateral position D.Observe the SCDs continue to inflate and deflate when the client is turned 149. When the nurse asks a male client with Bipolar Disorder if he is going to group session, he responds, "There is no use in me going to that group because all they talk about is Schizophrenia, which doesn't apply to me." Which response is best for the nurse to provide to this client? A. “Tell me what medications you are taking right now.” B.“You are probably right. The group really does not apply to your condition.”C.“It sounds to me like it may be better for you that you stay here.” D.“Let's talk about what you may have in common with the other group members.” 150. A client is admitted with a newly diagnosed case of active tuberculosis (TB). Which intervention should the nurse teach the client about controlling transmission of Tuberculosis (TB)? A.Proper disposal of tissues when coughing B.Importance of an adequate diet C.Complications of the disease D.Side effects of anti-tubercular medications 151. During CPR, when attempting to ventilate a client's lungs, the nurse notes that the chest is not rising. What action should the nurse take first? A. Reposition the head to ensure an open airway B. Inflate the lungs with more breaths and air pressure C. Finger sweet for a foreign body lodged in the oral cavity D. Reposition hands on chest and continue compressions 152. After a change of shift report, the nurse makes rounds on a postoperative unit. Which client finding necessitates the immediate attention of the nurse? A. A client who is having bright red drainage from the rectum following a colonoscopy with polyp removal B.A client who has pink urine draining from the indwelling urinary catheter following a transurethral prostatectomy C.An older client whose blood pressure is 100/70 after receiving meperidine for pain related to a hip fracture D.A client who has brown green bile draining from a T-tube after a Cholecystectomy for Cholelithiasis 153. Augmentin (amoxicillin/clavulanate) 500mg suspension is prescribed for an older adult client who has trouble swallowing. Thesuspension is available in 125mg/5mL solution. How many ml should the client receive? (Enter the numeric value only) 500mg/125mg X 5mL = 20mL 154. The nurse observes that there are secretions in the air vent lumen of client's double lumen Nasogastric tube (NGT). Which action should the nurse implement? A.Instill 20 mL of air into the second lumen B. Irrigate the primary lumen with 20 mL of saline C. Place the client in a High Fowler's position D. Turn the suction device to continuous suction 155. Which pediatric client is most likely to experience a disturbed body image? A.10-year-old with plantar warts B.14-year-old with acne vulgaris C.16-year-old with a perineal tinea infection D.12-year-uld with bacterial cellulitis 156. The first day after a cesarean section ( C-Section), when being assisted to the bathroom for the first time, a primavera client experiences a sudden gush of vaginal blood and notices that several blood clots are in the toilet. What action should the nurse take? A.Insert an indwelling catheter to empty the bladder and contract the fundus B.Return the client to bed and maintain bed rest until the lochial flow slows C.Check fundal consistency and continue to monitor the lochial flow amount D.Massage the fundus and avoid direct pressure on the cesarean incision 157. The nurse is emptying the bedpan of a client with a bleeding gastric ulcer. What type of stool can the nurse expect this client to have…A . B l a c k t a r r y s t o o l B . C o f f e e - g r o u n d s t o o l C . B r i g h t r e d b l o o d y s t o o l D . C l a y - c o l o r e d s t o o l 158. Which structure of the tracheobronchial tree is the most likely to compromise air passage when the smooth muscle layer is affected? A . S e c o n d a r y b r o n c h i B . B r o n c h i o l e s C . S e g m e n t a l b r o n c h i D . a l v e o l a r d u c t 159. The nurse is administering routine medications to an assigned group of elderly clients at an extended care facility. Which physiological change commonly associated with aging, increases the elderly client's risk of having an adverse response to the medication? A.Decreased gastrointestinal motility B . P o o r c o g n i t i v e f u n c t i o n C.Poor peripheral circulation D . D e c r e a s e d m o b i l i t y 160. A client with diabetes is admitted with a 1cm size ulcer on the left great toe. The nurse observes that the left foot has a dusky color. In planning the client's care, which intervention should the nurse implement first? A.Bathe the wound daily with soap and water B.Record the color and temperature of the leg C.Perform dorsal flexion and extension exercises D.Check the client's dorsalis pedis and posterior tibialis pulse point 161. An ambulatory client with an indwelling urinary catheter (Foley) is requesting to take a shower for the first time. What is the best intervention for the nurse to implement?A.Clamp the catheter and assist