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HESI RN Exit Comprehensive V3
(5 Sets of V3 Exams)
HESI RN EXIT Comprehensive V3 Exam
Set 1
- Which change in sleep patterns is most likely to occur in an older aduANS –
Has a decline in stage 4 sleep - The nurse is developing the plan of care for an older client who is immobileand at risk for pressure ulcers.Which contributing factor should the nurse include in the nursing diagnosis, “risk for altered skin integrity?”
ANS tissue ischemia
Prolonged, intense pressure affects cellular metabolism by impeding capillary blood
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flow to tissue over weight-bearing bony prominences, resulting in tissue ischemia,
skin breakdown, and tissue death - A male client tells the nurse that he is frequently constipated.Which findingshould the nurse identify as a common dietary cause of the complication
ANS In-adequate intake of dietary fiber and fluids - The nurse is obtaining a client’s consent for a paracentesis.What information should a nurse provide to ensure the client understands the purpose of
the procedure
ANS A needle is inserted to remove excessive fluid from the abdominalperitoneal
cavity. - The nurse is teaching a client with Addison’s disease about this new diagnosis. what pathophysio explanation should the nurse share with the client
ANS c.Adrenal insufficiency is an autoimmune dysfunction that results from white
blood cells damaging the adrenal cortex - The nurse is caring for a client with diabetic ketoacidosis (DKA) who is
manifesting rapid and deep rests.Which resp pattern should the nurse docu-
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ment
ANS Kussmaul respirations - The nurse is teaching a client who is newly diagnosed with Type 1 diabetesmellitus about diet and insulin. The client should be instructed to perform
glucose self-monitoring when which symptoms occur after exercising
ANS Shak-iness - Which action should the nurse implement when providing nasogastric (NG)feeding to an unresponsive client
ANS Check residual volume every four hours. - The healthcare provider prescribes digital evacuation a focal impaction foran older client who is admitted for a closed head injury after falling out of
bed. As a part of the procedure policy, the nurse applies a topical anestheticgel to the rectum. What rationale best supports the use of the anesthetic gel
ANS Decrease risk for bradycardia - What nursing intervention should the nurse include in the plan of care fora client following a bone marrow aspiration
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ANS Use of a compression dressing forfirm pressure to the site
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- A 64 year-old client scheduled for surgery with a general anesthetic refuses to remove a set of dentures prior to leaving the unit for the operating room. What would be the most appropriate intervention by the nurse?
A) Explain to the client that the dentures must come out as they may get lost or broken in the operating room
B) Ask the client if there are second thoughts about having the procedure
C) Notify the anesthesia department and the surgeon of the client’s refusal
D) Ask the client if the preference would be to remove the dentures in the operating room receiving area
D: Ask the client if the preference would be to remove the dentures in the operating room receiving area
- The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which form of evaluation would best measure learning?
A) Performance on written tests
B) Responses to verbal questions
C) Completion of a mailed survey
D) Reported behavioral changes
D: Reported behavioral changes
- The nurse is planning care for an 18 month-old child. Which action should be included in the child’s care?
A) Hold and cuddle the child frequently
B) Encourage the child to feed himself finger food
C) Allow the child to walk independently on the nursing unit
D) Engage the child in games with other children
B: Encourage the child to feed himself finger food
- A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that
A) Such fantasies can gratify unconscious wishes or prepare for anticipated future events
B) Detaching or dissociating in this way postpones painful feelings
C) This conversion or transferring of a mental conflict to a physical symptom can lead to marital conflict
D) To isolate the feelings in this way reduces conflict within the client and with others
A: Such fantasies can gratify unconscious wishes or prepare for anticipated future events
- An appropriate goal for a client with anxiety would be to
A) Ventilate anxious feelings to the nurse
B) Establish contact with reality
C) Learn self-help techniques
D) Become desensitized to past trauma
C: Learn self-help techniques
- While the nurse is administering medications to a client, the client states “I do not want to take that medicine today.” Which of the following responses by the nurse would be best?
A) “That’s OK, its all right to skip your medication now and then.”
B) “I will have to call your doctor and report this.”
C) “Is there a reason why you don’t want to take your medicine?”
D) “Do you understand the consequences of refusing your prescribed treatment?”
C: “Is there a reason why you don’t want to take your medicine?”
- While caring for a client, the nurse notes a pulsating mass in the client’s peri umbilical area. Which of the following assessments is appropriate for the nurse to perform?
A) Measure the length of the mass
B) Auscultate the mass
C) Percuss the mass
D) Palpate the mass
B: Auscultate the mass
- A client is admitted to the hospital with a history of confusion. The client has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?
A) “Good morning. Do you remember where you are?”
B) “Hello. My name is Elaine Jones and I am your nurse for today.”
C) “How are you today? Remember, you’re in the hospital.”
D) “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
D: “Good morning. You’re in the hospital. I am your nurse Elaine Jones.”
- The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?
A) Formula or breast milk
B) Dilute nonfat dry milk
C) Warmed fruit juice
D) Fluoridated tap water
A: Formula or breast milk - The family of a 6 year-old with a fractured femur asks the nurse if the child’s height will be affected by the injury. Which statement is true concerning long bone fractures in children?
A) Growth problems will occur if the fracture involves the periosteum
B) Epiphyseal fractures often interrupt a child’s normal growth pattern
C) Children usually heal very quickly, so growth problems are rare
D) Adequate blood supply to the bone prevents growth delay after fractures
B: Epiphyseal fractures often interrupt a child”s normal growth pattern
- The nurse is assessing a client who states her last menstrual period was March 16, and she has missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine test. What will the nurse calculate as the estimated date of delivery (EDD)?
A) April 8
B) January 15
C) February 11
D) December 23
D: December 23
- When screening children for scoliosis, at what time of development would the nurse expect early signs to appear?
A) Prenatally on ultrasound
B) In early infancy
C) When the child begins to bear weight
D) During the preadolescent growth spurt
D: During the preadolescent growth spurt
- A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
A) Discharge the client from home health care related to noncompliance
B) Notify the health care provider of the client’s failure to follow prescribed diet
C) Discuss diet with the client to learn the reasons for not following the diet
D) Make a referral to Meals-on-Wheels
C: Discuss diet with client to learn the reasons for not following the diet
We have an expert-written solution to this problem!
- A client states, “People think I’m no good, you know what I mean?” Which of these responses would be most therapeutic?
A) “Well people often take their own feelings of inadequacy out on others.”
B) “I think you’re good. So you see, there’s one person who likes you.”
C) “I’m not sure what you mean. Tell me a bit more about that.”
D) “Let’s discuss this to see the reasons to create this impression on people?”
C: “I’m not sure what you mean. Tell me a bit more about that.”
