2024 NGN HESI RN Exit V1 Exam with 160 Questions and Answers (Verified by Expert)

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HESI RN Exit V1 Exam with NGN Questions and Answers
(Verified by Expert)

The nurse is providing teaching to a client with type 2 diabetes mellitus
about important points for disease and symptom management. Which statement by the client indicates understanding?
A Using salt, herbs, and spices will improve the flavor of foods.
B Get an eye examination with an ophthalmologist annually.
C Arrange diet schedule around three regular meals a day.
D Inspect feet every month for ingrown nails, cuts, and calluses
ANS B Get an eyeexamination with an ophthalmologist annually.
The nurse is providing education to a client who experiences recurrent
levels of moderate anxiety to situations and perceived stress. In addition to
information about prescribed medication and administration, which instruction should the nurse include in the teaching?
A Center attention on positive upbeat music.
B Find outlets for more social interaction.
C Practice using muscle relaxation techniques.
D Think about reasons the episodes occur
ANS C Practice using muscle relaxationtechniques.

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The charge nurse is planning for the shift and has a registered nurse (RN)
and a practical nurse (PN) on the team.Which client should the charge nurseassign to the RN?
A A 75-year-old client with renal calculi who requires urine straining.
B A 64-year-old client who had a total hip replacement the previous day.
C A 30-year-old depressed client who admits to suicide ideation.
D An adolescent with multiple contusions due to a fall that occurred 2 days
ago
ANS C A 30-year-old depressed client who admits to suicide ideation.
A client with pancreatitis complains of severe epigastric pain, so the nurseadministers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse
implement?
A Raise head of bed until to a 90 degree angle.
B Position bedside table so the client can lean across it.
C Place bed in a reverse trendelenburg position.
D Encourage rest until the analgesic becomes effective
ANS B Position bedsidetable so the client can lean across it.

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The nurse is caring for a client who arrives to the emergency department
with reports of experiencing dizziness and difficulty walking to the bathroom.The nurse observes right-sided weakness and sluggish enunciation ofspeech.The nurse should immediately take which action?
A Maintain elevated positioning of the dependent joints on affected side.
B Keep the bed in the lowest position and initiate seizure and fall precautions.C Place an indwelling urinary catheter and measure strict intake and output.
D Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy
ANS D Start two large bore IV catheters and review inclusion criteria for IV
fibrinolytic therapy.
A male client with a brain tumor is scheduled for a biopsy in the morning.
During the admission procedure, the client has a tonic-clonic seizure that lasts50 seconds. Following the seizure, the client is lethargic and confused and hiswife tells the nurse that her husband has never had a seizure before and hasalways been alert and communicative. Which action should the nurse take?
A Ask the wife to wait outside the room until the nurse can talk with her.
B Keep orienting the client to time and space until he is less confused.
C Notify the emergency response team of the client’s seizure.
D Explain the postictal state that usually follows seizures
ANS D Explain the pos-tictal state that usually follows seizures.

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The nurse is providing lifestyle change education for a client to slow the
progression of coronary artery disease.Which statement(s)made by the clientshould the nurse recognize as needing additional education? (Select all that
apply.)
A Keep a food diary.
B Eat more canned vegetables.
C Consume foods with saturated fats.
D Walk 30 minutes per day.
E Include oatmeal for breakfast.
F Use a salt substitute
ANS B Eat more canned vegetables.C Consume foods
with saturated fats.
While caring for a toddler receiving oxygen via face mask, the nurse observes that the child’s lips and nares are dry and cracked.Which interventionshould the nurse implement?
A Use a water soluble lubricant on affected oral and nasal mucosa.
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The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management. Which statement by the client indicates understanding?

A Using salt, herbs, and spices will improve the flavor of foods.
B Get an eye examination with an ophthalmologist annually.
C Arrange diet schedule around three regular meals a day.
D Inspect feet every month for ingrown nails, cuts, and calluses.
B Get an eye examination with an ophthalmologist annually.

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

A Center attention on positive upbeat music.
B Find outlets for more social interaction.
C Practice using muscle relaxation techniques.
D Think about reasons the episodes occur.
C Practice using muscle relaxation techniques.

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

A A 75-year-old client with renal calculi who requires urine straining.
B A 64-year-old client who had a total hip replacement the previous day.
C A 30-year-old depressed client who admits to suicide ideation.
D An adolescent with multiple contusions due to a fall that occurred 2 days ago.
C A 30-year-old depressed client who admits to suicide ideation.

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

A Raise head of bed until to a 90 degree angle.
B Position bedside table so the client can lean across it.
C Place bed in a reverse trendelenburg position.
D Encourage rest until the analgesic becomes effective.
B Position bedside table so the client can lean across it.

The nurse is caring for a client who arrives to the emergency department with reports of experiencing dizziness and difficulty walking to the bathroom. The nurse observes right-sided weakness and sluggish enunciation of speech. The nurse should immediately take which action?

A Maintain elevated positioning of the dependent joints on affected side.
B Keep the bed in the lowest position and initiate seizure and fall precautions.
C Place an indwelling urinary catheter and measure strict intake and output.
D Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
D Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.

A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take?

A Ask the wife to wait outside the room until the nurse can talk with her.
B Keep orienting the client to time and space until he is less confused.
C Notify the emergency response team of the client’s seizure.
D Explain the postictal state that usually follows seizures.
D Explain the postictal state that usually follows seizures.

The nurse is providing lifestyle change education for a client to slow the progression of coronary artery disease. Which statement(s)made by the client should the nurse recognize as needing additional education? (Select all that apply.)

A Keep a food diary.
B Eat more canned vegetables.
C Consume foods with saturated fats.
D Walk 30 minutes per day.
E Include oatmeal for breakfast.
F Use a salt substitute.
B Eat more canned vegetables.
C Consume foods with saturated fats.

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child’s lips and nares are dry and cracked. Which intervention should the nurse implement?

A Use a water soluble lubricant on affected oral and nasal mucosa.
B Use a topical lidocaine analgesic for cracked lips.
C Ask the mother what she usually uses on the child’s lips and nose.
D Apply a petroleum jelly to the child’s nose and lips.
A Use a water soluble lubricant on affected oral and nasal mucosa.

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. What action should the nurse implement first?

A Increase intravenous infusion.
B Massage the uterus to decrease atony.
C Review the hemoglobin to determine hemorrhage.
D Check for a distended bladder.
D Check for a distended bladder.

The nurse is caring for a client on the first day postoperative for a descending aortic aneurysm repair. Which assessment finding should the nurse prioritize reporting to the healthcare provider?

