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EXIT HESI V1 EXAM
with NGN Questions and Verified Rationalized Answers
100% Guarantee Pass
This Test Consists Of 160 Multiple Questions And Answers
1. When preparing to administer a prescribed medication to a homeless client
at a community psychiatric clinic. The client tells the nurse that the usual
dosage taken is different from the dose the nurse is giving. Which action
should the nurse take?
A) Inform the client that he may refuse the medication and document whether or
not the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the next
healthcare team meeting
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.:Ans>> B) Withhold the medication until the dosage can be confirmed.
2. The charge nurse is making assignments for one practical nurse and three
registered nurses who are caring for neurologically compromised clients. Which
client with which change in status is best to assign to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10 to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40
.:Ans>> B) Viral meningitis whose temperature change from 101 S to 102F.
3. The nurse is caring for a client with pneumonia who now develops initial signs
of septic shock and multi organ failure. The healthcare provider pre- scribes a sepsis
protocol. Which intervention is most important for the nurse to include in the plan
of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level
.:Ans>> A) Maintain strict intake and output.
4. And adolescent client is admitted to the hospital because of writing a suicide
note to a teacher at school. On the second day of hospitalization, the nurse asked
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the client to meet with the treatment team. After the team meeting, the client leaves
in tears and goes to their room. Which nursing intervention is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
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C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened
.:Ans>> D) Go to the clients room and ask what happened.
5. The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once a day for a client who weighs 154 pounds. The medication is
available and 25,000 units per milliliter vial. How many milliliters should the nurse
administer? (Enter numerical value only. If rounding is required, round to the
nearest 10th.): Ans>> 0.6
6. NGN: The client is a 49-year-old male who reports flu like symptoms in- cluding
fever and chest congestion for four days. He came to the emergency department last
night when he was having more difficulty breathing he has a history of 1/2 pack a
day cigarette smoking for 20 years. He has no significant medical or surgical
history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
D) Chest x-ray.
E) Acetominophen 350 mg PO every six hours for temperature control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
H) NPO
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.:Ans>> B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
7. NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum
culture, start a peripheral IV infusion, start oxygen 3 L per minute via nasal
cannula, begin 0.9% sodium chloride IV infusion at 150 mL per hour, acetaminophen 350 mg PO every six hours for temperature.
To start the client on oxygen as ordered which items should the nurse collects from
the supply room? SATA
A) humidifier bottle.
B)Suction canister. C)Sterile
water.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
G) Tape
.:Ans>> D) Nasal cannula.
E) Flow meter.
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8. NGN: states, I am feeling extremely anxious right now. The client has decreased breath sounds in the left lower low. His mucus membranes are dry. He has
a productive cough with thick, yellow secretions. His capillary refill is four
seconds. Vital signs, temperature 100.2. Heart rate 101 bpm, respiratory rate 28
breaths per minute, blood pressure 145/89, oxygen saturation 90% on room air.
(for each body system click to specify the assessment findings that indicates
hypoxia)
Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure
145/89.
Neurological: anxious, awake and alert, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm,
productive
cough
.:Ans>> Cardiovascular: capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm.
9. NGN: The client is a 49-year-old male who reports flu like symptoms in- cluding
fever and chest congestion for four days. He came to the emergency department last
night when he was having more difficulty breathing he has a history of 1/2 pack a
day cigarette smoking for 20 years. He has no significant medical or surgical
history.
The nurse should place the client in a
position to promote
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.:Ans>> Semi-Fowler , lung expansion.
10. NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO,
sputum culture, start a PIV, start oxygen 3L via nasal cannula, normal saline 150
ML per hour, acetaminophen 350mg PO every six hours for temp greater than
101F, chest x-ray.
0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater than
94%.
(mark whether the statements by the new grad nurse indicate understanding or no
understanding of the use of facemask in the care of this client)
-I should clean the facemask once per shift.
-The client should take a 1 to 2 minute break from the facemask each hour.
-I should put gauze under the elastic straps over the ears.
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-I can adjust the oxygen level on the flow meter to keep the clients oxygen
saturation greater than 94%.
-The mask should cover only the mouth and leave the nose open for expira- tion.
-I should place the mask first over the nose and then cover the mouth
.:Ans>> -I should clean the facemask once per shift. (UNDERSTANDING)
-The client should take a 1 to 2 minute break from the facemask each hour. (NOT
UNDERSTANDING)
-I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING
????)
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation
greater than 94%. (UNDERSTANDING)
-The mask should cover only the mouth and leave the nose open for expiration. (NOT
UNDERSTANDING)
-I should place the mask first over the nose and then cover the mouth. (UNDERSTANDING)
11. NGN: Nurses Notes: 0400, the client is awake and alert but restless. He states
I am feeling extremely anxious right now. The client has decreased breath sounds
in the left lower lobe. His mucus membranes are dry. He has a productive cough
with thick, yellow secretions. His capillary refill is four
seconds. Heart rate 101 BPM, oxygen saturation 90%. Blood pressure 145/89,
temperature 100.2 F, respiratory rate 28 BPM.
0500: Placedthe client in semi-Fowlers position. No improvement in oxygen
saturation on 3L nasal cannula...
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(Which are the three most important goals?)
A) The client will remain free of skin breakdown.
B) The client will have quit smoking.
C) The client will be afebrile for 24 hours.
D) The client will maintain oxygen saturation of 96% without supplemental
oxygen.
E) The client will report pain less than 3/10
.:Ans>> B) The client will have quit smoking.
C) The client will be afebrile for 24 hours.
E) The client will report pain less than 3/10.
12. The nurse has completed the diet teaching of a client who is being dis- charged
following treatment of a leg wound. A high-protein diet is encouraged to promote
wound healing. Which lunch toys by the client indicates that the teaching was
effective?
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A) A peanut butter sandwich with soda and cookies.
B) Vegetable soup, crackers, and milk.
C) A tuna fish sandwich with chips and ice cream.
D) A salad with three kinds of lettuce and fruit
.:Ans>> C) A tuna fish sandwich with chips and ice cream.
13. A client with foul-smelling drainage from an incision on the upper left arm is
admitted with a suspected MRSA. Which nursing intervention should the nurse
include in the plan of care? SATA.
A) Institute contact precautions for staff and visitors.
B) Use standard precautions and wear a mask.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
E) Explain the purpose of a low bacteria diet
.:Ans>> A) Institute contact precautions for staff and visitors.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
14. An adult client who is admitted to the mental health unit for treatment of
bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which
assessment finding is most important for the nurse to report to the healthcare
provider?
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A) Weight loss of 10 pounds in the past month.
B) Six hours of sleep in the past three days.
C) Blood alcohol level of 0.09%.
D) Serum lithium level of 1.6
.:Ans>> D) Serum lithium level of 1.6.
15. When conducting diet teaching for a client who is on a post operative full
liquid diet, which foods should the nurse encouraged the client to eat? SATA.
A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
D) Creamy peanut butter.
E) Canned fruit cocktail
.:Ans>> A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
16. An infant born with esophageal atresia and tracheoesophageal fistula re- ceives
a prescription for internal feedings after corrective surgery.To promote
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normal growth and development of the infant, which action should the nurse
include in the plan of care?: Offer a pacifier for non-Nutritive sucking
17. The nurse is preparing a four year-old client with a serum bilirubin level of 19
for discharge from the hospital. When teaching the parents about home photo
therapy, which instruction should the nurse include in the discharge teaching plan?
A) Cover with a receiving blanket.
B) Perform diaper changes under the light.
C) Feed the infant every four hours.
D) Reposition the infant every two hours
.:Ans>> D) Reposition the infant every two hours.
18. The nurse initiate the procedure to remove a clients peripherally inserted
central catheter when a code blue is called for another client in the unit
who collapse in the hallway while ambulating with the unlicensed assistive
personnel. Which action should the nurse take?
A) Close the room door.
B) Finish the procedure.
C) Respond to the code.
D) Call for an assistant
.:Ans>> B) Finish the procedure.
19. Which nursing intervention is most important for the nurse to include in the
plan of care for a client with alcohol withdrawal delirium?
A) Maintain a quiet, non-stimulating environment.
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B) Confront the clients denial of substance abuse.
C) Force oral fluids and provide frequent small meals.
D) Encourage attendance and group participation
.:Ans>> A) Maintain a quiet, non-stimulating environment.
20. A client arrives at the emergency department describing chest pain that began
three hours earlier which has not subsided. To assess the quality of the clients
chest pain. Which approach for the nurse use?
A) Provide a numeric pain scale.
B) Ask the client to describe the pain.
C) Identify effective pain relief measures.
D) Observe body language and movement
.:Ans>> B) Ask the client to describe the pain.
21. An adolescent who was diagnosed with type one diabetes Molite us at the
age of nine, is admitted to the hospital in diabetic keto acidosis. Which
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occurrence is the most likely cause of the keto acidosis?
A) Ate an extra peanut butter sandwich before gym class.