- A client being treated for hypertension returns to the community clinic for follow up. The client says, “I know these pills are important, but I just can’t take these water pills anymore. I drive a truck for a living, and I can’t be stopping every 20 minutes to go to the bathroom.” Which of these is the best nursing diagnosis?
A) Noncompliance related to medication side effects
B) Knowledge deficit related to misunderstanding of disease state
C) Defensive coping related to chronic illness
D) Altered health maintenance related to occupation
A: Noncompliance related to medication side effects
- When teaching effective stress management techniques to a client 1 hour before surgery, which of the following should the nurse recommend?
A) Biofeedback
B) Deep breathing
C) Distraction
D) Imagery
B: Deep breathing
- When observing 4 year-old children playing in the hospital playroom, what activity would the nurse expect to see the children participating in?
A) Competitive board games with older children
B) Playing with their own toys along side with other children
C) Playing alone with hand held computer games
D) Playing cooperatively with other preschoolers
D: Playing cooperatively with other preschoolers
- The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
A) Hold a rattle
B) Bang two blocks
C) Drink from a cup
D) Wave “bye-bye”
A: Hold a rattle
- When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child?
A) Provide a verbal explanation just prior to the surgery
B) Provide the child with a booklet to read about the surgery
C) Introduce the child to another child who had heart surgery 3 days ago
D) Explain the surgery using a model of the heart
D: Explain the surgery using a model of the heart
We have an expert-written solution to this problem!
- The parents of a child who has suddenly been hospitalized for an acute illness state that they should have taken the child to the pediatrician earlier. Which approach by the nurse is best when dealing with the parents’ comments?
A) Focus on the child’s needs and recovery
B) Explain the cause of the child’s illness
C) Acknowledge that early care would have been better
D) Accept their feelings without judgment
D: Accept their feelings without judgment
- When caring for a client with total parenteral nutrition (TPN), what is the most important action on the part of the nurse?
A) Record the number of stools per day
B) Maintain strict intake and output records
C) Sterile technique for dressing change at IV site
D) Monitor for cardiac arrhythmias
C: Sterile technique for dressing change at IV site
- When caring for a client who is receiving a thrombolytic agent to open a clot
occluded coronary artery after a myocardial infarction, which finding would be of greatest concern to the nurse?
A) Sero sanginous drainage from gums
B) Hematemesis
C) Pink frothy sputum
D) Slight red color at urine
B: Hematemesis
- A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client complains of chills and headache. Which action should the nurse implement first?
A) Notify the health care provider
B) Check the client’s temperature
C) Stop the transfusion
D) Obtain a urine specimen
C: Stop the transfusion
- An adolescent client is hospitalized with menarthrosis from a Hemophilia A bleeding episode. Which order should be questioned by the nurse?
A) Passive range of motion
B) Replacement of factor VIII
C) Aspirin for pain management
D) Immobilization splint
C: Aspirin for pain management
- The nurse is giving instructions to the mother of a newborn infant with oral candidiasis. Which statement by the mother would indicate the need for further teaching?
A) “Nystatin should be given 4 times a day after my baby eats.”
B) “I will boil the nipples and pacifiers for twenty minutes.”
C) “I should be taking the medication prescribed for this infection.”
D) “The therapy can be discontinued when the spots disappear.”
D: “The therapy can be discontinued when the spots disappear.”
- The nurse is preparing a client for discharge following in-patient treatment for pulmonary tuberculosis. Which of these instructions should be given to the client?
A) Continue medication until findings are relieved
B) Continue medication use as prescribed
C) Avoid contact with children, pregnant women or immune depressed persons
D) Take medication with Amphogel if epigastric distress occurs
B: Continue medication use as prescribed
- The nurse is administering an intravenous piggyback infusion of penicillin. Which of the following client statements would require the nurse’s immediate attention?
A) “I have a burning sensation when I urinate.”
B) “I have soreness and aching in my muscles.”
C) “I am itching all over.”
D) “I have cramping in my stomach.”
C: “I am itching all over.”
- A woman diagnosed with bipolar disorder is to take lithium (Lithane) as part of the treatment. What should the nurse discuss with the client as part of the teaching plan?
A) Risks of oral contraceptives
B) Reduction in exercise program
C) Avoidance of alcohol
D) Cessation of smoking
C: Avoidance of alcohol
- The nurse prepares to administer eye drops to a 6 year-old child. Which of these demonstrates the correct method for instillation of eye drops?
A) Directly on the anterior surface of the eyeball
B) In the corner where the lids meet
C) Under the upper lid as it is pulled upward
D) In the conjunctival sac as the lower lid is pulled down
D: In the conjunctival sac as the lower lid is pulled down
- A depressed client is experiencing severe insomnia. The health care provider orders trazadone (Desyrel). The nurse tells the client to expect
A) Improvement of acne
B) Relief of insomnia
C) Reduced arthritic pain
D) Less nasal stuffiness
B: Relief of insomnia
- A client with diabetes has a blood sugar is 306 this morning. After the nurse reports this lab result and the client’s symptoms of excessive hunger and thirst, what would the nurse expect the health care provider to order?
A) Orange juice
B) Regular insulin
C) NPH Insulin
D) Repeat blood sugar level
B: Regular insulin
- The nurse is planning to administer otic drops to a 6 year-old child. Which of the following is the correct procedure?
A) Hold the pinna up and back to instill the drops
B) Place several drops in the outer ear
C) Insert cotton in the outer ear after giving medication
D) Assist the child to lie on the affected side afterwards
A: Hold the pinna up and back to instill the drops
- A 1 year-old child is receiving temporary total parental nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time?
A) Use aseptic technique during dressing changes
B) Maintain central line catheter integrity
C) Monitor serum glucose levels
D) Check results of liver function tests
C: Monitor serum glucose levels
- Today’s prothrombin time for a client receiving Coumadin is 20 (normal range listed by the lab is 10-14). What is the appropriate nursing action?
A) Notify the health care provider immediately
B) Recognize that this is a therapeutic level
C) Observe the client for hematoma development
D) Assess for bleeding at gums or IV sites
B: Recognize that this is a therapeutic level
- The nurse administered intravenous gamma globulin to an 18 month-old child with AIDS. The parent asks why this medication is being given. What is the nurse’s best response?
A) “It will slow down the replication of the virus.”
B) “This medication will improve your child’s overall health status.”
C) “This medication is used to prevent bacterial infections.”
D) “It will increase the effectiveness of the other medications your child receives.”
C: “This medication is used to prevent bacterial infections.”
- The nurse is administering the initial total parenteral nutrition solution to a client.
Which of the following assessments requires the nurse’s immediate attention?