the client with a tub bath B.Keep the catheter intact and assist the client with a shower C.Encourage the client to do self-care and provide personal care products D.Assist the client with a sponge bath in a chair or the bed 162. The nurse overhears a conversation between an unlicensed assistive personnel (UAP) and another staff member in the hospital cafeteria line concerning a client's reaction to being given a diagnosis of terminal cancer. What is the best Nursing action? A.Approach the individuals involved and ask them to stop B.Write an incident report and submit it to the unit manager C.Tell the client of the UAPs concern for him D.Try not to listen to the conversation since it is confidential 163. During the past 30 days an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of the daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the nurse take? A.Withhold any medications that may cause these side effects B.Motivate the client by offering favorite foods as a prize C.Ask the family members to visit more often to stimulate the client D.Record the findings and report the symptoms to the charge nurse 164. A client is receiving nitroglycerin sublingual tablets for angina. What response should the nurse expect the client to manifest in response to the administration of this drug during an acute anginal episode? A.Pulse oximetry within normal limits B.Cessation of acute chest pain C . H y p e r t e n s i o n a n d h e a d a c h e D.Premature ventricular contractions (PVC)165. After a client returns from Hemodialysis, the nurse measures the client's weight and notes a 3-poundweight loss from the predialysis weight. The client reports feeling weak and fatigued. What action should the nurse take next? A.Measure the client's blood pressure B.Auscultate the client's breath sounds C.Observe the client's legs for edema D.Determine the client's blood glucose 166. When providing oral care to an unconscious client who is a mouth breather and does not swallow, which action is most important for the nurse to implement? A.Use an oral suction catheter in the buccal cavity B.Inspect the oral cavity using gloves fingers C.Perform oral cleansing with a sponge toothette D.Apply a petroleum based lubricant to the client's lips 167. Wrist restraints were applied to a client who was severely agitated and disoriented. In monitoring the client, who is now asleep, which finding should be reported to the charge nurse? A.Respiratory rate decreases from 22 to 16 per minute B.Radial pulse volume decreases from +3 to +1 C.Blood pressure decreases from 130/84 to 120/76 D.Apical pulse rate decreases from 94-84 per minute 168. The nurse is providing wound care for a client with a stage III pressure ulcer on the left heel. To achieve the goal, "An increase in granulation tissue will develop within 2 weeks," which intervention should the nurse implement? A.Remove heel protector every two hours B.Irrigate wound with sterile normal saline C.Replace dry sterile dressings as needed D.Apply heat for 15 minutes three times daily169. A client's chief complaint is being able to swallow only small bites of solid food and liquid's for the last 3months. The nurse should assess the client for what additional information? A.History of alcohol and tobacco use B.Average daily consumption of hot beverages C.Past traumatic injury to the neck D.Daily dietary roughage intake 170. The care plan for a male client with amyotrophic lateral sclerosis includes the Nursing diagnosis, "Decisional conflict related to concerns about mechanical ventilation." When assigned to care for this client, what intervention should the nurse implement based on this diagnosis? A. Provide an opportunity for the client to meet with survivors of the disease who have undergone mechanical ventilation B. Remind the client that a mechanical ventilator is usually only needed for a short period of time C. Ask the hospice nurse to visit with the client to discuss his options for care if he chooses not to undergo mechanical ventilation D. Encourage the client to discuss his feelings and concerns related to the use of mechanical ventilation 171. The client with Pruritus has a presentation for 25mg diphenhydramine (Benadryl) IM. The medication is available in a 50 mg/mL vial. How many mL should the nurse administer to the client? (If rounding is required, round to the nearest tenth. click the chosen location on the syringe calibration. To change, click on the new location.) 