B) Incorrectly administered too much insulin.
C) Had a cold and ear infection for the past two days.
D) Skipped eating lunch while at school
.:Ans>> C) Had a cold and ear infection for the past two days.
22. When is it most important for the nurse to assess a pregnant client's deep tendon
reflexes?
A) Within the first trimester of pregnancy.
B) When the client has ankle edema.
C) During admission to labor and delivery.
D) If the client has an elevated blood pressure
.:Ans>> D) If the client has an elevated blood pressure.
23. NGN: The client has returned to work at in accounting firm and has started
going to a grief support group. She reports she is seeking care from a healthcare
professional because her father is worried about her. The client says she only gets 2
to 3 hours of sleep due to nightmares about the crash. She informed that exercising
right after work helps her get better sleep and to relax. She feels that she is "jumpy"
after the accident, especially when she is in the car. She also stated, "I feel so sad
that I can't seem to feel anything at all". In addition to her father, the client has a
large family and friend support system. She denies alcohol or drug use.
(highlight areas in the above paragraph that the nurse should...): -she only gets 2 to 3
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hours of sleep due to nightmares about the crash.
-She feels that she is "jumpy" after the accident, especially when she is in the car.
- "I feel so sad that I can't seem to feel anything at all"
24. The client is a 26 year old female who was in a car accident six months ago that
killed her mother, husband, and two year old son. She and her father were the only
survivors of the crash. She is seeking care for depression.
The client is exhibiting symptoms of
related to
and
.:Ans>> Post traumatic stress disorder , experiencing a life-threatening event ,
losing a loved one.
25. NGN: Orders, diagnosis, depression and posttraumatic stress disorder.
Diphenhydramine 12.5 mg PO every night at sleep. BuspironeHydrochloride
7.5 mg PO twice a day.
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(how can the nurse build a therapeutic relationship with the client? Select all
that apply)
A) The nurse can show no emotion when talking to the client.
B) The nurse can be open honest and sincere.
C) The nurse can talk as much as needed to get the client talking.
D) The nurse can focus energy on the client.
E) The nurse can communicate acceptance of the client as she is
F) The nurse can establish a meaningful connection
.:Ans>> B) the nurse can be open, honest and sincere.
E) The nurse can communicate acceptance of the client as she is
F) The nurse can establish a meaningful connection.
26. NGN: The client has returned to work at in accounting firm and has started
going to a grief support group. She reports she is seeking care from a healthcare
professional because her father is worried about her. The client says she only gets 2
to 3 hours of sleep due to nightmares about the crash. She informed that exercising
right after work helps her get better sleep and to relax. She feels that she is "jumpy"
after the accident, especially when she is in the car. She also stated, "I feel so sad
that I can't seem to feel anything at all". In addition to her father, the client has a
large family and friend support system. She denies alcohol or drug use. The client
states, "I don't want to kill myself, but sometimes I wish I had died in the crash."
The statement by the client presents
and should be followed
up with
.:Ans>> Suicidal ideation, assessment of respecters for suicide.
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27. The client is a 26 year old female who was in a car accident six months ago that
killed her mother, husband, and two year old son. She and her father were the only
survivors of the crash. She is seeking care for depression.
(what would be some affective strategies that the nurse could use to decrease the
clients risk of suicide in the future? SATA.)
A) Have the client remove any sharp objects from the home.
B) Have the client sign a no suicide contract.
C) Help the client unless the help of friends and family.
D) Make the client feel too guilty to commit suicide.
E) Place the client in a locked unit.
F) Refer the client for cognitive behavioral therapy
.:Ans>> B) Have the client sign a no suicide contract.
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C) Help the client unless the help of friends and family.
F) Refer the client for cognitive behavioral therapy.
28. The client is a 26 year old female who was in a car accident six months ago that
killed her mother, husband, and two year old son. She and her father were the only
survivors of the crash. She is seeking care for depression.
(which findings are effective or ineffective)
-The client states she feels less jumpy and more relaxed.
-The client states she feels numb when thinking about the crash.
-The client talks to her father and her best friend when she starts to feel sad.
-The client reports sleeping 6 to 7 hours per night.
-The client states that she avoids driving altogether and takes the bus
.:Ans>> -The client states she feels less jumpy and more relaxed. (EFFECTIVE)
-The client states she feels numb when thinking about the crash. (INEFFECTIVE)
-The client talks to her father and her best friend when she starts to feel sad.
(EFFECTIVE)
-The client reports sleeping 6 to 7 hours per night. (EFFECTIVE)
-The client states that she avoids driving altogether and takes the bus. (INEFFECTIVE)
29. The healthcare provider prescribes acarbose, an alpha-glucosidase in- hibitor,
for a client with type two diabetes. Which information provides the best indicator of
the drugs effectiveness?
A) Body mass index between 20 and 24.
B) Blood pressure readings less than 120/80.
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C) Self-reported glucose levels 120 to 150.
D) Hemoglobin A1c readings less than 7%
.:Ans>> D) Hemoglobin A1c readings less than 7%.
30. After receiving report on an inpatient acute care unit which client should the
nurse assess first?
A) The client who had surgery yesterday and is experiencing a paralytic ileus with
absent bowel sounds.
B) The client with a small bowel obstruction who has a nasogastric tube that is
draining greenish fluid.
C) The client with an obstruction of the large intestine who is experiencing
abdominal distention.
D) The client with a bowel obstruction due to a volvulus who is experiencing
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abdominal rigidity
.:Ans>> D) The client with a bowel obstruction due to a volvulus who is
experiencing abdominal rigidity.
31. Client presents at the emergency department reporting a raspy voice, cold
intolerance, and fatigue. Laboratory tests indicate an elevated thyroid stimulating
hormone and a low T3 and T4 levels. After the client is admitted to the telemetary
unit, which intervention is most appropriate for the nurse to implement?
A) administer prescribed dose of level thyroxine.
B) Note clients most recent hemoglobin level.
C) Offer additional blankets and a warm drink.
D) Assess for the presence of nonpitting edema
.:Ans>> A) administer prescribed dose of level thyroxine.
32. While caring for a client post operative dressing, the nurse observes purulent
wound drainage. Previously, the wound was inflamed and tender but without
drainage. Which is the most important action for the nurse to take?
A) Determine if the drainage has an unpleasant odor.
B) Cleanse the wound with a sterile saline solution.
C) Monitor the clients white blood cell count.
D) Request a culture and sensitivity of the wound
.:Ans>> D) Request a culture and sensitivity of the wound.
33. The school nurse is screening students for scoliosis and notes that one student
has lordosis. Which finding should the nurse document in the student screening
record?
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A) Lateral curvature that creates a symmetry of the shoulders.
B) Posterior curvature that is convex in the thoracic area.
C) Excessive concave curvature of the lumbar spine.
D) Rounded spine from head to hips without concave curbs
.:Ans>> C) Excessive concave curvature of the lumbar spine.
34. The nurse is assigned to care for for surgical clients. After receiving report, which
client should the nurse see first?
A) An older client who is receiving packed red blood cells on the third day post
operative for colon resection.
B) An older client with continuous bladder irrigation who is two days post
operative for bladder surgery.
C) An adult who is in bucks traction, and scheduled for hip arthroplasty within
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the just 12 hours.
D) An adult one day post operative laparoscopic cholecystectomy requesting pain
medication
.:Ans>> A) An older client who is receiving packed red blood cells on the third day
post operative for colon resection.
35. The nurse is providing education to a client who experiences recurrent levels of
moderate anxiety to situation and perceived stress. In addition to information
about prescribe medication and administration, which instruction should the nurse
include in the teaching?
A) Think about reasons the episodes occur.
B) Center attention on positive upbeat music.
C) Practice using muscle relaxation techniques.
D) Find outlets for more social interaction
.:Ans>> C) Practice using muscle relaxation techniques.
36. The nurse is preparing a client who had a below the knee amputation for
discharge to home. Which recommendations should the nurse provide this client?
SATA.
A) Use a residual limb shrinker.
B) Inspect skin for redness.
C) Apply alcohol to the residual limb after bathing.
D) Wash the residual limb with soap and water.
E) Avoid range of motion exercises
.:Ans>> A) Use a residual limb shrinker.
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B) Inspect skin for redness.
D) Wash the residual limb with soap and water.
37. The nurse is assessing the feet of a client with type one diabetes mellitis.
Which finding requires immediate intervention by the nurse?
A) Hard, painless nodule over metatarsophalangeal joint of first toe.
B) Painful corns and calluses over hammer toes on both feet.
C) Erythema and edema at the base of the left great toe.
D) Decreased response to pain discrimination on dorsal surface of foot
.:Ans>> D) Decreased response to pain discrimination on dorsal surface of foot.
38. The school nurse is called to the soccer field because a child has epistaxis. In
which position should the nurse place the child?
A) Side-lying with the head slightly elevated.
B) Sitting up and leaning forward.
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C) Standing with the head leaning backwards.