A) Temperature of 37.5 degrees Celsius
B) Urine output of 300 cc in 4 hours
C) Poor skin turgor
D) Blood glucose of 350 mg/dl
D: Blood glucose of 350 mg/dl
- The nurse is teaching a client with asthma about the correct use of the Azmacort (triamcinolone) inhaler. Which of the following statements, if made by the client, would indicate that the teaching was effective?
A) “The inhaler can be used whenever I feel short of breath.”
B) “I should rinse my mouth after using the inhaler.”
C) “If I forget a dose, I can double up on the next dose.”
D) I should not use a spacer with my Azmacort.
B: “I should rinse my mouth after using the inhaler.”
- A client is admitted to the hospital because of heart failure and digoxin toxicity. At home, the client was taking digoxin (Lanoxin) and furosemide (Lasix). Which symptom would the nurse anticipate finding on the initial assessment?
- A) Muscle weakness and cramping
B) Confusion
C) Blood in the urine
D) Tinnitis
A: Muscle weakness and cramping
- The nurse admits a client with hypertension who complains of dizziness after taking diltiazem (Cardizem). Which of the following is the most important information for the nurse to assess?
A) Schedule for taking medicine
B) Daily intake of potassium
C) Activity and rest patterns
D) Baseline heart rate
A: Schedule for taking medicine (Review Information)
- Which of the following classifications of medications would be most often used for clients with schizophrenia?
A) Anti-depressants
B) Mood stabilizers
C) Anxiolytics
D) Neuroleptics
D: Neuroleptics
- A hospitalized 8 month-old infant is receiving digoxin for the treatment of Tetralogy of Fallot. Prior to administering the next dose of medication, the parent reports that the baby has vomited one time, just after breakfast. The heart rate is 62. What is the initial response of the nurse?
A) Give the dose after lunch
B) Reduce the next dose by half
C) Double the next dose
- D) Hold the medication
D: Hold the medication
- A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning. Which of these should the nurse assess first ?
A) Serum potassium level
B) Blood calcium level
C) Urinary output
D) Deep tendon reflexes
C: Urinary output
- The nurse is assessing a client who has taken haldol (Haloperidol) for several months. Which of the following is a side effect of this medication and must be reported immediately to the health care provider?
A) Muscle flaccidity
B) Dystonic reaction
C) Mood swings
D) Dry, harsh cough
B: Dystonic reaction
- The nurse is caring for a client with renal calculi. Which health care provider order would be a priority?
A) Morphine sulfate as client controlled analgesia
B) Push oral fluids and keep vein open
C) Continuous warm compresses to the flank area
D) Intravenous antibiotics
A: Morphine sulfate as client controlled analgesia
- A client with angina has been instructed about the use of sublingual nitroglycerin. Which of the following statements made to the nurse indicates a need for further teaching?
A) “I will rest briefly right after taking 1 tablet.”
B) “I can take 2-3 tablets at once if I have severe pain.”
C) “I’ll call the doctor if pain continues after 3 tablets 5 minutes apart.”
D) “I understand that the medication should be kept in the dark bottle.”
B: “I can take 2-3 tablets at once if I have severe pain.”
- The nurse is teaching administration of albuterol inhalation to an adult with asthma. Which of the following demonstrates proper teaching?
A) “Use this medication at bedtime to promote rest.”
B) “Discontinue the inhalation if you are dizzy.”
C) “Inhale this medication after other asthma sprays.”
D) “Notify the health care provider if you need the drug more often.”
D: “Notify the health care provider if you need the drug more often.”
- A hospitalized 8 month-old is receiving gentamicin (Cidomycin). In monitoring the infant for drug toxicity, the nurse should review which laboratory results first?
A) Blood urea nitrogen
B) Thyroxin levels
C) Growth hormone levels
D) Platelet counts
A: Blood urea nitrogen
- A client who is receiving chemotherapy through a central line is admitted to the hospital with a diagnosis of sepsis. Which of the following nursing interventions should receive priority?
A) Inspect all sites that may serve as entry ports for bacteria
B) Place the client in reverse isolation
C) Change the dressing over the site of the central line
D) Restrict contact with persons having known, or recent, infections
A: Inspect all sites that may serve as entry ports for bacteria
- The nurse is caring for a client with Parkinson’s disease who has developed hallucinations. Which of the following medications that the client is receiving may have been a contributing factor?
A) L-Dopa
B) Cogentin
C) Baclofen
D) Benadryl
A: L-Dopa
- The nurse is caring for a child receiving albuterol (Proventil) for asthma. The parents ask the nurse why their child is receiving this medication. Which explanation is correct?
A) decrease the swelling in the airways.”
- B) relax the smooth muscles in the airways.”
C) reduce the secretions blocking the airways.”
D) stimulate the respiratory center in the brain that control respirations.”
B: relax the smooth muscles in the airways.”
- The nurse prepares to give a one year-old child an intramuscular injection. Where is the best site for this injection?
A) Deltoid muscle
B) Ventrogluteal muscle
C) Dorsogluteal muscle
D) Vastus lateralis muscle
D: Vastus lateralis muscle
- The nurse is administering albuterol (Proventil) to a child with asthma. Which of the following assessments by the nurse indicate the need for an adjustment of the medication?
A) Lethargy and fatigue
B) Edema is the lower extremities
C) Apical Pulse of 112
D) Temperature of 101 degrees Fahrenheit
C: Apical Pulse of 112
- To which of the following nursing home residents could the nurse safely administer tricyclic antidepressants without questioning the health care provider’s order?
A) An 85 year-old male with narrow-angle glaucoma
B) An African-American with benign prostatic hypertrophy
C) A 65 year-old female with mild hypertension
D) A Hispanic female with coronary artery disease
C: A 65 year-old female with mild hypertension
- The nurse is teaching a client about precautions with Coumadin. The nurse should instruct the client to avoid foods with excessive amounts of which nutrient
A) Calcium
B) Vitamin K
C) Iron
D) Vitamin E
B: Vitamin K
- The nurse is caring for a 15 month-old child with a first episode of otitis media. Which of the following interventions should the nurse include in instructions to the child’s parents?
A) Explain that the child should complete the full 5 days of antibiotics
B) Provide them with handout describing care of myringotomy tubes
C) Describe the tympanocentesis to detect persistent infections
D) Emphasize the importance of a return visit after completion of antibiotics
D: Emphasize the importance of a return visit after completion of antibiotics
- The nurse is caring for an 81 year-old client with colorectal cancer. The client’s pain has been managed until now with acetaminophen with codeine. Because of increased pain, intravenous morphine is added. What should the nurse recognize about the validity of this order?
A) Inappropriate because of potential respiratory depression
B) Appropriate despite the expected effect of mental confusion
C) Inappropriate and demonstrates poor knowledge of pain control
D) Appropriate pain management around-the-clock
D: Appropriate pain management around-the-clock
- Before administering digoxin (Lanoxin) to a client, which of the following nursing assessments is a priority?