Reference Range
Potassium (Reference Range: 3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

A Serum potassium 4.8 mEg/L (4.8 mmol/L).
B Electrocardiogram ST segment elevation.
C Urine output 30 mL/hour.
D Blood pressure 130/80.
B Electrocardiogram ST segment elevation.

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicate to the nurse that the
client understand the prescribed diet?

A Roast pork, fresh strawberries.
B Baked potato with skin, raw carrots.
C Roasted turkey, canned vegetables.
D Pancakes, whole-grain cereals.
C Roasted turkey, canned vegetables.

The psychiatric nurse is caring for clients in an adolescent unit. Which client requires the nurse’s immediate attention?

A An 18-year-old client with antisocial behavior who is being yelled at by other clients.
B A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.
C A 16-year-old client diagnosed with major depression who refuses to participate in a group.
D A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.
A. An 18-year-old client with antisocial behavior who is being yelled at by other clients.

A client recovering from pneumonia who has a history of severe chronic obstructive pulmonary disease (COPD) and peripheral vascular disease (PVD) is being discharged from a skilled nursing facility. Which action is most important for the nurse to implement?

A Explain exercise daily regimen.
B Demonstrate specific strengthening exercises.
C Provide typed instructions for healthy diet selection
D Reinforce need for adequate hydration.
C Provide typed instructions for healthy diet selection

A 6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

A Instruct parents regarding care of the incisional area.
B Mark an outline of the “olive-Shaped” mass in the right epigastric area.
C Initiate a continuous infusion of IV fluids per prescription.
D Monitor amount of intake and infant’s response to feedings.
C Initiate a continuous infusion of IV fluids per prescription.

NGN: The client is a 26 yr old female who was in a car accident 6 months ago that killed her mother, husband, and 2 yr old son. She and her father were the only survivors of the crash. She is seeking care for depression.

Choose the most likely options for the information missing from the statement by selecting from the list of options provided.

The client is exhibiting symptoms of relating to __ and __.
The client is exhibiting symptoms of PTSD relating to EXPERIENCING A LIFE-THREATENING EVENT and LOSING A LOVE ONE.

NGN: After the examination by the physician, the client was diagnosed with depression and PSTD. The physician wrote orders for medication that need to be filled. The nurse speaks with the client again to educate her about her diagnose and medication. How can the nurse build a therapeutic relationship with the client? Select all that apply.

A The nurse can establish a meaningful connection
B The nurse can be open, honest, and sincere
C The nurse can communicate acceptance of the client as she is
D The nurse can talk as much as needed to get the client talking
E The nurse can focus energy on the client
F The nurse can show no emotion when talking to the client
A The nurse can establish a meaningful connection
B The nurse can be open, honest, and sincere
C The nurse can communicate acceptance of the client as she is

NGN: During the conversation with the client, the nurse documents a statement by the client about wishing she had died in the crash. Choose the most likely options for the information missing from the statement by selecting the list of options provided.

The statement by the client represents and should be followed up with ___.
The statement by the client represents SUICIDAL IDEATION and should be followed up with AN ASSESSMENT OF RISK FACTORS FOR SUICIDE.

NGN: What would be some effective strategies that the nurse could use to decrease the client’s risk of suicide in the future? Select all that apply.

A Have the client sign a no-suicide contract
B Refer the client for cognitive behavioral therapy
C Make the client feel too guilty to commit suicide
D Place the client in a locked unit
E Have the client remove any sharp objects from the home
F Help the client enlist the help of friends and family
A Have the client sign a no-suicide contract
F Help the client enlist the help of friends and family

Dopamine 5 mcg/kg/minute IV is prescribed for a client who weighs 132 pounds. The pharmacy dispenses a 500 mL IV solution of 0.9% normal saline with dopamine 1600 mg. The nurse should program the infusion pump to deliver how many mL/hour? (Enter numeric value only. If rounding is required, round to the nearest tenth.)

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?

Reference Range:
Blood alcohol level [Reference Range: 0 to 10.9 mmol/L (0% to 0.05%)]
Lithium (Reference Range: 0.8 to 1.2 mEq/L or 0.8 to 1.2 mmol/L]

A Blood alcohol level of 0.09% (90 mmol/L)
B Serum lithium level of 1.6 mEq/L (1.6 mmol/L)
C Six hours of sleep in the past three days.
D Weight loss of 10 pounds (4.5 kg) in past month.
B Serum lithium level of 1.6 mEq/L (1.6 mmol/L)

A male client reports to the on-call clinic nurse that he took tadalafil 10mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina, but denies experiencing any current or recent chest pain. What action should the nurse take?

A Tell the client to have someone bring him to an emergency department immediately.
B Instruct the client to increase his intake of oral fluids until the skin flushing is relieved.
C Reassure the client that skin flushing is a common side effect of the medication.
D Advise the client to place one nitroglycerin tablet under his tongue as a precaution.
C Reassure the client that skin flushing is a common side effect of the medication.

An adult client experiences a gasoline tank fire when riding a motorcycle and is admitted to the emergency department (ED) with full thickness burns to all surfaces of both lower extremities. Which percentage of body surface area should the nurse document in the electronic medical record (EMR)?

A 9%.
B 36%.
C 18%.
D 45 %.
B 36%.

An unlicensed assistive personnel (UP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UP’s behavior? (Place the actions in order from first on top to last on bottom.)
1 Note date and time of the behavior.
2 Discuss the issue privately with the UAP.
3 Plan for scheduled break times.
4 Evaluate the UP for signs of improvement.

What nursing intervention is particularly indicated for the second stage of labor?

A Assessing the fetal heart rate and pattern for signs of fetal distress.
B Monitoring effects gf oxytocin administration to help achieve cervical dilation.
C Providing pain medication to increase the client’s tolerance of labor pains.
D Assisting the client to push effectively so that expulsion of the fetus can be achieved.
D Assisting the client to push effectively so that expulsion of the fetus can be achieved.

A child with peripheral edema who weighs 44 pounds receives a prescription for furosemide 2 mg/kg intravenously every 12 hours. The vial is labeled, “10 mg/mL.” How many mL should the nurse administer? (Enter numeric value only.)
4 mL

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?

A Erythrocytes, hemoglobin, and hematocrit.
B Serum potassium, calcium, and phosphorus.
C Blood pressure, heart rate, and temperature.
D Leukocytes, neutrophils, and thyroxine.
B Serum potassium, calcium, and phosphorus.

A client with a history of dementia has become increasingly confused at night and is picking at an abdominal surgical dressing and the tape securing the intravenous (IV) line. The abdominal dressing is no longer occlusive, and the IV insertion site is pink. Which intervention should the nurse implement?