D) Supine with the legs raised
.:Ans>> B) Sitting up and leaning forward.
39. The nurse is auscultating a clients lung sounds. Which description should the
nurse use to document this sound? Please listen to the audio file to select the option
that applies.
A) High pitch squeeze.
B) Rhonchi.
C) High-pitched or fine crackles.
D) Stridor
.:Ans>> C) High-pitched or fine crackles.
40. NGN: Flow Sheet, vital signs, heart rate 104 bpm, respiratory rate 31 bpm.
The client is experiencing
and
: Tachypnea , tachycardia
41. NGN: Orders, 1300 admit to the surgical unit, vital signs every four hours,
advanced diet as tolerated, administer lactated ringers IV at 85 mL per hour,
ibuprofen 800 mg PO every eight hours PRN for pain.
(the nurse would anticipate which of the following could be affecting the clients
current condition? SATA.
A) stress.
B) Medication.
C) Anemia.
.-
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D) Fever.
E) Hypothermia.
F) Hypertension.
G) Pain
.:Ans>> A) stress.
B) Medication.
G) Pain.
42. NGN: the client is a 34-year-old female who had a surgical procedure to
remove a benign abdominal tumor.
(Select which is understanding or not understanding)
-The tubing should be tucked under the chin and secured with the sliding
adjustment piece.
-Humidification of oxygen is not needed for administration under 4 L per
minute.
-The nasal cannula can deliver up to 10 L per minute of oxygen.
-A nasal cannula delivers 100% oxygen to the client
.:Ans>> -The tubing should be
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tucked under the chin and secured with the sliding adjustment piece. (UNDERSTANDING)
-Humidification of oxygen is not needed for administration under 4 L per minute.
(UNDERSTANDING)
-The nasal cannula can deliver up to 10 L per minute of oxygen. (NOT UNDERSTANDING)
-A nasal cannula delivers 100% oxygen to the client. (NOT UNDERSTANDING)
43. NGN: Orders, 1300 admit to the surgical unit, vital signs every four hours,
advanced diet as tolerated, administer lactated ringers IV at 85 mL per hour,
ibuprofen 800 mg PO every eight hours PRN for pain.
1310: supplemental oxygen at 2
(what diagnostic test would be appropriate for this client? SATA)
A) Doppler.
B) Blood gases.
C) Blood culture.
D) Complete blood count.
E) Urinalysis.
F) Chest radiograph.
G) Echocardiogram
.:Ans>> B) Blood gases.
D) Complete blood count.
F) Chest radiograph.
44. NGN: Nurses Notes, saturation is low. Noted cyanosis in the clients lips.
Healthcare provider made aware.
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1310: pain rating for on a pain scale of 0 to 10. Temperature elevation noted. The
client is anxious and using accessory muscles to breathe. Alerted the surgeon about
the client status. New orders noted.
(what does the nurse need to document at 1330? SATA)
A) urine output.
B) Respiratory rate.
C) Blood pressure.
D) Pain.
E) Temperature.
F) Flow rate of oxygen.
G) Oxygen saturation
.:Ans>> B) Respiratory rate.
C) Blood pressure.
D) Pain.
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E) Temperature.
G) Oxygen saturation.
45. NGN: Match the activity with the most appropriate person to do the activity.
-Provide mouth care.
-Document changes in respiratory status.
-Set up the oxygen administration system.
-Change the gauze under the nasal cannula
.:Ans>> -Provide mouth care. (UAP)
-Document changes in respiratory status. (RN/RT)
-Set up the oxygen administration system. (RN/RT)
-Change the gauze under the nasal cannula. (UAP)
46. A client experiencing an acute dystonic reaction presents with a laryngeal
spasm. Which treatment should the nurse prepare?
A) IV administration of benztropine.
B) IV administration of isotonic crystalloid fluid.
C) PO administration of lorazepam.
D) PO administration of divalproex
.:Ans>> A) IV administration of benztropine.
47. A client with heart failure become short of breath, anxious, and has au- dible
reasoning with pink frothy sputum. The nurse sits the client upright and provides
oxygen per nasal cannula. The nurse receives a prescription to administer a one
time dose of morphine sulfate IV. Which action should the nurse take?
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A) Administer the dose of morphine sulfate as prescribed.
B) Consult with the charge nurse regarding the morphine prescription.
C) Review the need for the prescription with the healthcare provider.
D) Withhold the morphine until the clients dyspnea resolves
.:Ans>> A) Administer the dose of morphine sulfate as prescribed.
48. A client with acute asthma exacerbation is manifesting inspiratory and expiratory wheezes and a decreased forced expiratory volume. Which prescribed drug
class should the nurse administer first to the client?
A) Inhaled short acting beta two agonists.
B) Inhaled corticosteroids.
C) Anti-cholinergics.
D) Leukotriene modifiers
.:Ans>> B) Inhaled corticosteroids.
49. The nurse enters a clients room to administer oral medication's and find an
unlicensed assistive personnel providing personal care to the client, whose
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condition has obviously deteriorated. The client is lying in a supine position
and is weak, pale, and diaphoretic. Which is the priority nursing action?
A) Determine why the UAP did not notify the nurse of the change in the clients
condition.
B) Advised the UAP to stop providing care so the nurse can assess the clients
condition.
C) Explain to the UAP that changes in a clients condition should be reported
immediately.
D) Ask for UAP to position the client so the oral medication's can be administered
.:Ans>> B) Advised the UAP to stop providing care so the nurse can assess the
clients condition.
50. The client who was admitted yesterday with severe dehydration is report- ing
pain where a 24 gauge IV catheter with 0.9% sodium chloride is infusing at a rate
of 150 mL per hour. Which intervention should the nurse implement first?
A) Discontinue the 24 gauge IV.
B) Establish a second IV site.
C) Stop the 0.9% sodium chloride infusion.
D) Assess the IV for blood return
.:Ans>> C) Stop the 0.9% sodium chloride infusion.
51. Client should the nurse assess frequently because of the risk for overflow
incontinence?
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A) a client with hematuria and decreasing hemoglobin and hematocrit levels.
B) A client who has been fast, with increased serum creatinine levels.
C) A client who is confused and frequently forgets to go to the bathroom.
D) A client who has a history of frequent urinary tract infections
.:Ans>> C) A client who is confused and frequently forgets to go to the bathroom.
52. After a spider bite on the lower extremity, a client is admitted for treatment of
an infection that is spreading up the leg. Which admission assessment findings
should the nurse report to the healthcare provider? SATA.
A) Location of the initial IV site.
B) Swollen lymph nodes in the groin.
C) Red blood cell count.
D) White blood cell count.
E) Core body temperature
.:Ans>> B) Swollen lymph nodes in the groin.
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D) White blood cell count.
E) Core body temperature.
53. A client develops your to Caria on the trunk and neck shortly after a
secondary infusion of pepper Sillen is initiated. In which order should the nurse
implement these interventions?
Document reaction of the drug. Contact
the healthcare provider. Assess vital
signs.
Stop the infusion.
Initiate an adverse event report
.:Ans>> Stop the infusion. Assess vital signs.
Contact the healthcare provider.
Initiate an adverse event report.
Document reaction to drug.
54. What nursing intervention is particularly indicated for the second stage of
labor?
A) Assessing the fetal heart rate and patterns for signs of fetal distress.
B) Monitoring effects of oxytocin administration to help achieve cervical
dilation.
C) Providing pain medication to increase the clients tolerance of labor pains.
D) Assisting the client to push effectively so that expulsion of the fetus can be
achieved
.:Ans>> D) Assisting the client to push effectively so that expulsion of the fetus can
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be achieved.
55. A client receives a prescription for Aceta medicine 1000 mg PO every eight hours
PRN for pain. The bottle is labeled acetaminophen for oral suspension, US P 500
mg per 15 mL. How many tablespoons should the nurse administer with each dose?
(Enter numerical value only.): 2
15 mL per tablespoon
56. The nurse is administering multiple prescribe vaccines to a toddler. Which
strategy should the nurse prioritized to reduce the duration of pain?
A) Supine positioning.
B) Verbal reassurance.
C) Simultaneous injections.
D) Physical soothing
.:Ans>> C) Simultaneous injections.
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57. NGN: Dean 30, admit to the medical floor, vital signs every four hours,
regular diet, out of bed with assist.
Complete diagram with one condition, two actions, and two parameters
.:Ans>> Ac- tions: the client for a nutrition history, encourage the client to drink
Condition: Malnutrition
Actions: ?????
????????
58. When assessing a multigravida on the first postpartum day, the nurse finds a
moderate amount of lochia rubra, with the uterus firm, and three fingerbreadths
above the umbilicus. Which action should the nurse implement first?
A) Check for a distended bladder.
B) Review the hemoglobin to determine hemorrhage.
C) Increase IV infusion rate.
D) Massage the uterus to decrease atony
.:Ans>> A) Check for a distended bladder.
59. A client who is receiving zidovudine reports the appearance of pinpoint, red,
brown spots on the skin. Which result should the nurse report to the healthcare
provider?