A) Auscultate breath sounds
B) Check for bowel sounds
C) Monitor the heart rate
D) Measure the blood pressure
C: Monitor the heart rate
- When teaching a client about the use of sublingual nitroglycerin, the nurse should emphasize that which of these is the most common side effect?
A) Headache
B) Dry mouth
C) Depression
D) Anorexia
A: Headache
- What would the nurse expect to see in a client who is experiencing symptoms of tardive dyskinesia?
A) Rapid tongue movements
B) Uncontrolled hand tremors during meals
C) Behavioral changes
D) Repetitive slapping movements
A: Rapid tongue movements
We have an expert-written solution to this problem!
- The nurse is teaching a client who has a new prescription for sublingual nitroglycerin. Which of the following must be emphasized?
A) Rest in bed for an hour after taking medication
B) Take the medication at the same time each day
C) Keep the medication bottle in the refrigerator
D) Carry the nitroglycerine with you at all times
D: Carry the nitroglycerine with you at all times
- The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
A) Ask the client and family if they are satisfied with the care given
B) Determine if the home health aide’s care is consistent with the plan of care
C) Investigate if the home health aide is prompt and stays an appropriate length of time for care
D) Check the documentation of the aide for appropriateness and comprehensiveness
B: Determine if the home health aide is following the plan of care
- The nurse in the same day surgery unit assigns the unlicensed assistive personnel (UAP) to give a 1000 ml soap solution enema (SSE) to a client scheduled for an abdominal hysterectomy. Which statement by the nurse is most appropriate?
A) “Administer enemas until the results are clear.”
B) “Give 3 enemas before surgery.”
C) “Let me know the results of the enema.”
D) “Slow the flow of the solution if cramping occurs.”
D: “Slow the flow of the solution if cramping occurs.”
- An RN from the women’s health clinic is temporarily reassigned to a medical-surgical unit. Which of these client assignments would be most appropriate for this nurse?
A) A newly diagnosed client with type 2 diabetes mellitus who is learning foot care
B) A client from a motor vehicle accident with an external fixation device on the leg
C) A client admitted for a barium swallow after a transient ischemic attack
D) A newly admitted client with a diagnosis of pancreatic cancer
B: A motor vehicle accident (MVA) client with an external fixation device on the leg
- Which client data should the nurse act upon when a home health aide calls the nurse from the client’s home to report these items?
A) The client has complaints of not sleeping well for the past week.
B) The family wants to discontinue the home meal service, meals on wheels.
C) The urine in the urinary catheter bag is of a deeper amber, almost brown color.
D) The partner says the client has slower days every other day.
C: The urine in the urinary catheter bag is of a deeper amber almost brown color.
- A client is receiving an intravenous (IV) infusion for pain control. When caring for this client, which one of these actions can the RN safely assign to an unlicensed assistive personnel (UAP)?
A) Ask the client the degree of relief and document the client’s response
B) Decrease the set rate on the pump by 2 ml/minute
C) Check the IV site for drainage and loose tape
D) Assist the client with ambulation and a gown change
D: Assist the client with ambulation and a gown change
- A practical nurse (PN) from the pediatric unit is assigned to work in a critical care unit. Which client assignment would be appropriate?
A) A client admitted with multiple trauma with a history of a newly implanted pacemaker
B) A new admission with left-sided weakness from a stroke and mild confusion C) A 53 year-old client diagnosed with cardiac arrest from a suspected myocardial infarction
D) A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident
D: A 35 year-old client in balanced traction admitted 6 days ago after a motor vehicle accident
- A 25 year-old client, unresponsive after a motor vehicle accident, is being transferred from the hospital to a long term care facility. To which o staff members should the charge nurse assign the client?
A) Unlicensed assistive personnel (UAP)
B) Senior nursing student
C) PN
D) RN
D: An RN
- Which statement by the nurse is appropriate when giving an assignment to an unlicensed assistive personnel (UAP) to ambulate a client for the first time after a colon resection?
A) “Have the client sit on the side of the bed before helping the client to walk.”
B) “If the client is dizzy ask the client to take some slow, deep breaths.”
C) “Help the client to walk in the room as often as the client wishes.”
D) “When you help the client to walk, ask if any pain occurs.”
A: “Have the client sit on the side of the bed before helping him/her to walk.”
- A charge nurse working in a long term care facility is making out assignments. Which assignment to an unlicensed assistive personnel (UAP), if made by the nurse, requires intervention by the supervisor?
A) Provide decubitus ulcer care and apply a dry dressing
B) Bathe and feed a client on bed rest
C) Oral suctioning of an unresponsive elderly client
D) Teaching a family intermittent (bolus) feedings via G-tube before discharge
D: Teaching a family intermittent (bolus) feedings via G-tube before discharge
- Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?
A) Document skin turgor and color changes
B) Test stool for occult blood and urine for glucose
C) Suggest foods high in iron and those easily consumed
D) Report mental status changes and the degree of mental clarity
B: Test stool for occult blood and urine for glucose
- Which one of these tasks can be safely delegated to a PN?
A) Assess the function of a newly created ileostomy
B) Care for a client with a recent complicated double barrel colostomy
C) Provide stoma care for a client with a well functioning
C: Provide stoma care for a client with a well functioning ostomy.
- The nurse assigns an unlicensed assistive personnel (UAP) to care for a client with a musculoskeletal disorder. The client ambulates with a leg splint. Which task requires supervision of the UAP?
A) Report signs of redness overlying a joint
B) Monitor the client’s response to ambulatory activity
C) Encouragement for the independence in self-care
D) Assist the client to transfer from a bed to a chair
B: Monitor the client”s response to ambulatory activity
- Which of these clients would be most appropriate to assign to a PN?
A) A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection
B) A client with newly diagnosed type 2 diabetes mellitus and a client with a history of
AIDS admitted for pneumonia
C) A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation
D) A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure
C: A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation.
- A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)?
A) Teach the client how to cough up secretions
B) Changes the tracheostomy trach ties
C) Monitor if client has shortness of breath
D) Perform routine tracheostomy dressing care
D: Perform routine tracheostomy dressing care
- Which of these clients would be appropriate to assign to a PN?
A) A trauma victim with multiple lacerations and requires complex dressings.
B) An elderly client with cystitis and an indwelling urethral catheter.
C) A confused client whose family complains about the nursing care 2 days after surgery.
D) A client admitted for possible transient ischemic attack with unstable neuro signs.
B: An elderly client with cystitis and an indwelling urethral catheter.