A Leave the lights on in the room at night.
B Redress the abdominal incision
C Apply soft bilateral wrist restraints.
D Replace the IV site with a smaller gauge.
B Redress the abdominal incision

The nurse is planning care for a client who admits having suicidal thoughts. Which client behavior indicates the highest risk for the
client acting on these suicidal thoughts?

A Begins to show signs of improvement in effect.
B Expresses feelings of sadness and loneliness.
C Neglects personal hygiene and has no appetite.
D Lacks interest in the activities of family and friends.
A. Begins to show signs of improvement in effect.

NGN: The client is a 42 yr old female who had a right above the knee amputation for osteomyelitis. The client has a drain in place and a surgical dressing that will need to be changed by the surgeon on post-op day 1.

The nurse is discussing the client’s pain management with a student nurse.

Choose the most likely options for the information missing from the statement (s) by selecting from the lists of options provided.

Morphine is a(n) _ and it activates _ receptors and is used to relieve _.
Morphine is a(n) AGONIST-ANTAGONIST OPIOD and it activates BETA receptors and is used to relieve PAIN.

What actions should the nurse take to assure safety during morphine administration? Select all that apply.

A Have a manual resuscitation bag at the bedside
B Ask the client about other medications she takes
C Perform a 12-lead electrocardiogram
D Take an initial respiratory rate
E Suction the client to clear the airway
F Restrain the client with soft restraints
B Ask the client about other medications she takes
D Take an initial respiratory rate

What other medications would the nurse expect the surgeon to prescribe along with Morphine? Select all that apply.

A Docusate sodium
B Methadone
C Propofol
D Naloxone
E Senna
F Ibuprofen
A Docusate sodium
D Naloxone

The charge nurse places a fall precautions sign on the client’s door. What side effects of Morphine could contribute to this client’s fall risk? Select all that apply.

A Urinary retention
B Seizures
C Orthostatic hypotension
D Sedation
E Nausea
F Itching
G Euphoria
C Orthostatic hypotension
D Sedation
G Euphoria

An older client with a history of cataracts is recovering from intraocular lens implant (OL) surgery to the left eye. During the post-procedure period, which intervention should the nurse implement?

A Encourage deep breathing and coughing exercises.
B Obtain vital signs every 2 hours during hospitalization.
C Provide an eye shield to be worn while sleeping.
D Teach a family member to administer eye drops.
C Provide an eye shield to be worn while sleeping.

An adult client is admitted to the critical care unit with systemic inflammatory response syndrome (SIRS) as a result of a postbur infection. The client has a long line peripherally inserted IV catheter for fluid and medication administration and current vital signs include temperature 102.8° F (39.3° C), heart rate 108 beats/minute, respirations 32 breaths/minute. Which action should the nurse implement first?

A Provide bedside equipment for transmission and protective precautions.
B Culture sputum, urine, burn wound, and all intravenous access sites.
C Implement central line-associated bloodstream infection (CLABSI) protocols.
D Evaluate daily serum electrolytes and hydration status.
B Culture sputum, urine, burn wound, and all intravenous access sites.

Five days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client may have had a pulmonary embolus. Which action should the nurse take first?

A Bring the emergency crash cart to the bedside.
B Prepare a continuous heparin infusion per protocol.
C Notify the healthcare provider.
D Provide supplemental oxygen.
D Provide supplemental oxygen.

The nurse is preparing a dose of 60 mcg of teriparatide. The medication is labeled “750 mcg/2.4 mL.”. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth.)
0.2 mL

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse
to report to the healthcare provider?

A Watery diarrhea.
B Increased fatigue.
C Yellow-tinged sputum.
D Nausea and headache.
A Watery diarrhea.

The nurse observes an unlicensed assistive personnel (UP) applying an alcohol-based hand rub while leaving a client’s room after taking vital signs. Which action should the nurse take?

A Instruct the UP to return to the client’s room to perform hand washing.
B Advise the UP to wear gloves when obtaining vital signs for all clients.
C Supervise the UP in the next client’s room to evaluate hand hygiene.
D Remind the UAP to continue rubbing the hands together until they are dry.
D Remind the UAP to continue rubbing the hands together until they are dry.

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

A Perform daily surgical dressing change for a client who had an abdominal hysterectomy.
B Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM).
C Initiate patient controlled analgesia (PCA) pumps for two clients immediately postoperatively.
D Start the second blood transfusion for a client twelve hours following a below knee amputation.
E Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.
A Perform daily surgical dressing change for a client who had an abdominal hysterectomy.
B Administer a dose of insulin per sliding scale for a client with type 2 diabetes mellitus (DM).
E Obtain postoperative vital signs for a client one day following unilateral knee arthroplasty.

Which assessment should the home health nurse include during a routine home visit for a client who was discharged home with a
suprapubic catheter?

A Assess perineal area.
B Observe insertion site.
C Palpate flank area.
D Measure abdominal girth
B Observe insertion site.

A client with cancer develops tumor lysis syndrome (TLS) following chemotherapy. Which nursing action has the highest priority in responding to the symptoms of this syndrome?

A Instruct the client to take analgesics on a regular schedule.
B Encourage the client to verbalize anxiety and grief.
C Maintain intravenous therapy.
D Identify potential sources of infection.
C Maintain intravenous therapy.

NGN: The client is 74 yr old female with a hx of HTN and HLD. She takes lisinopril, simvastatin, and melatonin for sleep. She was admitted today for pneumonia. She visited her PCP last week, and she has lost 2.8kg since that visit.

Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing. 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client’s progress.

1 Potential Condition:
dehydration, malnutrition, hypoxia, CVA

2 Actions to take:
Measure BP, ask the client for a nutrition hx, perform chest physiotherapy, encourage the client to drink, administer O2

2 Parameters to monitor: Capillary refill, BG, pupil size, albumin level
Potential Condition: dehydration

Actions to take: Measure BP and Ask the client for a nutrition hx

Parameters to monitor: Capillary refill and BG

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide?

A Inform that follow-up may end after the treatment is finished.
B Emphasize that using safe sex practices removes the risk of STIs.
C Clarify that all STIs are transmitted through sexual intercourse.
D Remain non-judgmental and assure the client of confidentiality.
D Remain non-judgmental and assure the client of confidentiality.

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which information should the nurse include in this client’s teaching plan? (Select all that apply.)

A Report persistent polyuria to the healthcare provider.
B Use sliding scale insulin for fingerstick glucose elevations.
C Take metformin with the morning and evening meal.
D Recognize signs and symptoms of hypoglycemia.
E Take an additional dose for signs of hyperglycemia.
A Report persistent polyuria to the healthcare provider.
C Take metformin with the morning and evening meal.
D Recognize signs and symptoms of hypoglycemia.