25mg/50mg X 1mL = 1.5 or ½ 172. What is the function of neutrophils? A . H e p a r i n s e c r e t i o n B . T r a n s p o r t o x y g e n C . P h a g o c y t o t i c a c t i o nD . A n t i b o d y f o r m a t i o n 173. Which membrane lines the abdominal cavity? A . P e r i n e u m B . P e r i c a r d i u m C . P l e u r a D . P e r i t o n e u m 174. A man who was brought to the psychiatric hospital by the sheriff because he was hallucinating and stumbling on a downtown street, refuses to wait for a psychiatric evaluation. Which action should the nurse take? A.Tell the man when the evalua tor will see him B.Alert the staff to monitor exits to prevent escape C.Warn the client that he is likely to have a seizure D.Offer a hot meal a clean bed and a sleeping pill 175. The nurse is assessing care for residents on a 12-bed unit in an extended care facility. The staff consists of 1unlicensed assistive personnel (UAP) and 1 certified medication aide. Which task should the nurse perform? A.Ambulate the client who has left hemiplegia and uses a cane B.Administer medications and formula to a client with a gastronomy tube C.Change a hydrocolloid dressing for a client with a stage II pressure ulcer D.Provide self-catheterization equipment for a client with paraplegia 176. A client is diagnosed with terminal cancer and tells the nurse, "The doctor told me I have cancer and do not have long to live." Which response should the nurse offer? A.“Would you like me to call your chaplain?” B.“There's always hope. Don't give up.” C.“That's correct, you do not have long to live.” D.“Yes, your condition is serious.”177. The nurse is reviewing the discharge medication instructions with a client for disulfiram 10mg (Antabuse).Which instruction should the PN reinforce with the client? A.Avoid all sources of alcohol while taking this drug including cough syrups B.The medication should be taken at the same time each day C.Stop the drug if nausea, vomiting and/or prostration occur D.Have weekly blood tests to determine therapeutic drug levels and serum sodium 178. The nurse is preparing a client for a bone marrow aspiration. Which erythropoietic site is most likely to be used to obtain the specimen? A . V e r t e b r a e B . R i b s C . C r a n i a l b o n e s D . I l i a c c r e s t 179. A male client admitted the morning of his scheduled surgery tells the nurse that he drank a glass of water during the night. What intervention will the nurse implement first? A.Auscultate the client for bowel sounds and ability to urinate B.Determine the amount of water and exact time it was taken C.Notify the healthcare provider of the client's fluid intake D.Reassure the client that a small amount of water is not harmful 180. The nurse is providing care for a client receiving an intravenous antibiotic to treat an infection. Which assessment findings require the most immediate action by the RN? A.Warm skin with elastic turgor B . D r y mo u t h w i t h t h i r s t C.Low grade fever with diaphoresis D . H i v e s w i t h p r u r i t u s181. The nurse should perform oral suctioning for a client with what problem? A . A t e l a c t a s i s B . D y s p h a s i a C . G a s t r i c r e f l u x D . D y s p h a g i a 182. An elderly client at an adult daycare center with Type2 Diabetes Mellitus becomes unresponsive verbally and then tells the nurse, "I just don't feel right" Which initial action should the nurse take? A . A s s e s s t e m p e r a t u r e B.Evaluate deep tendon reflexes C.Give 4 ounces of apple juice D.Administer glucagon 0.5mg IM 183. The nurse is working at a family planning clinic. Under which circumstance should the client who is taking oral contraceptives for birth control be told to use additional protection? A.When taking antibiotics for an infection B.For 6 months while breastfeeding C.If she has an elevated serum cholesterol D.During the first 3 months postpartum 184. A 75-year-old male client with Alzheimer’s Disease (AD) is admitted to an extended care facility. What intervention should the nurse include into his client's Nursing care plan? A.Describe the activities available to the residents and encourage him to choose the ones he prefers B.Introduce the client to the Nursing staff and the residents as soon as possible C.Plan to have the same Nursing staff provide care for the client whenever possible D.Encourage the client to remain on the unit for 3 weeks until he is oriented to his new surroundings185. A newborn infant with a tracheoesophageal repair is receiving Gastrostomy (GT) feedings postoperatively. What intervention should the nurse implement during the GT feedings? A.Offer a pacifier during the feedings to satiate the sucking reflex associated with feedings B.Flush the GT with 50mL of water and clamp the GT to prevent leakage C.Place the infant in the right lateral position to facilitate gastric emptying D.Burp the infant after each 10mL of formula administration and re-feed any volume that is spit up 186. Which intervention is within the scope of practice for a nurse? A.Demonstrating deep breathing and coughing to postoperative client B.Teaching the use of glucometer to a newly diagnosed diabetic client C.Presenting support options that are available to those with cancer D.Discharge teaching about newly prescribed medications 187. The nurse is preparing a client for a mammogram. What instructions should the nurse provide the client? A.Do not exercise the upper body on the day of the procedure B.Avoid taking aspirin for one week prior to the procedure C.Avoid eating or drinking 6 hours prior to the procedure D.Do not use underarm deodorant on the day of the procedure 188. An older client is transferred to the rehabilitation unit with the diagnosis of Cerebrovascular Accident (CVA)with left sided hemiplegia. The nurse addresses the client from the right side, and the client points to the left legend states, "There is a leg in my bed!" What is the best response by the nurse?A.