- Two people call in sick on the medical-surgical unit and no additional help is available. The team consists of an RN, an LPN and an unlicensed assistive personnel (UAP). Which of these activities should the nurse assign to the UAP?
A) Assist with plans for any clients discharged
B) Provide basic hygiene care to all clients on the unit
C) Assess a client after an acute myocardial infarction
D) Gather the vital signs of all clients on the unit
B: Provide basic hygiene care to all clients on the unit
- During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?
A) What degree of supervision for basic care do you think you need?
B) Let’s review your skills check-list for type and level of skill.
C) Are you comfortable working independently?
D) What client care tasks or assignments do you prefer?
B: Let’s review your skills check-list for type and level of skill.
- An unlicensed assistive personnel (UAP), who usually works in pediatrics is assigned to work on a medical-surgical unit. Which one of the questions by the charge nurse would be most appropriate prior to making delegation decisions?
A) “How long have you been a UAP?”
B) “What type of care did you give in pediatrics?”
C) “Do you have your competency checklist that we can review?”
D) “How comfortable are you to care for adult clients?”
C: “Do you have your competency checklist that we can review?”
- The measurement and documentation of vital signs is expected for clients in a long term facility. Which staff type would it be a priority to delegate these tasks to?
A) Practical nurse (PN)
B) Registered Nurse (RN)
C) Unlicensed assistive personnel (UAP)
D) Volunteer
C: Unlicensed assistive personnel (UAP)
- The RN delegates the task of taking vital signs of all the clients on the medical- surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client’s blood pressure on the left arm. Later as the RN is making rounds, the nurse finds the blood pressure cuff on that client’s left arm. Which of these statements is most accurate?
A) The RN is accountable for this situation.
B) The RN did not delegate appropriately.
C) The UAP is covered by the RN’s license.
D) The UAP is responsible for following instructions.
D: The UAP is responsible for following instructions.
- As the RN responsible for a client in isolation, which can be delegated to the PN?
A) Reinforcement of isolation precautions
B) Assessment of the client’s attitude about infection control
C) Evaluation of staffs’ compliance with control measures
D) Observation of the client’s total environment for risks
A: Reinforcement of isolation precautions
- The care of which of the following clients can the nurse safely delegate to an unlicensed assistive personnel (UAP)?
A) A client with peripheral vascular disease and an ulceration of the lower leg.
B) A pre-operative client awaiting adrenalectomy with a history of asthma
C) An elderly client with hypertension and self-reported noncompliance
D) A new admission with a history of transient ischemic attacks and dizziness
A: A client with peripheral vascular disease and an ulceration of the lower leg.
- The charge nurse on a cardiac step-down unit makes assignments for the team consisting of an RN, a PN, and an unlicensed assistive person. Which client should be assigned to the PN?
A) A 49 year-old with new onset atrial fibrillation with a rapid ventricular response
B) A 58 year-old hypertensive with possible angina.
C) A 35 year-old scheduled for cardiac catheterization.
D) A 65 year-old for discharge after angioplasty and stent placement.
B: A 58 year-old hypertensive with possible angina.
- When walking past a client’s room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?
A) “If we work together we can get all of the client care completed.”
B) “Since I am late for lunch, would you do this one client’s glucose test?”
C) “This client seems confused, we need to watch monitor closely.”
D) “I’ll come back and make the bed after I go to the lab.”
B: “Since I am late for lunch, would you do this one client”s glucose test?”
- A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?
A) I will arrange for a conference with you and the UAP within the next week.
B) I can assure you that I will look into the matter.
C) I would like for you to approach the UAP about the problem the next time it occurs.
D) I will add this concern to the agenda for the next unit meeting.
C: Suggest that the nurse approach the assistant about the problem
- A client experiences intense anxiety after the home was destroyed by a fire. The client escaped from the fire with only minor injuries. The nurse knows that the most important initial intervention would be to:
A) Suggest the client rent an apartment with a sprinkler system
B) Provide a brochure on methods to promote relaxation.
C) Determine available community and personal resources
D) Explore the feelings of grief associated with the loss
C: Determine available community and personal resources
- An elderly client with tuberculosis has difficulty coughing up secretions for a sputum specimen. Which nursing action is appropriate?
A) Spray the oropharynx with saline
B) Ask the client to drink a warm liquid
C) Force fluids for the next 8 hours
D) Raise the head of the bed to at least 45 degrees
D: Raise the head of the bed to at least 45 degrees
- The nurse is caring for a 16 year-old client with femur fracture 14 hours after surgery. Assessment findings include tachycardia, increased shortness of breath, a temperature of 100.2 degrees
Fahrenheit, complaints of feeling anxious, and oxygen saturation level of 88%. In immediately notifying the provider of these findings, the nurse recognizes the client is at risk for
A) compartment syndrome
B) atelectasis
C) myocardial infarction
D) fatty embolism
D: fatty embolism
- The client referred for a mammography questions the nurses about the cancer risks from radiation exposure. What is the appropriate response by the nurse?
A) The radiation from a mammography is equivalent to 1 hour of sun exposure.
B) You have nothing to worry about; it is less than tanning in the nude.
C) A chest x-ray gives you more radiation exposure.
D) Exposure to mammography every 2 years is not dangerous.
A: The radiation from a mammography is equivalent to one hour of sun exposure.
- On admission to the ambulatory surgery unit, the nurse notices the client’s painted finger nails. On reviewing the pre-op orders, the nurse notes that pulse oximetry has been ordered. Which statement by the nurse is appropriate?
A) “In order to measure your oxygen level, please remove the polish from at least 2 nails.”
B) “If you do not remove all your polish, I will request a needle stick to test oxygen levels.”
C) “I am sorry. All your nail polish must go off.”
D) “I will ask your provider if we must ruin those beautiful nails.”
A: “In order to measure your oxygen level, please remove the polish from at least 2 nails.”
- The nurse is removing a fecal impaction on a 75 year-old client. It is most important that the nurse remember that
A) the procedure be done prior to the bath
B) family members should be taught the procedure
C) cardiac dysrhythmias can result during the process
D) increased dietary fiber can minimize such problems
C: cardiac dysrhythmias can result during the process
- When taking the client’s blood pressure (BP), the nurse cannot hear the sounds through the stethoscope. Which action should the nurse take first?