A) Skin biopsy.
B) Complete blood count.
C) Allergy test.
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D) Electromyography
.:Ans>> B) Complete blood count.
Petechiae can occur due to low platelet counts. Zidovudine is used for HIV and can
cause hematological toxicity, anemia neutropenia.
60. A child newly diagnosed with sickle cell anemia is being discharged from the
hospital. Which information is most important for the nurse to provide the parents
prior to discharge?
A) Instructions about how much fluid the child to drink daily.
B) Referral for social services for the child and family.
C) Signs of addiction to opioid pain medications.
D) Information about nonpharmaceutical pain relief measures
.:Ans>> A) Instructions about how much fluid the child to drink daily.
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61. During discharge teaching, and overweight client with heart failure is
asked to make a grocery list for the nurse to review. Which food choices include
it on the clients list should the nurse encouraged? SATA.
A) Cheddar cheese cubes.
B) Canned fruit in heavy syrup.
C) Lightly salted potato chips.
D) Plain, air-popped popcorn.
E) Natural whole almonds
.:Ans>> D) Plain, air-popped popcorn.
E) Natural whole almonds.
62. A client is receiving IV fluids by gravity infusion and exhibit signs of fluid
volume overload. When assessing the clients IV delivery system, where should the
nurse assess first?: A
I can't see all the pics. Use the clamp on the IV tubing.
63. The nurse observes a client prepare a meal in the kitchen of a rehabilitation
facility prior to discharge. Which behaviors indicate the client understands how to
maintain balance safely? SATA.
A) Widen stance while working near the sink.
B) Leans forward to pull a pan from a high shelf.
C) Tenths from the waist to pick trash off the floor.
D) Brings a heavy can close to body before lifting.
E) Lots knees while preparing food on the counter
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.:Ans>> A) Widen stance while working near the sink.
D) Brings a heavy can close to body before lifting.
64. A client is receiving methylamine 800 mg PO three times a day. Which
assessment should the nurse perform to assess the effectiveness of the
medication?
A) Bowel patterns.
B) Pupillary response.
C) Peripheral pulses.
D) Oxygen saturation
.:Ans>> A) Bowel patterns.
Ulcerative colitis medication that helps reduce inflammation in the G.I..
65. Five days after surgical fixation of a fractured femur, a client suddenly reports
chest pain and difficulty in breathing.The nurse suspect the client may have had a
pulmonary embolus. Which action should the nurse take first?
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A) Provide supplemental oxygen.
B) Prepare a continuous heparin infusion per protocol.
C) Bring the emergency craft cart to the bedside.
D) Notify the healthcare provider
.:Ans>> A) Provide supplemental oxygen.
66. The nurse identifies an electrolyte imbalance, elevated blood pressure, and
exhibited changes in mental status for a client with chronic kidney disease. Which
is the most important action for the nurse to take?
A) Monitor daily sodium intake.
B) Auscultate for a regular heart rate.
C) Document abdominal girth.
D) Measure ankle circumference
.:Ans>> B) Auscultate for a regular heart rate.
67. The older adult client who has difficulty hearing is being discharged from the
day surgeries following a cataract extraction and lens in plantation. Which
intervention is most important for the nurse to implement to help ensure the client
compliant with self-care?
A) Ensure that someone will stay with the client for 24 hours.
B) Have a client vocalize the instructions provided.
C) Speak clearly and face the client for lip reading.
D) Provide written instructions for eyedrop administration
.:Ans>> B) Have a client vocalize the instructions provided.
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68. NO QUESTION 68:
69. Well making rounds, the charge nurse notices that a young adult client with
asthma who has admitted yesterday is sitting on the side of the bed and leaning
over the side table. The client is currently receiving oxygen at 2 L per minute via
nasal cannula. The client is wheezing and is using per slip breathing. Which
intervention should the nurse implement?
A) Increase oxygen to 6 L per minute.
B) Call for an Ambu resuscitation bag.
C) This is the client to lie back in bed.
D) Administer a nebulizer treatment
.:Ans>> D) Administer a nebulizer treatment.
70. An older client with Alzheimer's disease is confused and asking the nurse to call
their mother who is deceased. Which non-pharmacological intervention should the
nurse implement?
A) Clarify reality with the client about delusional thoughts.
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B) Use distraction and therapeutic communication skills.
C) Reduce the clients interaction with others during the day.
D) Awakening the client for reality checks every four hours at night
.:Ans>> B) Use distraction and therapeutic communication skills.
71. Four hours after surgery, a client reports nausea and begins to vomit. The nurse
knows that the client has a scopolamine transdermal patch applied behind the ear.
Which action should the nurse take?
A) Reposition the transdermal patch to the clients trunk.
B) Remove the transdermal patch until the vomiting subsides.
C) Notify the clients healthcare provider of the vomiting.
D) Explain that this is a side effect of the medication in the patch
.:Ans>> C) Notify the clients healthcare provider of the vomiting.
This medication is used for nausea and the provider should be made aware if the
medication is not effective.
72. The adult child of an older adult client who has Parkinson's disease, calls the
clinic and reports that the client has been confused for the past week. Which action
should the nurse take? SATA.
A) Instruct the adult child to check the clients temperature.
B) Encourage increased intake of high protein foods.
C) Determine if the client has recently experienced a fall.
D) Reviewed the clients current food and medication allergies.
E) Ask if the client is experiencing any pain with urination
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.:Ans>> A) Instruct the adult child to check the clients temperature.
C) Determine if the client has recently experienced a fall.
E) Ask if the client is experiencing any pain with urination.
73. The healthcare provider prescribes 30 survive for a four-year-old child who has a
ventricular septal defect. Which outcome indicates to the nurse that this
pharmacological intervention was effective?
A) Urine specific gravity change from 1.0212 1.031.
B) Urinary output decreases of 5 mL per hour.
C) Daily weight decrease of 2 pounds.
D) Blood urea nitrogen increase from 8 to 12
.:Ans>> C) Daily weight decrease of 2 pounds.
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Lasix is a diarrhetic so there would not be a decrease in urine output, it is used for
fluid retention so decreased weight would be appropriate.
74. NGN: Nurses Notes, 1800: the client is a female neonate born at 37 weeks of
gestation to a gravida to party one mother, who was diagnosed with ges- tational
diabetes following a spontaneous vaginal birth, she received Apgar scores of seven
at one minute and eight at five minutes. The client weighs
8 lbs. 9 oz. and appears pink with acrocyanosis and a moderate amount of
subcutaneous fat. She is noted to be slightly jittery at 30....
The nurse recognizes that the infant of a diabetic mother is
at risk for
,
, and
.:Ans>> Hyperbilirubinemia , respiratory distress syn- drome , cardiomyopathy
75. NGN: (Nurses Notes)1800: The client is a female neonate born at 37 weeks of
gestation to a G 2 P 1 mother, who was diagnosed with gestational diabetes.
Following a spontaneous vaginal birth, she received Apgar scores of seven at one
minute and eight at five minutes. The client weighs 4036.97g (8lbs 9oz) and appears
pink with acrocyanosis and a moderate amount of subcutaneous fat. She is noted to
be slightly jittery at 30min of age. Axillary temperature 96F,
.....
(For each assessment finding, click to indicate whether the findings are asso- ciated
with an infant of a diabetic mother or normal presentation.)
-Mongolian spot.
-Acrocyanosis.
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-Jittery at 30 minutes of age.
-Blood glucose 35.
-Billirubin 7.
-Respiratory rate 80 breaths per minute.
-Apgar 7 at one minute, 8 at five minutes.
-Soft fontanelles: -Mongolian spot. (NORMAL)
-Acrocyanosis. (NORMAL)
-Jittery at 30 minutes of age. (NOT NORMAL)
-Blood glucose 35. (NOT NORMAL)
-Billirubin 7. (NOT NORMAL)
-Respiratory rate 80 breaths per minute. (NORMAL)
-Apgar 7 at one minute, 8 at five minutes. (NORMAL)
-Soft fontanelles (NORMAL)
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76. NGN: For newborn baby.
Which six orders take priority?
A) Transfer to neonatal intensive care unit.
B) Blood glucose level.
C) Feed immediately.
D) Bolus of 2 mL per kilogram glucose 10% IV.
E) Monitor for respiratory distress.
F) Echocardiogram.
G) Contact respiratory therapy for ABG and oxygen therapy.
H) Monitor temperature every 30 minutes.
I) Keep in warmer with bilirubin lights.
J) Apply dextrose gel inside the babies cheek
.:Ans>> A) Transfer to neonatal intensive care unit.
B) Blood glucose level.
C) Feed immediately.
D) Bolus of 2 mL per kilogram glucose 10% IV.
E) Monitor for respiratory distress.
J) Apply dextrose gel inside the babies cheek.
77. NGN: For newborn baby.
(which actions are appropriate for the nurse to take at this time? SATA)
A) Keep infant in warmer with Billirubin lights to maintain temp.