A client with a prescription for “do not resuscitate” (DNR) begins to manifest signs of impending death. After notifying the family of the client’s status, what priority action should the nurse implement?

A The nurse manager should be updated on the client’s status.
B The client’s status should be conveyed to the chaplain.
C The impending signs of death should be documented.
D The client’s need for pain medication should be determined.
D The client’s need for pain medication should be determined.

A 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse’s station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse included in the plan of care?

A Anxiety related to treatment plan.
B Decisional conflict due to stress.
C Deficient knowledge of lifestyle changes.
D. Ineffective coping related to denial.
D. Ineffective coping related to denial.

A client receives a prescription for norepinephrine 3 mcg/min IV. The IV bag is contains norepinephrine 4mg in dextrose 5 % in water 1000mL. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only).

The nurse is performing a routine assessment of an IV site for a client receiving both IV fluids and medications through the line. The client reports tenderness when the nurse touches the arm above the site. Which finding should the nurse expect which will require immediate intervention?

A Circumferential skin irritation.
B Red streak tracking the vein.
C Cool sensation above the site.
D A sluggish blood return.
B Red streak tracking the vein.

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) donning gloves and a gown to assist the cent. Which action should the nurse take?

A Remind the UP to apply a fitted respirator mask before entering the client’s room.
B Assign the UP to provide care for another client and assume full care of the client.
C Instruct the UP to notify the nurse of any changes in the client’s respiratory status.
D Review the need for the UP to wear a face mask while in close contact with the client.
D Review the need for the UP to wear a face mask while in close contact with the client.

An older adult with terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. Which intervention(s) should he nurse include in this client’s plan of care? (Select all that apply).

A Record the client’s desire to live.
B Teach client how to use guided imagery.
C Instruct client and family to reconsider end of life choices.
D Encourage family to bring the client old photographs.
E Encourage family to visit frequently.
B Teach client how to use guided imagery.
D Encourage family to bring the client old photographs.
E Encourage family to visit frequently.

While making rounds, the charge nurse notices that a young adult client with asthma who was admitted yesterday is sitting on the side of the bed and leaning over the bed-side table. The client is currently receiving oxygen at 2 liters/minute via nasal cannula. The client is wheezing and is using pursed-lip breathing. Which intervention should the nurse implement?

A Administer a nebulizer treatment.
B Call for an Ambu resuscitation bag.
C Increase oxygen to 6 liters/minute.
D Assist the client to lie back in bed.
A Administer a nebulizer treatment.

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. What question is most important for the nurse to include in the assessment of this client?

A “What are the voices saying?”
B “Which medication works best?”
C “When do you hear voices?”
D “How do you cope with the voices?”
A “What are the voices saying?”

A client is being discharged with a prescription for warfarin. Which instruction should the nurse provide this client regarding diet?

A Avoid eating all foods that contain any vitamin K because it is an antagonist of warfarin.
B Increase the intake of dark green leafy vegetables while taking warfarin.
C Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.
D Eat two servings of raw dark green leafy vegetables daily and continue for 30 days after warfarin therapy is completed.
C Eat approximately the same amount of leafy green vegetables daily so the amount of vitamin K consumed is consistent.

The daughter of an older woman who has Parkinson’s disease, calls the clinic and reports that her mother has been confused for the past week. Which action(s) should the nurse take? (Select all that apply.)

A Encourage increased intake of high protein foods.
B Instruct the daughter to check her mother’s temperature.
C Determine if the mother has recently experienced a fall.
D Ask if the mother is experiencing any pain with urination.
E Review the client’s current food and medication allergies.
B Instruct the daughter to check her mother’s temperature.
C Determine if the mother has recently experienced a fall.
D Ask if the mother is experiencing any pain with urination.

The nurse is preparing a 4-day-old infant with a serum bilirubin level of 19 mg/dI (325 Mcmol/L) for discharge from the hospital. When teaching the parents about home phototherapy, which instruction should the nurse include in the discharge teaching plan?

Reference Range
Total Bilirubin [Reference Range: Newborn:0.1 to 10.5 mg/dL (1.7 to 180 Mcmol/L)]

A Cover with a receiving blanket.
B Perform diaper changes under the light.
CFeed the infant every 4 hours.
D Reposition the infant every 2 hours.
D Reposition the infant every 2 hours.

The nurse is teaching an older client about the prevention of osteoporosis. Which foods should the nurse recommend to the client to
increase in the diet?

A Fresh fruits and vegetables.
B Iron-rich meats.
C Water and herbal teas.
D Low fat dairy products.
D Low fat dairy products.

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first?

A Report the finding to the police department.
B Explore client’s readiness to discuss the situation.
C Determine the frequency and type of client’s abuse.
D Discuss treatment options for abusive partners.
B Explore client’s readiness to discuss the situation.

When conducting an admission assessment, the nurse notes that an adult female client has developed two new allergies since her last admission. The client describes herself as lactose intolerant and states that she is unable to eat eggs. Which intervention(s) should the nurse implement? (Select all that apply.)

A Ask the client to describe her reaction to milk and eggs.
B Add egg allergy to client’s identification arm band.
C Eliminate the chicken selections from the client’s menu.
D Notify the dietary department of the client’s egg intolerance.
E Enter new allergy information in the client’s electronic medical record.
B Add egg allergy to client’s identification arm band.
D Notify the dietary department of the client’s egg intolerance.
E Enter new allergy information in the client’s electronic medical record.

NGN: The client is a 49 yr old who reports flu-like symptoms including fever and chest congestion for 4 days. He came to the ED last night when he was having more difficulty breathing. He has a hx of one-half pack a day of cigarette smoking for 20 yrs. He has no significant medical or surgical hx.

What 2 orders should the nurse complete first?

A Sputum culture
B Place the client on a cardiorespiratory monitor
C Start a PIV
D NPO
E Acetaminophen 350mg PO q6h for temperature greater than 101F
F Start O2 3L via NC
G Chest x-ray
H Normal saline 150 mL/hr
B Place the client on a cardiorespiratory monitor
F Start O2 3L via NC

To start the client on oxygen as ordered, what should the nurse collect from the supply room? Select all that apply.

A Sterile water
B Flowmeter
C Lamb’s wool
D Suction canister
E Humidifier bottle
F Tape
G Nasal cannula
B Flowmeter
G Nasal cannula

NGN: 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 4 seconds. Heart rate 101 bpm. Oxygen saturation 90%. Blood pressure 145/89 mmHg. Temperature 100.2F. Respiratory rate 28 bpm.

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and document it in the chart

For each body system, click to specify the assessment findings that indicates hypoxia.