“Your stroke has impaired your ability to recognize your paralyzed leg.” B.“Look at your legs and you will see that they both belong to you.” C.“Please explain to me what you thing happened to your leg.” D.“I know you think there is an extra leg in your bed, but I do not see it.” 189. Which technique should the nurse use to give a Z-track intramuscular injection? A.Ensure that no air is present in the syringe B.Inject the medication into the dorsal gluteal site C.Select a 22-gauge, 1 inch needle for injection D.Massage the site for 2 minutes after the injection 190. The nurse observe that the IV catheter is no longer in a client's arm. It is on the bed, and the sheets are moist with IV fluid. The client is disoriented and states he does not remember pulling the catheter out. How should the nurse document this situations? A.Client does not remember pulling out the IV B.IV catheter found lying on bed sheets C.IV catheter pulled out by disoriented clien t D.IV discontinued and wet sheets changed 191. The nurse identifies several findings in an older female who is on prolonged bed rest. Which finding requires prompt action by the nurse? A.Heart rate increases of 10 beats per minute B.Bowel movements decrease to 1 every third day C.Urinary output decreases of 250mL in the last 24 hours D.Systolic blood pressure decrease of 10mmHg 192. A nurse sees a colleague taking drugs from the hospital unit. What action should the nurse take?A.Report the incident to the person in charge of the unit or Nursing supervisor B.Notify the hospital security staff to retrieve the drugs from the colleague C.Report the colleague to the peer review committee of the hospital D.Confront the colleague and tell him/her to take the drugs back to the unit 193. Which term describes 2 or more tissues that compose a structure and perform a specific function? A . E l a s t i c t i s s u e B . O r g a n C . S y s t e m D . S e r o u s m e m b r a n e 194. How many mL should the nurse document when calculating a client's 8-hour fluid intake? (Enter the numeric value only.)0730 - 4 ounces of orange juice, hardboiled egg, and toast1130 - 1/2 cup of soup, one half sandwich, and 1/2 cup of apple juice1300 - vomitus of 100 mL1400 - voided 250 ml and consumed one 12-ounce can of soft drink(type your answer in the box below) =720 1oz = 30mL; so 4oz of orange juice X 30mL = 120mL of orange juiceThen 1 cup = 240; so ½ cup is 120mL of soup and ½ cup of apple juice is 120mL of apple juice = 240mL total vomitus is output, not intake, so ignore voided is output, not intake, so ignore 1 oz = 30mL; so 12oz is 12oz X 30mL = 360mL add them all; 120mL + 240mL + 360mL = 720mL 195. A male client is receiving ferrous sulfate (iron), docusate sodium (Colace) and codeine. He reports that his last bowel movement was 3 days ago. During medication administration, which action should the nurse implement? A.Offer the client a full glass of waterB.Give medications 2 hours apart C.Provide a snack with the medications D.Administer only the docusate sodium 196. The nurse is caring for a prima gravida 5 hours after a vaginal delivery. Which finding should the nurse report immediately to the charge nurse? A.Pulse rate of 90 beats/minute B.Rubor lochia saturating 3 perineal pads per hour C.Complaints of perineal pain D.Firm fundus between umbilicus and the symphysis pubis 197. A client with recurrent urinary tract infections (UTI) is being discharged. What instruction is appropriate for the nurse to include in the discharge teaching plan? A.Drink 3 quarts of w ater daily B.Avoid swimming in public pools C.Avoid intercourse until all antibiotics have been taken D.Drink 3, 6-ounce cans of cranberry juice daily 198. Which criterion is best for the nurse to use when evaluating a client's response to an analgesic that was administered for postoperative pain? A.Amount of medication required to relieve pain B.Activity without guarding or grimacing C.Objective parameters of blood pressure and respirations D.Subjective score on a 1 to 10 pain scale 199. A client is diagnosed with Pericarditis after a Myocardial Infarction (MI) and asks the nurse, "Why did this happen?" What explanation should the nurse offer? A. The sac surrounding the heart has become inflamed from the cells damaged by the heart attack B. The space around your heart is filling with fluid and your healthcare provider will have to explain the treatmentC. The heart cells have been infiltrated by organisms and a secondary autoimmune reaction has occurred D. This is an infection of the lining of the heart caused by bacteria entering