B) Continue to monitor glucose levels.
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C) Observe for signs of respiratory distress and monitor oxygen.
D) Tell the mother that she will need to discuss any concerns.
E) Explain to the mother that the babies respiratory rate needs.
F) Monitor temperature.
G) Informed the mother that the baby is stable enough to take
.:Ans>> B) Continue to monitor glucose levels.
C) Observe for signs of respiratory distress and monitor oxygen.
F) Monitor temperature.
78. NGN:
79. NGN: day 2. 0630: Vitals have remained stable throughout the night. Oxy- gen
98% on 0.25 L per minute oxygen via nasal cannula. Mother to breast-feed in
nursery on demand. Able to tolerate breastmilk. Glucose after feeding was 60,
temp 97.8 F axillary when you return to warmer and Billy Rubin light. Chest x-ray
and echocardiogram results were normal. Calcium and magnesium
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within normal limits. Direct bilirubin five. Discharge teaching initiated, with
goal of discharging infant and mother on day three.
Highlight notes that demonstrate improvement
.:Ans>> -Vitals have remained stable
-Oxygen 98% on 0.25 L per minute oxygen via nasal cannula
-Able to tolerate breastmilk.
-Glucose after feeding was 60, temp 97.8 F axillary
-Calcium and magnesium within normal limits.
-Direct bilirubin five
80. The nurse discovers that an older adult client with no history of cardiac or renal
disease has an elevated serum magnesium level. To further investigate the cause of
this electrolyte imbalance, which information is most important for the nurse to
obtain from the clients medical history?
A) length and frequency of the clients tobacco use.
B) Genetically inherited disorders of family members.
C) Frequency of laxative use for chronic constipation.
D) Ingestion of shellfish or fish oil capsules daily
.:Ans>> D) Ingestion of shellfish or fish oil capsules daily.
81. Client who underwent an uncomplicated gastric bypass surgery is having
difficulty with diet management. Which dietary instruction is most important for
the nurse to explain to the client?
A) To food slowly and thoroughly before attempting to swallow.
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B) Plan volume controlled, evenly space meals throughout the day.
C) Sip fluids Chloe with each meal and between meals.
D) Eliminate or reduce intake a fatty and gas forming foods
.:Ans>> B) Plan volume controlled, evenly space meals throughout the day.
82. A client with an acute myocardial infarction is given a thrombolytic medication, aspirin, and IV heparin in the emergency department. Which finding
indicates the client is having a satisfactory response?
A) Activated partial thromboplastin (aPTT) time is two times the control value.
B) Cardiac tracing shows 1.2 MM wide Q waves half the height of the complex.
C) Guiac test of the stools is positive.
D) S3 heart sounds are present with auscultation: A) Activated partial thromboplastin (aPTT) time is two times the control value.
83. An adolescent client who has been treated in the past for a seizure disorder is
admitted to the hospital immediately after admission the client begins to
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have a grand mal seizure. Which action should the nurse implement?
A) Place a padded tongue blade between the clients teeth.
B) Observe the client carefully.
C) Obtain assistance in holding the client to prevent injury.
D) Call a rapid response team
.:Ans>> B) Observe the client carefully.
84. Client with leukemia who is receiving a myelosuppressive chemotherapy has a
platelet count of 25,000. Which intervention is most important for the nurse to
include in the clients plan of care?
A) Obtain a clients temperature every four hours.
B) Assess urine and stool for occult blood.
C) Require visitors to wear respiratory masks.
D) Monitor for signs of activity intolerance
.:Ans>> B) Assess urine and stool for occult blood.
85. A client with diabetes insipidus has an average urinary output of 500 ML of
dilute urine every hour for the past four hours. Which laboratory test is most
important for the nurse to monitor?
A) Urine specific gravity.
B) Capillary glucose.
C) Serum sodium.
D) White blood count
.:Ans>> C) Serum sodium.
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86. The nurse is managing the care of a client with Cushing syndrome. Which
intervention should the nurse delegate to be unlicensed assistive personnel? SATA.
A) Weigh the client and report any weight gain.
B) Note and report the clients food and liquid intake during meals and snacks.
C) Assess the client for weakness and fatigue.
D) Evaluate the client for sleep disturbances.
E) Report any client mention of pain or discomfort
.:Ans>> A) Weigh the client and report any weight gain.
B) Note and report the clients food and liquid intake during meals and snacks.
E) Report any client mention of pain or discomfort.
87. A client with persistent low back pain has received a prescription for an
electronic stimulator tens unit. After the nurse applies the electrodes and turns on the
power, the client reports feeling a tingling sensation. How should the nurse
respond?
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A) Check the amount of gel coating on the electrodes.
B) Decrease the strength of the electrical signals.
C) Remove electrodes and observe for skin redness.
D) Determine if the sensation feels uncomfortable
.:Ans>> D) Determine if the sensa- tion feels uncomfortable.
88. Before leaving the room of a confuse client, the nurse notes that a half bow not
was used to attach the clients wrist restraints to the movable portion of the clients
bed frame. What action should the nurse take before leaving the room?
A) Ensure that the number cannot be quickly released.
B) Ensure that the restraints are snug against the clients risk.
C) Tie the knot with a double turn or square knot.
D) Move the ties so the restraints are secured to the side rails
.:Ans>> A) Ensure that the number cannot be quickly released.
89. A client is being urgently transported to radiology for a CT scan after a sudden
decrease in level of consciousness. The client is orally intubated and has a left
lateral chest tube of 20 cm section. Which action is most important for the nurse to
take?
A) Secure the chest tube to the stretcher for transport.
B) Keep the chest tube container below the site of insertion.
C) Administer a PRN pain management prior to transport.
D) Mark the amount of chest drainage on the container
.:Ans>> B) Keep the chest tube container below the site of insertion.
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90. The nurse is managing for clients in the ICU who are mechanically venti- lated.
After performing a quick visual assessment, the nurse should prioritize care for the
client who is exhibiting which finding?
A) Diminished breath sounds in the right posterior base.
B) Restrained and restless with a slow volume alarm sounding.
C) High-pressure alarm sounds when client is coughing.
D) An audible voice when client is trying to communicate
.:Ans>> B) Restrained and restless with a slow volume alarm sounding.
91. NGN: ????
92.
Nurse is caring for a client with a sexually transmitted infections syphilis.
The client reports having had prior sexually transmitted infections. Which
response should the nurse provide?
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A) Notify that persons with STDs are reported to local health departments.
B) Answer questions directly and correct any misinformation.
C) Provide counseling that most contraceptives protect against infection.
D) Discuss that partners without similar symptoms may not be infected
.:Ans>> B) Answer questions directly and correct any misinformation.
93.
Which instruction should the nurse delegate to an unlicensed assistive
personnel?
A) Call the pharmacy to obtain clients new antibiotic dose.
B) Observe the clients gate to determine the need for assistance.
C) Bring a sterile chest drainage unit from central supply to the unit.
D) Evaluate a clients urinary catheter for proper drainage
.:Ans>> C) Bring a sterile chest drainage unit from central supply to the unit.
94.
A client with unilateral hearing loss is admitted for a schedule surgery.
Which technique should the nurse use to provide education about pain relief
options?
A) Speak directly facing the client.
B) Write information on a whiteboard.
C) Talk loudly into the infected ear.
D) Repeat information to the client
.:Ans>> A) Speak directly facing the client.
95.
A client who is 65 kg receives a prescription for lorazepam 44 mcg/kg IV
to be administered 20 minutes before a scheduled procedure. The medication is
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available in 2 mg/mL vial. How many milliliters should the nurse administer?
(Enter numerical value only. If rounding is required, round to the nearest 10th):
1.4
96.
The nurse on a medical surgical unit receives a report from a post anes-
thesia care unit nurse for a client who is being transferred following a right
hemicolectomy. The PACU nurse reports, the client has an IV infusion of 1000
mL of lactated ringers infusing at 125 mL per hour into the left wrist with 300
mL remaining. Prescriptions and food morphine sulfate 2 mg IV every 2 to
4 hours for pain. Last administer 30 minutes ago, and aspirin 4 mg IV every eight
hours for nausea, last administered 15 minutes ago. Which additional
information is most important for the nurse to obtain in the report?
A) History of vomiting at home for three days prior to surgery.
B) Peripheral pulse is present with full range of motion of both legs.
C) Soft abdomen, absent bowel sounds, no bleeding on dressing.
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D) Declining to take ice chips for complaints of dry mouth
.:Ans>> C) Soft abdomen,
absent bowel sounds, no bleeding on dressing.
97.
Entering the room of a sedated postoperative client, which assessment
requires immediate intervention by the nurse?
A) Low intermittent suction prescribe for the nasal gastric tube is turned off.
B) The urinary catheter drainage bag is almost completely full of amber urine.
C) A Hemovac drain is partially full of serious drainage and he's not impressed.