Respiratory
A Respiratory rate 28 bpm
B Productive cough
C Oxygen saturation 90%

Cardiovascular
A Heart rate 101 bpm
B BP 145/89 mmHg
C Capillary refill 4 seconds
Respiratory
A Respiratory rate 28 bpm
C Oxygen saturation 90%

Cardiovascular
A Heart rate 101 bpm
C Capillary refill 4 seconds

Drag from the choices below to fill in each blank in the following sentence.

The nurse should place the client in a ANSWER 1 position to promote ANSWER 2.

Answer 1: trendelenburg, supine, prone, or semi-folwer’s

Answer 2: venous return, gastric motility, skin integrity, or lung expansion
The nurse should place the client in a SEMI-FOWLER’S position to promote LUNG EXPANSION.

A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client’s therapeutic response to this medication, which assessment should the nurse obtain?

A Blood glucose level.
B Percussion of abdomen.
C Serum electrolytes.
D Level of consciousness.
D Level of consciousness.

) A male client is admitted for the removal of an internal fixation device that was inserted for a fractured ankle. During the client’s admission history, he tells the nurse that he recently received vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA)
wound infection. Which action(s) should the nurse take? (Select all that apply.)

A Collect multiple site screening cultures for MRSA.
B Place the client on contact transmission precautions.
C Call healthcare provider for a prescription for linezolid.
D Obtain a sputum specimen for culture and sensitivity.
E Continue to monitor the client for signs of an infection.
A Collect multiple site screening cultures for MRSA.
B Place the client on contact transmission precautions.
E Continue to monitor the client for signs of an infection.

An older client admitted for observation following a fall while getting out of the bath tub becomes increasingly confused. The family arrives with the home medication list and the client’s healthcare power of attorney. When providing a report to the healthcare provider using BAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?

A Increasing confusion of the client.
B Client’s healthcare power of attorney.
C Fall at home as reason for admission.
D Currently prescribed medications.
A Increasing confusion of the client.

A nurse took drugs from the unit for personal use was temporarily released from duty. After completion of mandatory counseling, the impaired nurse has asked nursing administration to allow return to work. When the nurse administrator approaches the charge nurse with the impaired nurse’s request, which action is best fo the charge nurse to take?

A Meet with staff to assess their feelings about the impaired nurse’s return to the unit.
B Allow the impaired nurse to return to work and monitor medication administration.
C Ask to meet with the impaired nurse’s therapist before allowing the nurse back on the unit.
D Since treatment is completed, assign the nurse to routine R responsibilities.
B Allow the impaired nurse to return to work and monitor medication administration.

When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?

A Explain to the client that the dosage has been changed.
B Tell him to take the medication then verify the dosage at the next healthcare team meeting.
C Withhold the medication until the dosage can be confirmed.
D Inform him that he may refuse the medication and document whether or not he takes it
C Withhold the medication until the dosage can be confirmed.

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention (s) should the nurse implement? (Select all that apply.)

A Report serum albumin and globulin levels.
B Provide diet low in phosphorus.
C Increase oral fluid intake to 1,500 mL daily.
D Note signs of swelling and edema.
E Monitor abdominal girth.
A Report serum albumin and globulin levels.
D Note signs of swelling and edema.
E Monitor abdominal girth.

After receiving report, the nurse can most safely plan to assess which client last?

A An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed.
B An older client with a distended abdomen and no drainage from the nasogastric tube.
C An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
D An adult client with a rectal tube draining clear, pale red liquid drainage.
A An adult client with no postoperative drainage in the Jackson-Prat drain with the bulb compressed.

Which intervention Is most important for the nurse to include in the plan of Care for a client who is 12 hours post-thyroidectomy ?

A Resume antithyroid drug therapy.
B Prepare to administer radioactive iodine treatments.
C Anticipate and monitor for hypothermia.
D Maintain a semi-Fowler position.
A Resume antithyroid drug therapy.

A preschool-aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria?

A Red bumps across chest.
B White coating on tongue.
C High, protracted fever.
D Flaky, peeling skin.
B White coating on tongue.

The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize?

A Leg elevation.
B Pain management.
C Ambulation teaching.
D Neurovascular checks.
D Neurovascular checks.

Which environmental factor is most significant when planning care for a client with osteomalacia?

A Cool, moist air.
B Stimulating sounds and activity.
C Quiet, calm surroundings.
D Adequate sunlight.
D Adequate sunlight.

A client who weighs 176 pounds receives a prescription for enoxaparin sodium 1.5 mg/kg/day subcutaneously. The medication is available in 120 mg/0.8 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)
0.8 mL

What action should the school nurse implement to provide secondary prevention for
school-aged children?

A Initiate a hearing and vision screening program for first graders.
B Prepare a presentation on how to prevent the spread of lice.
C Observe a person with type 1 diabetes self-administer a dose of insulin.
D Collaborate with a science teacher to prepare a health lesson.
A Initiate a hearing and vision screening program for first graders.

An older client recently transferred to a rehabilitation facility after aortic valve replacement surgery is experiencing anxiety and difficulty adjusting to the transition. The healthcare provider prescribes an antidepressant and a mild sedative for sleep. Which intervention is most important for the nurse to include in client’s plan of care?

A Measure and record the client’s urinary output every day.
B Provide the client with teaching regarding a cardiac diet.
C Obtain a blood pressure reading before client gets out of bed.
D Obtain client’s vital signs every 4 hours when awake.
C Obtain a blood pressure reading before client gets out of bed.

The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?

A Push the undiluted Dextrose slowly through the currently infusing IV.
B Dilute the Dextrose in one liter of 0.9% Normal Saline solution.
C Mix the Dextrose in a 50 mL piggyback for a total volume of 100 mL.
D Ask the pharmacist to add the Dextrose to a TPN solution.
A Push the undiluted Dextrose slowly through the currently infusing IV.

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

A Suggest that the child be encouraged to participate in a team sport to encourage socialization.
B Explain that their child is too young to understand the risks associated with swimming.
C Provide a list of alternative activities that are less likely to cause the child to experience fatigue.
D Encourage the parents to allow the child to continue attending swimming lessons with supervision.
D Encourage the parents to allow the child to continue attending swimming lessons with supervision.

A male client admitted with chronic pulmonary obstruction disease (COPD) exacerbation is receiving assisted ventilation with continuous positive airway pressure (CPAP). His vital signs are: temperature 98.8 °F (37.1 °C), heart rate 118 beats/minute, respirations 46 breaths/minute, blood pressure 176/92 mmHg. While completing the pulmonary assessment, his oxygen saturation reading is 78% and he is difficult to arouse. Which action should the nurse implement?