A) take the BP again in 2 minutes in the same arm
B) retake the BP again immediately in the same arm
C) use an electronic BP cuff on the other arm
D) check to see if the stethoscope is plugged
A: take the BP again in 2 minutes in the same arm
- The client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube, the nurse should
A) ask the client to hold a breath
B) offer sips of water
C) bring the code cart to the bedside
D) empty the tube of all drainage
A: ask the client to hold a breath
- A client is being discharged home today, and will be taking K-dur 20mEq per day by mouth. The nurse should reinforce that potassium levels will be decreased by
A) foods seasoned with salt substitute
B) frequent daily snacks of black licorice
C) prescribed potassium-sparing diuretics
D) occasional use of a non steroidal anti-inflammatory drug (NSAID)
B: frequent daily snacks of black licorice
- A client has just returned from the Post-Anesthesia Care Unit (PACU) to the surgical unit after a cholecystectomy. When initial vital signs are taken the nurse notes a temperature of 94.8 degrees Fahrenheit. Which first nursing action is appropriate?
A) Continue to monitor the vital signs as indicated
B) Apply a warm blanket and check the temperature in 10 minutes
C) Ask the PACU nurse more details of what happened in PACU
D) Call the health care provider and obtain further orders for warming
B: Apply a warm blanket and check the temperature in ten minutes
- The client with amyotrophic lateral sclerosis is scheduled for 160 ml of enteral feeding as a bolus every 4 hours. Before flushing with water the nurse aspirates the feeding tube contents and gets back 180 ml of feeding. What is the next appropriate nursing action?
A) Administer the feeding as ordered
B) Hold the next feeding
C) Flush with sterile water
D) Discard the undigested feeding
B: Hold the next feeding
- The nurse is inserting a Foley catheter into the bladder of a female adult client. The nurse slips the catheter into an opening for four-5 inches and no urine is obtained. The most probable reason for this is that
A) there is no urine present in the bladder
B) the catheter is in the vagina
C) the catheter is not inserted in far enough
D) the bladder is over distended
B: the catheter is in the vagina
- After the death of a client, the family approaches the nurse and requests that a family member be allowed to perform a ritual bath on the deceased prior to moving the body. The appropriate response by the nurse is
A) I will have to check on hospital regulations and policies.
B) These procedures have to be carried out by our staff.
C) Is there anything you need from me to perform the ritual bath?
D) A ritual bath will have to wait until after post-mortem care
C: Is there anything you need from me to perform the ritual bath?
- The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?
A) Pack the nose and ears with sterile gauze
B) Apply pressure to the injury site
C) Apply bulky, loose dressing to nose and ears
D) Apply an ice pack to the back of the neck
C: Apply bulky, loose dressing to nose and ears
- A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are complaining. As a change
agent, the nurse manager should first
A) Support the planning committee and post the new schedule
B) Explore how the planning committee evaluated barriers to the plan
C) Design a different approach to deliver care with fewer staff
D) Retain the previous staffing pattern for another 6 months
B: Explore how the planning committee evaluated barriers to the plan
- The nurse is caring for a depressed client with a new prescription for an SSRI antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?
A) History of obesity
B) Prescribed use of an MAO inhibitor
C) Diagnosis of vascular disease
D) Takes antacids frequently
B: Prescribed use of an MAO inhibitor
- In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?
A) Cardizem SR tablet (diltiazem)
B) Lanoxin liquid
C) Os-cal tablet (calcium carbonate)
D) Tylenol liquid (acetaminophen)
A: Cardizem SR tablet (diltiazem)
- The most common reason for an Apgar score of 8 and 9 in a newborn is an abnormality of what parameter?
A) Heart rate
B) Muscle tone
C) Cry
D) Color
D: Color
- A nurse has asked a second staff nurse to sign for a wasted narcotic, which was not witnessed by another person. This seems to be a recent pattern of behavior. What is the appropriate initial action?
A) Report this immediately to the nurse manager
B) Confront the nurse about the suspected drug use
C) Sign the narcotic sheet and document the event in an incident report
D) Counsel the colleague about the risky behaviors
A: Report this immediately to the nurse manager
- To obtain data for the nursing assessment, the nurse should:
A) Observe carefully the client’s nonverbal behaviors
B) Adhere to pre-planned interview goals and structure
C) Allow clients to talk about whatever they want
D) Elicit clients’ description of their experiences, thoughts and behaviors
D: Elicit clients” description of their experiences, thoughts and behaviors
- The nurse will administer liquid medicine to a 9 month-old child. Which of the following methods is appropriate?
A) Allow the infant to drink the liquid from a medicine cup
B) Administer the medication with a syringe next to the tongue
C) Mix the medication with the infant’s formula in the bottle
D) Hold the child upright and administer the medicine by spoon
B: Administer the medication with a syringe next to the tongue
- A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate first action by the nurse?
A) Suggest isometric exercises
B) Maintain the client on bed rest
C) Ambulate for several minutes
D) Apply ice to the extremity
B: Maintain the client on bed rest
- The nurse is teaching diet restrictions for a client with Addison’s disease. The client would indicate an understanding of the diet by stating
A) “I will increase sodium and fluids and restrict potassium.”
B) “I will increase potassium and sodium and restrict fluids.”
C) “I will increase sodium, potassium and fluids.”
D) “I will increase fluids and restrict sodium and potassium.”
A: “I will increase sodium and fluids and restrict potassium.”
- A client refuses to take the medication prescribed because the client prefers to take self-prescribed herbal preparations. What is the initial action the nurse should take?
A) Report the behavior to the charge nurse
B) Talk with the client to find out about the preferred herbal preparation
C) Contact the client’s health care provider
D) Explain the importance of the medication to the client
B: Talk with the client to find out about the preferred herbal preparation
- During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client’s knees. The best action for the nurse to take is to
A) Ask the client for more information about the nature of the bruises
B) Ask the client and then the family about the findings
C) Report the bruising to social services to follow-up
D) Document the findings on the admission sheet
A: Ask the client for more information about the nature of the bruises
- A client with considerable pain asks: “What is your opinion regarding acupuncture as a drug-free method for alleviating pain?” The nurse responds, “I’d forget about it as those weird non-Western treatments can be scary.” The nurse’s response is an example of
A) Prejudice
B) Discrimination
C) Ethnocentrism
D) Cultural insensitivity
C: Ethnocentrism
- A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child’s greatest fear?
A) Change in body image
B) An unfamiliar environment
C) Perceived loss of control
D) Guilt over being hospitalized
C: Perceived loss of control
q113. A nurse arranges for a interpreter to facilitate communication between the health care team and a non-English speaking client. To promote therapeutic communication, the appropriate action for the nurse to remember when working with an interpreter is to
A) Promote verbal and nonverbal communication with both the client and the interpreter
B) Speak only a few sentences at a time and then pause for a few moments
C) Plan that the encounter will take more time than if the client spoke English
D) Ask the client to speak slowly and to look at the person spoken to
A: Promote verbal and nonverbal communication with both the client and the interpreter
- The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?
A) Separation anxiety
B) Fear of pain
C) Loss of control
D) Bodily injury
A: Separation anxiety
- Which statement describes strategies that help build personal power in an organization?