D) Oxygen has been administered via nasal cannula at 4 L per minute without
humidification
.:Ans>> C) A Hemovac drain is partially full of serious drainage and he's not
impressed.
98.
An older adult client presents to the emergency department with abdomi-
nal pain due to constipation. The nurse is providing a list of high fiber foods to
the client that the healthcare provider has recommended. Which action should the
nurse implement when reviewing the list of foods?
A) Turn on overhead lights while giving instructions.
B) Stand behind the client to avoid intimidation.
C) Use background music to promote relaxation.
D) Provide handouts written at a 12th grade reading level
.:Ans>> A) Turn on overhead lights while giving instructions.
99.
The nurse leading the care team on a medical surgical unit is assigning
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client care to a practical nurse and an unlicensed assistive personnel. Which
activity should the nurse assigned to the UAP?
A) Change the hydrocolloid dressing to a clients venous ulcer.
B) Start an adverse event report related to a clients fall incident.
C) Empty and measure drainage from closed will containers.
D) Introduced client teaching forecast care and crutch walking
.:Ans>> C) Empty and measure drainage from closed will containers.
100. Older adult client is admitted to the stroke unit after recovery from the
acute phase of an ischemic cerebral vascular accident. Which intervention
should the nurse include in the plan of care during convalescence and rehabilitation.? Select all that apply.
A) Place a bedside commode next to bed.
B) Measure neurological bagel signs every four hours.
C) Play classical music in room while client is awake.
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D) Section oral cavity every four hours.
E) Encourage family to participate in the clients care
.:Ans>> A) Place a bedside commode next to bed.
E) Encourage family to participate in the clients care.
101. The nurse enters the room of a client with Parkinson's disease who is
taking carbidopa levodopa.The client is a rising slowly from the chair while the
unlicensed assistive personnel stands next to the chair. Which action should the
nurse take?
A) Offer a PRN analgesic to reduce painful movement.
B) Tell the UAP to assess the quiet and moving more quickly.
C) Affirm that the client should arise slowly from the chair.
D) Demonstrate how to help the client move more efficiently
.:Ans>> C) Affirm that the client should arise slowly from the chair.
102. The healthcare provider prescribes 500 mL IV bolus of 0.9% normal saline
to be infused over 30 minutes. How many milliliters per hour should the nurse at
the infusion pump? (Enter numerical value only.): 1000
103. The nurse observes an unlicensed assistive personnel begin to remove
exam gloves after emptying a bedpan containing feces. The UAP slides two
fingers inside one of the gloves and begins to roll the glove off which action
should the nurse implement?
A) Advise the UAP that the technique being used will result in hand contamination.
B) Suggest that the UAP row both of the gloves off and inside out at the same time.
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C) Instructor UAP to use two pairs of gloves when fecal contamination is likely.
D) Remind the UAP to discard the gloves in the biohazard container after
removal
.:Ans>> A) Advise the UAP that the technique being used will result in hand
contamination.
104. Healthcare provider to move a client medication prescription from IV to
PO administration and doubles the dose. The nurse notes in the drug guide that
the prescribed medication, when given orally, has a high first pass effect and
reduce bio availability. Which action should the nurse implement?
A) Consult with the pharmacist regarding the error in prescription.
B) Give half the prescribed oral dose until the provider is consulted.
C) Administer the medication via the oral route as prescribed.
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D) Continue
to
administer
the
medication
via
the
IV
route
.:Ans>> C) Administer the
medication via the oral route as prescribed.
105. Three hours after birth, a newborn becomes jittery and tacky piña. Which
action should the nurse do first?
A) Feed 30 mL of 10% dextrose in water.
B) Obtain a capillary glucose level.
C) Wrapped tightly in a warm blanket.
D) Encourage
the
mother
to
breastfeed
.:Ans>> B) Obtain a capillary glucose level.
106. Unlicensed assistive personnel is assigned to a client with flu like symptoms who has been placed on a droplet precaution.The UAP request a change in
assignment because the UAP has not yet been fitted for a particulate filter
mask. Which action should the nurse take?
A) Before changing assignments, determine which staff members have fitted
particulate filter masks.
B) Advise the UAP to wear a standard facemask to obtain vital signs, and then get
fitted for a filter mask before providing care.
C) Instruct the UAP that a standard facemask is sufficient to be able to provide care
for the assigned client.
D) Send the UAP to be fitted for a particular filter mask immediately to be able to
provide
care
to
this
client
.:Ans>> B) Advise the UAP to wear a standard facemask to obtain vital signs, and
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then get fitted for a filter mask before providing care.
107. NGN
A) Administer promethazine 25 mg slow IV push every four hours.
B) Begin potassium chloride 10 MEQ over one hour per second.
C) Initiate continuous dopamine infusion at two mics per kilogram per minute.
D) Give a bolus of 0.9% sodium chloride 1000 mL over 30 minutes: D) Give a
bolus of 0.9% sodium chloride 1000 mL over 30 minutes
108. Client was brought in for his five-year-old well visit and to update vaccines. The mother reports that the child is having some trouble paying attention in school and has had a poor appetite in the past few weeks. Each column
must have at least one but may have more than one response selected. Which
interventions the nurse would include in the plan of care to manage the lead
poisoning level of 7.
-Monitor urine glucose and proteins for renal effects of lead.
-Monitor H&H for potential anemia.
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-Chelation therapy.
-Monitor blood lead levels at one month and then every 3 to 4 months.
-Provide family with lead..
.:Ans>> -Monitor urine glucose and proteins for renal effects of lead. (INCLUDE)
-Monitor H&H for potential anemia. (INCLUDE)
-Chelation therapy. (NOT INCLUDED)
-Monitor blood lead levels at one month and then every 3 to 4 months. (NOT
INCLUDED)
-Provide family with lead...
??????????
109. A client admitted with COPD exacerbation is receiving assisted ventilation with CPAP. The clients vital signs are an oral temperature 98.8 F, a heart
rate of 118 bpm, a respiratory rate of 46 breaths per minute, and a blood
pressure of 176/92. While completing the pulmonary assessment, the clients
oxygen saturation rating is 78% and he is difficult to arouse. Which action
should the nurse implement?
A) Increase the oxygen delivery by 10%.
B) Administer PRN nebulizer treatment.
C) Complete neurological assessment.
D) Prepare for rapid sequence intubation
.:Ans>> D) Prepare for rapid sequence intu- bation.
110. An older adult client asked the nurse about the best foods to help prevent
osteoporosis. Which type of foods should the nurse recommend to the client?
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A) Fresh fruits and vegetables
B) Low-fat dairy products
C) Water and herbal teas
D) Iron-rich me
.:Ans>> B) Low-fat dairy products
111. The nurse is providing teaching to a client with type two diabetes mellitus about managing care at home. Which information provided by the client
indicates an understanding of the teaching?
A) Ensure carbohydrate intake to be 35% of total calories.
B) Get an eye examination with an ophthalmologist annually.
C) Using salt, herbs, and spices will improve the flavor of foods.
D) Check blood sugar levels every 4 to 6 hours everyday
.:Ans>> B) Get an eye examination with an ophthalmologist annually.
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112. A client with chronic kidney disease reported to the nurse of feeling
increasingly tired. The client receives injections for epoetin alpha three times a
week. Which laboratory value should the nurse review?
A) Platelet count.
B) Liver enzymes.
C) Serum electrolytes.
D) Complete
blood
count
.:Ans>> D) Complete blood count.
This injection stimulates production of RBCs so check for anemia.
113. The nurse is planning care for a client with chronic kidney disease he was
a resident of a long-term nursing facility. The client is anuric and has
hemodialysis three times a week. Which intervention should the nurse include in
the clients plan of care?
A) Initiate toileting schedule.
B) Provide her nails skin barrier cream.
C) Encourage intake of high potassium foods.
D) Monitor for signs of anemia: A) Initiate toileting schedule.
????
114. Client who is having G.I. difficulties is undergoing diagnostic procedures.
The client asked the nurse about the difference between ulcerative colitis and
Crohn's disease. Which information should the nurse offer?
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A) Anal abscess and fistula rarely occur in Crohn's disease.
B) Constipation is more common in Crohn's disease.
C) Rectal bleeding is a predominant symptom and ulcerative colitis.
D) Both disorders are distributed along the entire G.I. tract
.:Ans>> C) Rectal bleeding is a predominant symptom and ulcerative colitis.
115. The nurse assesses a child in 90-90s skeletal traction. Where should the
nurse assess for signs of compartment syndrome? Click on correct location.: Click the lower calf area above the ankle, for the leg in traction.
116. The nurse receives shift report about a client with obsessive-compulsive
disorder.The nurse completes morning rounds and approaches the client who is
repeatedly washing the top of the same table. Which intervention should the
nurse implement?
A) Teach the client thought stopping techniques and ways to refocus behav-
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iors.
B) Assist the client to identify stimuli that precipitate the activity.
C) Encourage the client to be calm and relax for a little while.