A Prepare for rapid sequence intubation.
B Increase the oxygen delivery by 10%.
C Administer PRN nebulizer treatment.
D Complete neurological assessment.
A Prepare for rapid sequence intubation.

A client is admitted to the hospital after experiencing a stroke or cerebrovascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?

A Inappropriate or exaggerated mood swings.
B Persistent coughing while drinking.
C Abnormal responses for cranial nerves I and Il.
D Unilateral facial drooping.
B Persistent coughing while drinking.

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implements while administering this medication?

A Measure urinary output every hour.
B Initiate seizure precautions.
C Monitor serum potassium frequently.
D Assess pupillary response to light hourly
A Measure urinary output every hour.

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

A Twin siblings admitted with scarlet fever that is complicated with pneumonia.
B An older client with scabies who is admitted from an extended care facility.
C A female adolescent admitted with multiple genital Herpes simplex I lesions.
D A client with a positive Mantoux and sputum cultures results positive for AFB.
D A client with a positive Mantoux and sputum cultures results positive for AFB.

The nurse is planning to teach infant care and preventive measures for sudden infant death syndrome (SIDS) to a group of new parents. Which information is most important for the nurse to include?

A Prop the infant with a pillow when in a side-lying position.
B Ensure that the infant’s crib mattress is firm.
C Place the infant in a prone position whenever possible.
D Swaddle the infant in a blanket for sleeping.
B Ensure that the infant’s crib mattress is firm.

Which nursing intervention is most important for the nurse to include in the plan of care for a client with alcohol withdrawal delirium?

A Confront the client’s denial of substance abuse.
B Maintain a quiet, non-stimulating environment.
C Force oral fluids and provide frequent small meals.
D Encourage attendance and group participation.
B Maintain a quiet, non-stimulating environment.

A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

A Remove the catheter and palpate the client’s bladder for residual distention.
B Clamp the catheter for thirty minutes and then resume draining.
C Remove the catheter and replace it with an indwelling catheter.
D Allow the bladder to empty completely or up to 1,000 mL of urine.
D Allow the bladder to empty completely or up to 1,000 mL of urine.

NGN: Client was brought in for his 5 yr 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. Which intervention is appropriate to manage the lead poisoning level of 7ug/dL (0.34umol/L). Each row must have at least one, but may have more than one, response option selected.

Monitor h&H for potential anemia.
Monitor blood lead levels at 1 month, then every 3-4 months.
Chelation therapy.
Provide family with lea education, regular developmental and behavioral surveillance, and social service referral if necessary.
Ask parent about the age of their home and any home remedies that may have been taken.
Providing supplemental oxygen.
Monitor urine glucose and protein for renal effects of lead.
Monitor H&H for potential anemia.- NOT NEEDED
Monitor blood lead levels at 1 month, then every 3-4 months.- NEEDED
Chelation therapy.- NEEDED
Provide family with lea education, regular developmental and behavioral surveillance, and social service referral if necessary.- NEEDED
Ask parent about the age of their home and any home remedies that may have been taken.- NEEDED
Providing supplemental oxygen.- NEEDED
Monitor urine glucose and protein for renal effects of lead.- NOT NEEDED

A male client with heart failure becomes short of breath, anxious, and has audible wheezing with sputupink frothy m. 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 intravenously. What action should the nurse take?

A Consult with the charge nurse regarding the morphine prescription.
B Administer the dose of morphine sulfate as prescribed.
C Withhold the morphine until the client’s dyspnea resolves.
D Review the need for the prescription with the healthcare provider.
D Review the need for the prescription with the healthcare provider.

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

A Withhold this dose.
B Mix the next dose with food.
C Give another dose.
D Administer a half dose now
A Withhold this dose.

A client is receiving continuous ambulatory peritoneal dialysis since the arteriovenous (AV) graft in the right arm is no longer available to use for hemodialysis. The client has lost weight, has increasing peripheral edema, and has a serum albumin level of 1.5 g/dL (15 g/L). Which intervention is the priority for the nurse to implement?

Reference Range:
Serum Albumin [Reference Range: 3.5 to 5.5 g/dL (35 to 55 g/L)].

A Evaluate patency of the AV graft for resumption of hemodialysis.
B Ensure the client receives frequent small meals containing complete proteins.
C Instruct the client to continue to follow the prescribed rigid fluid restriction amounts.
D Recommend the use of support stockings to enhance venous return.
B Ensure the client receives frequent small meals containing complete proteins.

The nurse is assigning care of a client with prostatitis to a practical nurse (P). Which instruction should the nurse provide the PN regarding care of this client?

A Restrict oral fluid intake.
B Strain all urine.
C Maintain contact isolation.
D Avoid urinary catheterization.
D Avoid urinary catheterization.

The nurse observes an unlicensed assistive personnel (UP) who is preparing to provide personal care for a client who requires contact precautions. The UAP has applied a gown and gloves and secured the tops of the gloves over the gown sleeves. What action should the nurse take?

A Help the UAP reposition the gown sleeve over the glove edges.
B Remind the UP to wash hands frequently while in the room.
C Confirm that the gown is tied securely at the neck and waist.
D Assist the UAP with application of a face mask or face shield.
C Confirm that the gown is tied securely at the neck and waist.

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus, and tells the nurse the quarter is supposed to fix her child’s hernia. Which explanation should the nurse provide?

A Restrictive clothing will be adequate to help the hernia go away.
B This hernia is a normal variation that resolves without treatment.
C The quarter should be secured with an elastic bandage wrap.
D An abdominal binder can be worn daily to reduce the protrusion.
B This hernia is a normal variation that resolves without treatment.

At the end of a preoperative teaching session on pain management techniques, a client starts to cry and states, “I just know I can’t handle all the pain.” Which is the priority nursing problem for this client?

A Knowledge deficit.
B Pain (acute).
C Anticipatory grieving.
D Anxiety.
D Anxiety.

112) An adult male client reports that he recently experienced an episode of chest pressure and breathlessness when he was jogging. The client expresses concern because both of his deceased parents had heart disease and his father had diabetes. He lives with his male partner, is a vegetarian, and takes atenolol which maintains his blood pressure at 130/74 mm hg. Which risk factors should the nurse explore further with the client? (SATA)

A History of hypertension.
B Homosexual lifestyle.
C Vegetarian diet.
D Excessive aerobic exercise.
E Family health history.
A History of hypertension.
E Family health history.