through your gums 200. In describing the "at risk" individual for developing Breast Cancer, the nurse should recognize that which client is at the highest risk? The woman who is… A.a 40-year-old African American with Hypertension (HTN) B.a 35-year-old with trauma to the breast C.a 32-year-old whose mother had breast cancer D.a 50-year-old Caucasian who has never had a mammogram 201. What technique should the nurse use to administer a medicated ophthalmic ointment? A.Massage the lashes with the excess ointment that is squeezed out when shutting the lids B.Place a thin ribbon of ointment into the lower conjunctival sac from the inner to outer canthus C.Pull both upper and lower lids apart to drop the ointment onto the anterior surface of the eye D.Wear gloves when placing the tip of the ointment tube in the center of the lower lid 202. A client is using an incentive spirometer on the first postoperative day after an inguinal Herniorrghaphy. The nurse should re-teach the proper use of the spirometer when the client demonstrates what action? A.Using a tight seal around the mouth piece B.Exhaling slowly after two seconds C.Blowing forcefully into the mouthpiece D.Sitting upright during treatment 203. An 8-year-old recovering from a Celiac Crisis requests a bowl of cereal for breakfast. Which cereal should the nurse provide?A . C o r n f l a k e s B . G r a n o l a C . O a t m e a l D . W h e a t p u f f s E . R i c e 204. The nurse assumes care of a client who was admitted earlier in the day for a scheduled Hysterectomy in the morning. Which recorded assessment data obtained by the admitting registered nurse is objective? (Select all that apply). A . A n e m i a B . M e n o r r h a g i a C . T i r e d n e s s D.Orthostatic hypotension E . F e a r F . N e r v o u s n e s s 205. The nurse empties a large amount of serous drainage from a postoperative client's Hemovac drain. In what order should the nurse implement these procedures? (Place the first action on top and the last action on the bottom.) Compress drain… close drain… discard drain… document 206. The nurse is caring for a client with Thrombocytopenia. What intervention should the nurse implement to prevent complications? A.Avoid invasive interventions such as intramuscular injection B.Provide frequent rest periods between activities of daily living C.Avoid exposure to individuals with upper respiratory tract infections D.Administer around the clock analgesia sedation and force liquids 207. The nurse should recommend that males over the age of 45 obtain which test to screen for prostatic cancer?A.Prostate-specific antigen (PSA) B.Alpha-fetoprotein radio immunoassay (AFP) C . U l t r a s o u n d o f t h e s c r o t u m D . S e r u m t e s t o s t e r o n e l e v e l 208. The nurse is giving medications to a client who was admitted to the hospital with a diagnosis of Diabetes Mellitus Type II. After checking the finger stick glucose at 1630dL, what dose of insulin should the nurse administer? (enter the numeric value only) (Click on each chart tab for additional information. Please be sure to scroll to the bottom-right corner of each tab to view all information contained in the client's medical record.) 8 209. A client is receiving 0.5 grams of a prescription medication that is dispensed as 500 mg/5mL. How many ml should the PN administer? (enter the numeric value only. If rounding is required, round to the nearest tenth.) 5 210. The nurse is receiving a client following an emergency Cesarean Section (C-Section). Which information is most important for the nurse to obtain? A.Blood pressure and pulse rate B . G r a v i d a a n d p a r i t y C.Medications received du ring labor D.Temperature and respiratory rate 211. The nurse is preparing to insert an indwelling catheter for an 89- year-old client who has severe contractures of both lower extremities. The client cries in pain when positioned supine while the nurse attempts to abduct the hips to visualize the perineum. What action should the nurse take? A.Report to the charge nurse that the client cannot cooperate for the insertionB.Recruit two UAPs to hold the legs apart while the catheter is inserted C.Position laterally for posterior access in visualizing the meatus for insertion D.Pre-medicate the client with a narcotic analgesic to relax the skeletal muscles 212. An elderly client in the early postoperative period requires close monitoring due to aging and multisystem changes. The nurse monitors respirations and auscultates breath sounds frequently. What other intervention should the nurse implement related to the client's decreased vital capacity? A.Evaluate pulse oxygen saturation B . A l l o w e x t r a e d u c a t i o n t i m e C.Encourage high protein supplements D . M o n i t o r i n t a k e a n d o u t p u t 213. The nurse can also refer to the external ear as what other known name… A . P i n n a B . M a l l e u s C . I n c u s D . C o c h l e a 214. During immediate postoperative period, which condition has the highest