D) Allow time for the behavior and then redirect the client to other activities
.:Ans>> D) Allow time for the behavior and then redirect the client to other
activities.
117. Following morning care, a client with a C5 spinal cord injury who is
sitting in a wheelchair becomes flushed and complains of a headache. Which
intervention should the nurse implement first?
A) Assess the clients blood pressures every 15 minutes.
B) Relieve any kinks or obstruction in the clients Foley tubing.
C) Teach the client to recognize symptoms of dysreflexia.
D) Administer a prescribed PRN dose of hydralazine
.:Ans>> A) Assess the clients blood pressures every 15 minutes.
This likely dysreflexia but the BP needs to be monitored first. Dysreflexia is an
abnormal overreaction of the involuntary her nervous system. EXP, change in heart
rate, blood pressure, diaphoretic, skin flushing, throbbing HA, confusion/anxiety
118. In evaluating the effectiveness of a postoperative client intermittent pneumatic compression devices, which assessment is most important for the nurse to
complete?
A) Observe both lower extremities for redness and swelling.
B) Monitor the amount of drainage from the clients incision.
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C) Palpate all peripheral pulse points for volume and strength.
D) Evaluate the clients ability to use an incentive spirometer
.:Ans>> C) Palpate all peripheral pulse points for volume and strength.
Puzzler absent all week I can enter key compromise circulation, due to clock
formation.
119. A client with a history of hypertension and diabetes mellitus is admitted
with uncontrolled a fib. The healthcare provider prefers synchronized cardioversion and prescribed a stat dose of dronedarone 400 mg PO. Which
assessment finding warrants immediate intervention by the nurse?
A) Proximal a fib.
B) Third-degree heart block.
C) Elevated mean arterial pressure.
D) Premature ventricular beats
.:Ans>> B) Third-degree heart block.
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120. A home health nurse makes a home visit to a client with Amy trophic lateral sclerosis. The client is sitting upright while feeding themselves and coughs
frequently during the meal. Which action should the nurse implement?
A) Assess the client to lay down and turn to the side.
B) Demonstrate use of a tucked chin position while eating.
C) Recommend the use of supplemental liquid feedings.
D) Encourage the use of assistive feeding devices
.:Ans>> B) Demonstrate use of a tucked chin position while eating.
121. Which assessment showed the home health nurse include during a routine home visit for a client who was discharged home with a super pubic
catheter?
A) Palpate flank area.
B) Measure abdominal girth.
C) Assessed perineal area.
D) Observe insertion site
.:Ans>> D) Observe insertion site.
122. Which is the best approach for the nurse to use when interviewing a client
about sexual abuse?
A) Ask questions in a way, nonspecific format.
B) Get the most difficult questions over with first.
C) Begin with questions that are less sensitive in nature.
D) Share personal values to put the client at ease
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.:Ans>> C) Begin with questions that are less sensitive in nature.
123. *** Photo of quiet injecting insulin into outter thigh.
A) Demonstrate correct selection of the injection site.
B) Advise the client to change the angle of the needle.
C) Observe the injection site for signs of lipodystrophy.
D) Provide a pair of exam gloves for the client to wear
.:Ans>> A) Demonstrate correct selection of the injection site.
124. The nurse is assessing a one day postpartum client. Which finding is most
indicative of a postpartum infection?
A) Moderate amount of foul smelling lochia.
B) Blood pressure of 122/74.
C) White blood count of 19,000.
D) Oral temperature of 100.2
.:Ans>> A) Moderate amount of foul smelling lochia.
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125. The play is a 59-year-old female who is being hospitalized for symptoms
of heart failure. The client has had type 1 diabetes mellitus for 52 years and is
treated with multiple daily injections. She has no other medical conditions. For
surgical history includes the removal of a pilonidal cyst at age 22 and a cesarean
section at age 26. She takes insulin glargine and insulin aspart.
Complete diagram.
.:Ans>> ?????
126. When the parents of a six year old boy with a brain tumor are told that
his condition is terminal, the mother shouts at the father, "this is your fault!
It never would have happened if we had sought treatment sooner!" Which
intervention is best for the Nursing information?
A) Refer the parents to the chaplain to provide grief counseling.
B) I'm sure the parents that a terminal diagnosis was inevitable.
C) Explain to the parents that anger is a common response to grief.
D) Tell the parents that blaming each other will not change the situation
.:Ans>> C) Explain to the parents that anger is a common response to grief.
127. What time is recovering from pneumonia who has a history of severe
COPD and peripheral PVD is being discharged from the skilled nursing facility.
Which action is most important for the nurse to implement?
A) Demonstrate specific strengthening exercises.
B) Reinforce need for adequate hydration.
C) Explain exercise daily regimen.
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D) Provide typed instructions for healthy diet selections
.:Ans>> B) Reinforce need for adequate hydration.
128. A client with a history of type one diabetes mellitus and asthma is readmitted to the unit for the third time in two months with a current fasting blood
sugar of 325. The client describes to the nurse of not understanding why the
blood glucose level continues to be out of control. Which intervention should
the nurse implement? SATA.
A) Ask the client if they want a different manufacturers glucose monitoring
device.
B) Determine if the client is using a new insulin needle each administration.
C) Evaluate the clients asthma medication's that can elevate the blood glu- cose.
D) Have the client describe a typical day at work, home, and social activities.
E) Have the client demonstrate technique used to monitor blood glucose
levels
.:Ans>> C) Evaluate the clients asthma medication's that can elevate the blood
glucose.
D) Have the client describe a typical day at work, home, and social activities.
E) Have the client demonstrate technique used to monitor blood glucose levels.
129. The psychiatric nurse is caring for clients on an adolescent unit. Which
client requires the nurses immediate attention?
A) A 17 year-old client diagnosed with bipolar disorder who is pacing around the
lobby.
B) A 16 year old client diagnosed with major depression who accuses to
participate in group.
C) An 18 year old client with antisocial behavior who is being yelled at by other
clients.
D) A 14-year-old client with anorexia nervosa who is refusing to eat the evening
snack
.:Ans>> C) An 18 year old client with antisocial behavior who is being yelled at by
other clients.
130. The nurse is triaging several children as they present to the emergency
department after a school bus accident. Which child requires the most immediate intervention by the nurse?
A) An 11-year-old with a headache, nausea, and projectile vomiting.
B) An eight-year-old with a full leg air splint for a possible broken tibia.
C) A six year old with multiple superficial laceration of all extremities.
D) A 12-year-old reporting neck, arm, and lower back discomfort
.:Ans>> A) An 11-year-old with a headache, nausea, and projectile vomiting.
Concussion, ICP
131.A 45-year-old female client is admitted to the psychiatric unit for evaluation.
Her husband states that she is reluctant to leave home for the last 6 months. The
client has not gone to work for a month and has been terminated from her job. She
has not left the house since that time. This client is displaying symptoms of what
condition?
• Claustrophobia.
• Acrophobia.
• Agoraphobia
• Post-Traumatic stress disorder.: C
132. A 45-year-old male client tells the nurse that he used to believe he was Jesus
Christ, but now he knows he is not. Which response is best for the nurse to
make?
A. "Did you really believe you were Jesus Christ?"
B. "I think you're getting well."
C. "Others have had similar thoughts when under stress."
D. "Why did you think you were Jesus Christ?": C
133. A male client with schizophrenia tells the nurse that the voices he hears
are saying, "You must kill yourself." To assist the client is coping with these
thoughts, which response is best for the nurse to provide?
• "Tell yourself that the voices are unreasonable"
• "Exercise when you hear the voices."
• "Talk to someone when you hear the voices."
• "The voices aren't real, so ignore them.": A
134. A 25-year-old female client has been particularly restless and the nurse
finds her trying to leave the psychiatric unit. She tells the nurse, "Please let me
go! I must leave because the secret police are after me!" Which response is best
for the nurse to make?
• "No one is after you, you're safe here."
• "You'll feel better after you have rested."
• "I know you must feel lonely and frightened."
• "Come with me to your room and I will sit with you.": D
135. The nurse is conducting discharge teaching for a client with schizophrenia
who plans to live in a group home. Which statement is most indicative of the
need for careful follow-up after discharge?
• "Crickets are a good source of protein."
• "I have not heard any voices for a week."
• "Only my belief in God can help me"
• "Sometimes I have a hard time sitting still.": C
A 52-year-old male client in the ICU who has been oriented suddenly be-
136.
comes disoriented and fearful. Assessment of vital signs and other physical
parameters reveal no significant change and the nurse formulates the diagno- sis,
"confusion related to ICU psychosis". Which intervention would be best to
implement?
• Move all machines away from the client's immediate area.
• Attempt to allay the client's fears by explaining the etiology of his condition.
• Cluster care so that brief periods of rest can be scheduled during the day
• Extend visitation times for family and friends.: C
137. A male client is admitted to the psychiatric unit with a medical diagnosis
of paranoid schizophrenia. During the admission procedure, the client looks up
and states, "No it's not MY fault. You can't blame me. I didn't kill him, you
did." What action is best for the nurse to take?