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

A Sodium intake can be regulated by limiting canned foods in the diet.
B Salt substitutes can help with maintaining a healthy diet.
C Alcohol consumption will not produce vascular changes.
D Uncontrolled hypertension can lead to renal damage.
E Blood pressure readings should be taken at noontime.
F Weight management is promoted by taking daily walks for thirty minutes.
A Sodium intake can be regulated by limiting canned foods in the diet.
B Salt substitutes can help with maintaining a healthy diet.
D Uncontrolled hypertension can lead to renal damage.
F Weight management is promoted by taking daily walks for thirty minutes.

A female client with fibromyalgia asks the nurse to arrange for hospice care to help her manage the severe, chronic pain. Which Intervention should the nurse provide to address the client’s problem?

A Contact a hospice nurse for an evaluation.
B Arrange an appointment with a pain specialist.
C Form an interdisciplinary team for evaluation.
D Ask for a consultation with a psychologist.
B Arrange an appointment with a pain specialist.

Three hours after birth, a newborn becomes jittery and tachypneic. What should the nurse do first?

A Obtain a capillary glucose level.
B Feed 30 mL of 10% dextrose in water.
C Wrap tightly In a warm blanket.
D Encourage the mother to breastfeed.
A Obtain a capillary glucose level.

A client is being urgently transported to radiology for a Computerized Tomography (CT scan) after a sudden decrease in level of consciousness. The client is orally intubated and has a left lateral chest tube to 20 cm suction. Which action is most important for the nurse to take?

A Secure chest tube to the stretcher for transport.
B Administer PRN pain medication prior to transport.
C Keep chest tube container below the site of insertion.
D Mark the amount of chest drainage on the container.
C Keep chest tube container below the site of insertion.

The nurse receives a shift report about a male client with obsessive-compulsive disorder. The nurse completes morning rounds and approaches the client while he is repeatedly washing the top of the same table. Which intervention should the nurse implement?

A Allow time for the behavior and then redirect the client to other activities.
B Teach the client thought stopping techniques and ways to refocus behaviors.
C Assist the client to identify stimuli that precipitates the activity.
D Encourage the client to be calm and relax for a little while.
A Allow time for the behavior and then redirect the client to other activities.

The healthcare provider prescribes regular insulin 8 units/hr intravenously (IV). The IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline. How many mL/hr should the nurse program the infusion pump? (Enter numerical value only.)
0.08 mL/hr

To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Image: click on the location)
Place the red dot on the base of the neck

The nurse on a pediatric unit observes a distraught mother in the hallway scolding her 3-year-old son for wetting his pants. What initial action should the nurse take?

A Inform the mother that toilet training is slower for boys.
B Refer the mother to a community parent education program.
C Suggest that the mother consult a pediatric nephrologist.
D Provide disposable training pants while calming the mother.
D Provide disposable training pants while calming the mother.

When is it most important for the nurse to assess a pregnant client’s deep tendon reflexes (DTRS)?

A When the client has ankle edema.
B During admission to labor and delivery.
C If the client has an elevated blood pressure.
D Within the first trimester of pregnancy.
C If the client has an elevated blood pressure.

Which situation indicates a need for the nurse to discuss the use of mitten restraints with the healthcare provider?

A A client is walking the halls at night rubbing his hands together.
B A family member expresses concern about their relative “picking” at the NG tube.
C A16-year-old boy swung his fist at the nurse.
D A disoriented client removed the mesh wrapped IV line for the second time.
D A disoriented client removed the mesh wrapped IV line for the second time.

AUDIO OF LUNG SOUNDS:

The nurse is auscultating a client’s 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 pitched wheeze

B Low pitched or coarse crackles

C Stridor

D High pitched or fine crackles

C Stridor

VIDEO OF G-TUBE

The charge nurse observes a new nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feedings, as seen in the video. Which action(s) should the charge nurse take? (Select all that apply)

A Advise the nurse to use the plunger when giving medications.

B Encourage the nurse to flush the tube with more water.

C Confirm that the nurse determined the amount of gastric residual.

D Instruct the nurse to administer each medication separately.

E Add the liquid volumes when documenting fluid intake.

C Confirm that the nurse determined the amount of gastric residual.
D Instruct the nurse to administer each medication separately.
E Add the liquid volumes when documenting fluid intake.

An adult women who was recently diagnosed with type 2 DM is seen in the clinic for lab tests. The cline’s height is 5 ft 2 in and weight 165 lbs. Her recent lab findings are described above. In planning nutrition teaching for this client, which diet modification(s) should the nurse recommend? (Select all that apply)

A Decrease processed carbohydrate in diet.
B Increase dietary fiber such as whole grain.
C Reduce daily fat intake to 10% of total calories.
D Eliminate alcohol intake except for special occasions.
E Restrict protein to 10% of total calories in diet.
A Decrease processed carbohydrate in diet.
B Increase dietary fiber such as whole grain.
D Eliminate alcohol intake except for special occasions.

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

A Serum calcium.
B Hemoglobin.
C Osmolality.
D Erythrocyte sedimentation rate.
B Hemoglobin.

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

A Current diagnosis of hepatitis B.
B History of intravenous drug abuse.
C Length of time of the exposure to tuberculosis.
D Conversion of the client’s PPD test from negative to positive.
A Current diagnosis of hepatitis B.

129) A client with obstructive sleep apnea (OSA) ambulates in the hallway with the nurse prior to bedtime and intervention is most important for the nurse to implement before leaving the client?

A. Apply the client’s positive airway pressure device.
B Elevate the head of the bed to a 45 degree angle.
C Lift and lock the side rails in place.
D Remove dentures or other oral appliance.
A. Apply the client’s positive airway pressure device.

The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UP). Which task should the nurse assign to the PN?

A Determine the need for urinary catheterizations.
B Titrate oxygen to prescribed parameters.
C Evaluate and update plans of care for clients.
D Receive a postoperative client and conduct the assessment
B Titrate oxygen to prescribed parameters.

The nurse is planning to assess a client’s oxygen saturation to determine if additional oxygen is needed via nasal cannula. The client has a bilateral below the knee amputation and pedal pulses that are weak and thready. What action should the nurse take?

A Document that an accurate oxygen saturation reading cannot be obtained.
B Elevate to client’s hands for five minutes prior to obtaining a reading from the finger.
C Increase the oxygen based on the client’s breathing patterns and lungs sound.
D Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading.
D Place the oximeter clip on the ear lobe to obtain the oxygen saturation reading.

An unlicensed assistive personnel (UAP) is assigned to provide care for a client whose prescribed activity is bedrest with bedside commode use. The UAP reports to the nurse that the client is so obese that the UAP feels unable to safely assist the client in transferring from the bed to the bedside commode. How should the nurse respond?