A) Longevity in an organization, social ties to people in power, and a history as someone who does not back down in conflict ends with success
B) Goals are met with the use of networking, mentoring, and coalition building
C) High visibility and formal power are maintained with a confrontational style
D) Credibility to one’s position is enhanced when professional dress and demeanor are employed
B: Goals are meet with the use of networking, mentoring, and coalition building
- A 24 year-old male is admitted with a diagnosis of testicular cancer. The nurse would expect the client to have
A) Scrotal discoloration
B) Sustained painful erection
C) Inability to achieve erection
D) Heaviness in the affected testicle
D: Heaviness in the affected testicle
- A mother telephones the clinic and says “I am worried because my breast-fed 1 month-old infant has soft, yellow stools after each feeding.” The nurse’s best response would be which of these?
A) This type of stool is normal for breast fed infants. Keep doing as you have.
B) The stool should have turned to light brown by now. We need to test the stool
C) Formula supplements might need to be added to increase the bulk of the stools.
D) Water should be offered several times each day in addition to the breast feeding.
A: This type of stool is normal for breast fed infants. Keep doing as you have.
- Hospital staff requests that the parents with a Greek heritage of a hospitalized infant remove the amulet from around the child’s neck. The parents refuse. The nurse understands that the parents may be concerned about
A) Mental development delays
B) Evil eye or envy of others
C) Fright from spiritual beings
D) Balance in body systems
B: Evil eye or envy of others
- Which statement describes the use of a decision grid for decision making?
A) It is both a visual and a quantitative method of decision making
B) It is the fastest way for group decision making
C) It allows the data to be graphed for easy interpretation
D) It is the only truly objective way to make a decision in a group
A: It is both a visual and a quantitative method of decision making
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- The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
A) Massage legs frequently
B) Frequent turning
C) Moisten skin with lotions
D) Apply moist heat to reddened areas
B: Frequent turning
- Dual diagnosis indicates that there is a substance abuse problem as well as a
A) Cross addiction
B) Mental disorder
C) Disorder of any type
D) Medical problem
B: Mental disorder
- Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy?
A) Permission to videotape
B) Salivary pH
C) Mini-mental status exam
D) Pre-anesthesia work-up
D: Pre-anesthesia workup
- The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis?
A) Severe diarrhea for 24 hours
B) Nausea with anorexia
C) Alternating constipation and diarrhea
D) Vomiting for over 48 hours
A: Severe diarrhea
- The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
A) Skin irritation
B) Drug tolerance
C) Severe headaches
D) Postural hypotension
B: Drug tolerance
- What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
A) Acceptance of the pregnancy
B) Acceptance of the termination of the pregnancy
C) Acceptance of the fetus as a separate and unique being
D) Satisfactory resolution of fears related to giving birth
A: Acceptance of the pregnancy
- During the two-month well-baby visit, the mother complains that formula seems to stick to her baby’s mouth and tongue. Which of the following would provide the most valuable nursing assessment?
A) Inspect the baby’s mouth and throat
B) Obtain cultures of the mucous membranes
C) Flush both sides of the mouth with normal saline
D) Use a soft cloth to attempt to remove the patches
D: Use a soft cloth to attempt to remove the patches
- After successful alcohol detoxification, a client remarked to a friend, “I’ve tried to stop drinking but I just can’t, I can’t even work without having a drink.” The client’s belief that he needs alcohol indicates his dependence is primarily
A) Psychological
B) Physical
C) Biological
D) Social-cultural
A: Psychological
- A nurse is caring for a client with peripheral arterial insufficiency of the lower extremities. Which intervention should be included in the plan of care to reduce leg pain?
A) Elevate the legs above the heart
B) Increase ingestion of caffeine products
C) Apply cold compresses
D) Lower the legs to a dependent position
D: Lower the legs to a dependent position
- A diabetic client asks the nurse why the health care provider ordered a glycolsylated hemoglobin (HbA) measurement, since a blood glucose reading was just performed. You will explain to the client that the HbA test:
A) Provides a more precise blood glucose value than self-monitoring
B) Is performed to detect complications of diabetes
C) Measures circulating levels of insulin
D) Reflects an average blood sugar for several months
D: Reflects an average blood sugar for several months
- The nurse is speaking to a group of parents and school teachers of children about care for children with rheumatic fever. It is a priority to emphasize that
A) Home schooling is preferred to classroom instruction
B) Children may remain strep carriers for years
C) Most play activities will be restricted indefinitely
D) Clumsiness and behavior changes should be reported
D: Clumsiness and behavior changes should be reported
- A client admits to benzodiazepine dependence for several years. She is now in an outpatient detoxification program. The nurse must understand that a priority during withdrawal is
A) Avoid alcohol use during this time
B) Observe the client for hypotension
C) Abrupt discontinuation of the drug
D) Assess for mild physical symptoms
A: Avoid alcohol use during this time
- A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity?
A) Serum potassium
B) Protein intake
C) Lactose tolerance
D) Serum albumin
D: Serum albumin
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- A mother calls the clinic, concerned that her 5 week-old infant is “sleeping more than her brother did.” What is the best initial response?
A) “Do you remember his sleep patterns?”
B) “How old is your other child?”
C) “Why do you think this a concern?”
D) “Does the baby sleep after feeding?”
C: “Why do you think this a concern?”
- The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
A) Instruct the client to breathe into a paper bag
B) Place the client in a high Fowler’s position
C) Assist the client with pursed lip breathing
D) Administer oxygen at 6L/minute via nasal cannula
C: Assist the client with pursed lip breathing
- The nurse is caring for a client with a deep vein thrombosis. Which finding would require the nurse’s immediate attention?
A) Temperature of 102 degrees Fahrenheit
B) Pulse rate of 98 beats per minute
C) Respiratory rate of 32
D) Blood pressure of 90/50
C: Respiratory rate of 32
- A 6 year-old child diagnosed with acute glomerulonephritis (AGN) is experiencing anorexia, moderate edema and elevated blood urea nitrogen (BUN) levels. The child requests a peanut butter sandwich for lunch. What would the nurse’s best response to this request?
A) “That’s a good choice, and I know it is your favorite. You can have it today.”
B) “I’m sorry, that is not a good choice, but you could have pasta.”
C) “I know that is your favorite, but let me help you pick another lunch.”
D) “You cannot have the peanut butter until you are feeling better.”
C: “I know that is your favorite, but let me help you pick another lunch.”
- Which type of traction can the nurse expect to be used on a 7 year-old with a fractured femur and extensive skin damage?
A) Ninety-ninety
B) Buck’s
C) Bryant
D) Russell
A: Ninety-ninety
- A nurse aide is taking care of a 2 year-old child with Wilm’s tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
A) “Touching the abdomen could cause cancer cells to spread.”