• Reassure the client by telling him that his fear of the admission procedure is to
be expected.
• Tell the client that no one is accusing him of murder and remind him that the
hospital is safe
• Assess the content of the hallucinations by asking the client what he is
hearing
• Ignore the behavior and make no response at all to his delusional statements: C
138. Over a period of several weeks, one male participant of a socialization
group at a community day care center for the elderly monopolized most of the
group's time and interrupts others when they are talking. What is the best
action for the nurse to take in this situation?
• Talk to the client outside the group about his behavior during group meet- ings
• Remind the client to allow others in the group a change to talk
• Allow the group to handle the problem
• Ask the client to join another group: B
139. A client who is known to abuse drugs is admitted to the unit. Which
med- ication would the nurse anticipate administering to a client who is
exhibiting benzodiazepine withdrawal symptoms?
• Perphenazine (Trilafon)
• Diphenhydramine (Benadryl)
• Chlordiazepoxide (Librium)
• Isocarboxazid (Marplan): C
140. A male client with mental illness and substance dependency tells the
mental health nurse that he has started using illegal drugs again and wants
to seek treatment. Since he has a dual diagnosis, which person is best for the
nurse to refer this client to first?
A. The emergency room nurse.
B. His care manager
C. The clinic healthcare provider.
D. His support group sponsor.: B
141. A 46-year-old female client has been on antipsychotic neuroleptic medication for the past 3 days. She has had a decrease in psychotic behavior and
appears to be responding well to the medication. On the 4th day, the client's BP
increases, she becomes pale and febrile, and demonstrates muscular rigidity.
Which action will the nurse initiate?
A. Place the client on seizure precautions and monitor carefully
B. Immediately transfer the client to ICU
C. Describe the symptoms to the charge nurse and record on the client's chart.
D. No action is required at this time as these are known side effects of such drugs:
B
142. A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest
concern to the nurse and require further assessment?
A. "I will die if my cat dies"
B. "I don't feel like eating this morning."
C. "I just went to my friend's funeral."
D. "Don't you have more important things to do?": A
143. The nurse is planning discharge for a male client with schizophrenia. The
client insists that he is returning to his apartment, although the HCP informed
him that he will be moving to a boarding home. What is the most important
nursing diagnosis for discharge planning?
A. Ineffective denial related to situational anxiety.
B. Ineffective coping related to inadequate support.
C. Social isolation related to difficult interactions.
D. Self-care deficit related to cognitive impairment.: A
144. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is
most important for the nurse to report to the provider?
A. Decreased thyroid stimulating hormone level
B. Elevated liver function profile.
C. Increase white blood cell count.
D. Decrease hematocrit and hemoglobin levels.: A
145.
A client who is being treated with lithium carbonate for bipolar disorder
develops diarrhea, vomiting, and drowsiness. Which action should the nurse take?
A. Notify the health care provider immediately and prepare for administration of
an antidote.
B. Notify the HCP of the symptoms prior to the next administration of the drug
C. Record the symptoms as normal side effects and continue administration of the
prescribed dosage.
D. Hold the medication and refuse to administer additional amounts of the
drug.: B
146. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he
has no family that care about him and was living on the streets prior to this
admission. According to Erikson's theory of psychosocial development, which
stage is the client in at this time?
A. Isolation
B. Stagnation
C. Despair
D. Role confusion: B
147. The parents of a 14-year-old boy brings their son to the hospital. He is
lethargic, but responsive. The mother states, " I think he took some of my pain
pills." During initial assessment of the teenager, what information is most
important for the nurse to obtain from the parents?
A. If he has seemed depressed recently
B. If a drug overdose has ever occurred before.
C. If he might have taken any other drugs
D. If he has a desire to quit taking drugs.: C
148. The nurse observes a client who is admitted to the unit and identifies that
the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. The client's
behavior and thought processes are consistent with which syndrome?
A. Dementia
B. Depression
C. Schizophrenia
D. Chronic brain syndrome: C
149. A male adolescent is admitted with bipolar disorder after being released
from jail for assault with a deadly weapon. When the nurse askes the teen to
identify his reason for the assault, he replies, "Because he made me mad!"
Which goal is best for the nurse to include in the client's plan of care? The
client will...
A. Outline methods for managing anger.
B. Control impulsive actions towards self and others
C. Verbalize feelings when anger occurs.
D. Recognize consequences for behaviors exhibited.: B
150. A 65-year-old female client complains to the nurse that recently she has
been hearing voices. What question should the nurse ask the client first?
A. "Do you have problems with hallucinations?"
B. "Are you ever alone when you hear the voices?"
C. "Has anyone in your family had hearing problems?"
D. "Do you see things that others cannot see?": B
151. At the first meeting of a group of older adults at a daycare canter for the
elderly, the nurse asks one of the members what kinds of things she would like to
do with the group. The older woman shrugs her shoulders and says, "You tell
me, you're the leader." What is the best response for the nurse to make?
A. "Yes, I am the leader today. Would you like the be the leader tomorrow?"
B. "Yes, I will be leading this group. What would you like to accomplish during this
time?"
C. "Yes, I have been assigned to be the leader of this group. I will be here for the
next 6 weeks."
D. "Yes, I am the leader.You seem angry about not being the leader yourself": B
152. An 86-year-old female client with Alzheimer's disease is wandering the
busy halls of the extended care facility and asks the nurse, "Where should I
stand for the parade?" Which response is best for the nurse to provide?
A. "Anywhere you want to stand as long as you don't get hurt by those in the
parade."
B. "You are confused because of all the activity in the hall.There is no parade."
C. "Let's go back to the activity room and see what is going on in there."
D. "Remember I told you that this is a nursing home and I am your nurse.": C
153. Physical examination of a 6-year-old reveals several bite marks in various
locations on his body. X-ray examination reveals healed fractures of the ribs.
The mother tells the nurse that her child is always having accidents. Which
initial repose by the nurse is most appropriate?
A. "I need to inform the HCP about your child's tendency to be accident prone"
B. "Tell me more specifically about your child's accidents"
C. "I must report these injuries to the authorities because they do not seem
accidental"
D. "Boys this age always seem to require more supervision and can be quite
accident prone": B
154.
A child is brought to the ER with a broken arm. Because of other injuries,
the nurse suspects the child may be a victim of abuse. When the nurse tries to give
the child an injection, the child's mother becomes very loud and shouts, "I won't
leave my son! Don't you touch him! You'll hurt my child!" What is the best
interpretations of the mother's statements?
A. Regressing to an earlier behavior pattern
B. Sublimating her anger
C. Projecting her feelings onto the nurse
D. Suppressing her fear: C
155. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, "I
know you are trying to poison me with that food." Which response would be
most appropriate for the nurse to make?
A. "I'll leave your tray here. I am available if you need anything else."
B. "You're not being poisoned. Why do you think someone is trying to poison
you?"
C. "No one on this unit has ever died from poisoning. You're safe here"
D. "I will talk to your HCP about the possibility of changing your diet": A
156. A nurse working in the emergency room of a children's hospital admits a
child whose injuries could have resulted from abuse. Which statement most
accurately describes the nurse's responsibility in cases of suspected child abuse?
A. The nurse should obtain objective data such as x-rays before reporting
suspicions to the authorities.
B. The nurse should confirm any suspicions of child abuse with the health care
provider before reporting to the authorities.
C. The nurse should report any cases suspected child abuse to the nurse in charge.
D. The nurse should note in the clients record any suspicions child abuse that a
history of such suspicions can be tracked.: C
157. A client on a psychiatric unit appears to imitate a certain nurse on the unit.
The client seeks out this particular nurse and imitates the nurse's manner- isms.
The nurse knows that the client is using which defense mechanism?
A. Sublimation.
B. Identification.
C. Introjection.
D. Repression.: B
158. The nurse is planning to care, but 32-year-old male client with acute
depression. Which nursing intervention would be best in helping this client
deal with his depression?
A. Ensure that the client's day is filled with group activities.
B. Assist the client in exploring feelings of shame, anger, and guilt.
C. Allow the client to initiate and determine activities of daily living.
D. Encourage the client to explore the rationale of his depression.;: B
159. An anxious client expressing a fear of people and open places is admitted
to the psychiatric unit. What is the most effective way for the nurse to assist
this client?
A. Planet outing within the first week of admission.
B. Distract her whenever she expresses her discomfort about being with
others.
C. Confront her fears and discuss the possible causes of these fears.
D. Accompany her outside for an increasing amount of time each day.;: D
160. A client with bipolar disorder on the mental health unit becomes loud, and
shouts at one of the nurses, "You fat tub of lard! Get something done around
here!" What is the best initial action for the nurse to take?
A. Have the orderly escort the client to his room.
B. Tell the client his health care provider will be notified if he continues to be
verbally abusive.
C. Redirect the client's energy by asking him to tidy the recreation room.
D. Call the health care provider to obtain a prescription for a sedative.: C