priority when planning Nursing care? A . I n f e c t i o n B.Respiratory obstruction C . D e h y d r a t i o n D . C a r d i a c a r r e s t 215. The nurse is providing instructions to the unlicensed assistive personnel (UAP) preparing to instruction is most important for the nurse to emphasize?A.Keep the head of the bed raised while the tube feeding is infusing B.Report any drainage observed around the GT insertion site C.Raise the entire bed while bathing the client to reduce back strain D.Use plenty of pillows to position the client on the side after bathing 216. A client is admitted to the rehabilitation unit after a Thrombotic Cerebrovascular Accident (CVA) with Right Hemiplegia and expressive aphasia. What intervention should the nurse implement to communicate with the client? A.Picture communication board B.Request a family member to interpret C.Electronic larynx device D.Dysphagia precautions 217. The nurse is reviewing instructions for the use of pilocarpine eye drops with a client who has Glaucoma. The client states, "I should have these drops to anesthetize my eye if I experience pain" What action should the nurse implement? A.Explain to the client the eye drops do provide pain relief, but do not anesthetize the eyes B.Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common C.Re-teach the client about the action of the eye drops to decrease pressure in the eye D.Document in the chart that the client understands the action and use the eye drops 218. A client is complaining of muscle fatigue in the lower extremities. What is the physiological cause of muscle fatigue? A.The depletion of glycogen and energy stores B.Electrical stimulus failure at the neuromuscular junction C.Calcium concentration decrease in the muscle sarcomereD.Hyperoxygenation of the muscle fiber 219. A client asks the nurse to explain the location of the prostate gland. What is the best response? A.Close the rectal wall the prostate gland sits behind the symphysis pubis extending around thebeginning of the urethra B.At the bottom of the scrotal sac, the prostate gland rests beneath the testes, held in place by the spermatic fascia C.Attach to the front and sides of the pubic arch, the prostate is a mess of cavernous tissue held together by fibrous tissue D.Located at the lateral edge of the posterior segment of the testes, the prostate creates a bulge continuous with the vas deferens Prostate Location: The prostate gland is just below the bladder, behind the pubic bone and just in front of the rectum. The prostate wraps around the urethra, which is the tube that carries urine from the bladder to the penis. 220. A female client is being prepared for a speculum exam. In which position should the nurse place the client? A . L e f t S i m s B . S e m i - F o w l e r ' s C . L i t h o t o m y D . T r e n d e l e n b u r g 221. The nurse is caring for an elderly client who has suddenly become confused after 2 days of vomiting and diarrhea. What laboratory result should the nurse report first to the RN? A.Serum potassium 6mEq/L, serum sodium 126mnEq/L, and serum chloride 115mEq/L B.Glucose tolerance results fasting 80 mg/dL, 1hr: 110mg/dL 2hr: 120 mg/dL, 3hr: 90 mg/dL C.Negative Hepatitis B Surface Antigen, serum total biilirubin 0. 1 mg/dLw D.Troponin l < 0.1ng/mL and creatinine kinase MB (CK-MB) 2% of total 10 milliunits/L222. While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement? A.Swab the oral cavity with a washcloth B.Use oral swabs with normal saline C.Provide a Yankauer tip for oral suction D.Support the head with a small pillow 223. The nurse is caring for a mother who is bottle-feeding and develops breast engorgement. Which intervention is most effective in reducing breast engorgement? A.Wearing a tight-fitting bra B.Applying hot packs to the breasts C.Expressing milk from the breast by hand D.Exposing the breasts to air 224. A 6-month old male with Bronchiolitis is admitted to the hospital. In monitoring the respiratory status of this child, which symptom indicates the nurse that he is experiencing Respiratory Distress? A.Respiratory of 62 breaths/minute B . A b d o mi n a l b r e a t h i n g C . A h i g h - p i t c h e d c r y D . D r y f l u s h e d s k i n 225. During vital sign assessment of a client, the nurse counts the left radial pulse at 88, and the pulse oximeter clipped to a finger on the left hand records a pulse rate of 68 with an oxygen saturation of 95%. What is the best initial action by the nurse? A.Count the right radial pulse rate B.Reposition the oximeter clip C . D o c u me n t a p u l s e d e f i c i t D.Count the apical pulse rate226. Which client should the nurse assess first? A.A young female client who reports that she is afraid of her roommate who is psychotic B.An older client who is asking for a priest to offer Last Rites C.A female client who is anxious about being discharged because she has no assistance at home D.A client who is ambulating with partial weight-bearing after a total hip replacement