B) “Examining the area would cause difficulty to the child.”
C) “Pushing on the stomach might lead to the spread of infection.”
D) “Placing any pressure on the abdomen may cause an abnormal experience.”
A: “Touching the abdomen could cause cancer cells to spread.”
- A nurse admits a 3 week-old infant to the special care nursery with a diagnosis of bronchopulmonary dysplasia. As the nurse reviews the birth history, which data would be most consistent with this diagnosis?
A) Gestational age assessment suggested growth retardation
B) Meconium was cleared from the airway at delivery
C) Phototherapy was used to treat Rh incompatibility
D) The infant received mechanical ventilation for 2 weeks
D: The infant received mechanical ventilation for 2 weeks
- A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is
A) “You need to take your medicine, this is how you get well.”
B) “If you refuse your medicine, we’ll just have to give you a shot.”
C) “What is it about the medicine that you don’t like?”
D) “I can see that you are uncomfortable right now, I’ll wait until tomorrow.”
C: “What is it about the medicine that you don’t like?”
- The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client’s progress, the nurse recognizes that the most revealing resistant behavior is
A) Recurring crises
B) Continuing drug use
C) Rationalizing comments
D) Missing appointments
B: Continuing drug use
- A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor?
A) Information is clarified as needed
B) A teacher-coach role is taken by the mentor
C) The mentor accepts feedback objectively
D) The mentor is randomly assigned by administration
B: A teacher-coach role is taken by the mentor
- Parents of a 6 month-old breast fed baby ask the nurse about increasing the baby’s diet. Which of the following should be added first?
A) Cereal
B) Eggs
C) Meat
D) Juice
A: Cereal
- A nurse is eating in the hospital cafeteria when a toddler at a nearby table chokes on a piece of food and appears slightly blue. The appropriate initial action should be to
A) Begin mouth to mouth resuscitation
B) Give the child water to help in swallowing
C) Perform 5 abdominal thrusts
D) Call for the emergency response team
C: Perform 5 abdominal thrusts
- A victim of domestic violence states, “If I were better, I would not have been beat.” Which feeling best describes what the victim may be experiencing?
A) Fear
B) Helplessness
C) Self-blame
D) Rejection
C: Self-blame
- A client has been admitted with complaints of lower abdominal pain, difficulty swallowing, nausea, dizziness, headache and fatigue. The client is agitated, fearful, tachycardic and complains of being “too sick to return to work.” The client is diagnosed as having somatoform disorder. In formulating a plan of care, the nurse must consider that the client’s behavior
A) Is controlled by their subconscious mind
B) Is manipulative to avoid work responsibilities
C) Would respond to psychoeducational strategies
D) Could be modified through reality therapy
A: Is controlled by their subconscious mind
- Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?
A) “I know there is a problem since my baby is always constipated.”
B) “My child doesn’t like many fruits and vegetables, but she really loves her milk.”
C) “I can’t understand why my child is not eating as much as she did 4 months ago.”
D) “My child doesn’t drink a whole glass of juice or water at 1 time.”
B: “My child doesn’t like many fruits and vegetables, but she really loves her milk.”
- The nurse is planning care for a client during the acute phase of a sickle cell vaso- occlusive crisis. Which of the following actions would be most appropriate?
A) Fluid restriction 1000cc per day
B) Ambulate in hallway 4 times a day
C) Administer analgesic therapy as ordered
D) Encourage increased caloric intake
C: Administer analgesic therapy as ordered
- Following surgery for placement of a ventriculoperitoneal (VP) shunt as treatment for hydrocephalus, the parents question why the infant has a small abdominal incision. The best response by the nurse would be to explain that the incision was made in order to
A) Pass the catheter into the abdominal cavity
B) Place the tubing into the urinary bladder
C) Visualize abdominal organs for catheter placement
D) Insert the catheter into the stomach
A: Pass the catheter into the abdominal cavity
- The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize
A) The need for at least 5 servings of dairy products daily
B) Restriction of fluid intake to less than 1 liter per day
C) The importance of walking as much as possible
D) Early recognition of findings associated with tetany
C: The importance of walking as much as possible
- A nurse and client are talking about the client’s progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?
A) Pre-interaction
B) Orientation
C) Working
D) Termination
C: Working
- A child is sent to the school nurse by a teacher who has a written note that Fifth’s disease is suspected. Which characteristic would the nurse expect to find?
A) Macule that rapidly progresses to papule and then vesicles
B) Erythema on the face, primarily on cheeks giving a “slapped face” appearance
C) Discrete rose pink macules will appear first on the trunk and fade when pressure is applied
D) Kopeck spots appear first followed by a rash that appears first on the face and spreads downward
B: Erythema on the face, primarily on cheeks giving a “slapped face” appearance
- Delirium tremens could best be described as
A) Disorganized thinking, feelings of terror and non-purposeful behavior
B) A generalized shaking of the body accompanied by repetitive thoughts
C) An excited state accompanied by disorientation, hallucination and tachycardia
D) Single or multiple jerks caused by rapid contracting muscles
C: An excited state accompanied by disorientation, hallucination and tachycardia
- An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
A) “Have you had a recent heart attack?”
B) “Do you become short of breath during your normal dailyactivities?”
C) “How many pillows do you use at night to sleep comfortably?”
D) “Do you smoke?”
B: “Do you become short of breath during your normal daily activities?”
- The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
A) Chronic vessel plaque formation
B) Pulmonary embolism
C) Occlusions at the vessel bifurcations
D) Coronary artery aneurysms
D: Coronary artery aneurysms
- The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which finding is most likely to occur?
A) Chest pain
B) Peripheral edema
C) Nail clubbing
D) Lethargy
B: Peripheral edema
- While working with an obese adolescent, it is important for the nurse to recognize that obesity in adolescents is most often associated with what other behavior?
A) Sexual promiscuity
B) Poor body image
C) Dropping out of school
D) Drug experimentation
B: Poor body image
- The nurse should initiate discharge planning for a client
A) When the client or family demonstrate readiness to learn self care modalities
B) When informed that a date for discharge has been determined
C) Upon admission to the emergency room
D) When the client’s condition is stabilized on the assigned unit
C: Upon admission to the emergency room
- The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?
A) Protection for the granulation tissue
B) Heal infection
C) Decried eschar
D) Keep the tissue intact
D: Keep the tissue intact
- When providing nursing measures to relieve a 102-degree Fahrenheit fever in a toddler with an infection, what is the most effective intervention?
A) Use medications to lower the temperature set point
B) Apply extra layers of clothing to prevent shivering
C) Immerse the child in a tub containing cool water
D) Give a tepid sponge bath prior to giving an antipyretic
A: Use medications to lower the temperature set point