A Determine the client’s level of mobility and need for assistance.
B Instruct the UAP that all clients deserve equal care.
C Advice the client to maintain bedrest so that safety can be ensured.
D Assigned another UAP to care for the client.
C Advice the client to maintain bedrest so that safety can be ensured.

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

A. Diapering will be provided since hospitalization is stressful to preschoolers
B. Children usually resume their toileting behaviors when they leave the hospital
C. A potty chair should be brought from home so he can maintain his toileting skills
D. A retraining program will need to be initiated when the child returns home
B. Children usually resume their toileting behaviors when they leave the hospital

A clinical trial is recommended for a female client with metastatic breast cancer, but she refuses to participate and tells her family that she does not wish to have further treatments. the client’s son and daughter ask the nurse to try and convince their mother to reconsider this decision. How should the nurse respond?

A. Explain to the family that they must accept their mother’s decision
B. Discuss success of clinical trials and ask the client to consider participating for one month
C. Ask the client with her children present if she fully understands the decision she has made
D. Explore the client’s decision to refuse treatment and offer support.
D. Explore the client’s decision to refuse treatment and offer support.

After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

a. Apply oxygen via nasal cannula
b. Administer PRN nebulizer treatment.
c. Obtain 12 lead electrocardiogram.
d. Monitor continuous oxygen saturation.
e. Give PRN dose of regular insulin
b. Administer PRN nebulizer treatment.
c. Obtain 12 lead electrocardiogram.
d. Monitor continuous oxygen saturation.

An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse …. The client provides the nurse with a living will and DNR. What action should the nurse implement?

a- Inform the family of the client’s wishes
b- Obtain a prescription for DNR
c- Clergy consultation
d- Ask the patient why he made this choice
b- Obtain a prescription for DNR

When caring for a client with traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client’s GCS score has been 14. What does this GCS finding indicate about the client?
Neurologically stable without indications of an increased ICP
A family member of a frail elderly adult asks the nurse about eligibilityrequirements for hospice care. What information should the nurse provide? (Select all that apply.)

a. All family must agree about the need for hospice care.
b. Hospice services are covered under Medicare Part B.
c. A client must be willing to accept palliative care, not curative care.
d. The healthcare provider must project that the client has 6 months or less to live.
e. All medications except pain treatment will be stopped during hospice care.
c. A client must be willing to accept palliative care, not curative care.
d. The healthcare provider must project that the client has 6 months or less to live.

The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?

a. An adult female who has been depressed for the past several months and denies suicidal ideations.
b. A middle-age male who is in depressive phase on bipolar disease and is receiving Lithium.
c. A young male with schizophrenia who said voices is telling him to kill his psychiatric.
d. An elderly male who tells the staff and other client that he is superman and he can fly.
c. A young male with schizophrenia who said voices is telling him to kill his psychiatric.

Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client’s arm?

a. Explain the temporary burning of the IV site may occur.
b. Assess IV site frequently for signs of extravasation
c. Apply a topical anesthetic of the infusion site for burning
d. Monitor capillary refill distal to the infusion site.
b. Assess IV site frequently for signs of extravasation

A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

a. Blindness secondary to cataracts
b. Acute kidney injury due to glomerular damage
c. Stroke secondary to hemorrhage
d. Heart block due to myocardial damage
c. Stroke secondary to hemorrhage

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction & lens implantation. Which intervention is most important for the nurse to implement to ensure the client’s compliance with self-care?

a- Speak clearly and face the clients for lip reading
b- Provide written instructions for eyes drop administration
c- Ensure that someone will stay with the client for 24 hours.
d- Have the client vocalize the instructions provided.
d- Have the client vocalize the instructions provided.

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?

a. Withhold food and fluid intake.
b. Initiate IV fluid replacement.
c. Administer antiemetic as needed.
d. Evaluate intake and output ratio.
a. Withhold food and fluid intake.

A client who had a small bowel resection acquired methicillin resistant staphylococcus aureus (MRSA) while hospitalized. He treated and released, but is readmitted today because of diarrhea and dehydration. It is most important for the nurse to implement which intervention.

a. Maintain contact transmission precaution
b. Review white blood cell (WBC) count daily
c. Instruct visitors to gown and wash hands
d. Collect serial stool specimens for culture
a. Maintain contact transmission precaution

A client is admitted to isolation with the diagnosis of active tuberculosis (TB). Which infection control measures should the nurse implement?

a. Negative pressure environment
b. Contact precautions
c. Droplet precautions
d. Protective environment
a. Negative pressure environment

an older client is admitted to the hospital because of transient ischemic attacks. Neurological serial assessments for the past 24 hours were within normal limits. One day after admission, the client suddenly becomes confused and combative indicating impaired mental status (IMS). What intervention should the nurse implement first?

a. document neurologic changes.
b. reduce environmental stimuli
c. administer prescribed neuroleptic
d. review medications for interactions
b. reduce environmental stimuli

A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin 500 mg PO twice daily. Which information should the nurse include in this client’s teaching plan? (Select all that apply.)

A Report persistent polyuria to the healthcare provider.
B Use sliding scale insulin for fingerstick glucose elevations.
C Take metformin with the morning and evening meal.
D Recognize signs and symptoms of hypoglycemia.
E Take an additional dose for signs of hyperglycemia.
A. Report persistent polyuria to the healthcare provider.
C. Take metformin with the morning and evening meal.
D. Recognize signs and symptoms of hypoglycemia.

he parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy tell the nurse that their child wants to continue attending swimming classes. How should the nurse respond?

A Suggest that the child be encouraged to participate in a team sport to encourage socialization.
B Explain that their child is too young to understand the risks associated with swimming.
C Provide a list of alternative activities that are less likely to cause the child to experience fatigue.
D Encourage the parents to allow the child to continue attending swimming lessons with supervision.
D. Encourage the parents to allow the child to continue attending swimming lessons with supervision.

A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the developing which acid base imbalance?
Respiratory alkalosis

A client whose wrists are sutured from a recent suicide attempt has been transferred from a medical unit. Which nursing diagnosis is of the highest priority?

a- Risk for self-directed violence related to impulsive actions
b- Risk for violence related to feeling of guilt and failure
c- Low self-esteem related to feeling of loss of control
d- Ineffective coping related to violent actions towards self.
a- Risk for self-directed violence related to impulsive actions

The charge nurse is making assignment on a psychiatric unit for a practical nurse (PN) and newly license register nurse (RN). Which client should be assigned to the RN?

a. An adult female who has been depressed for the past several months and denies suicidal ideations.
b. A middle-age male who is in a depressive phase of bipolar disease and is receiving Lithium.
c. A young male with schizophrenia who said voices are telling him to kill his psychiatrist.
d. An elderly male who tells the staff and other clients that he is superman and he can fly.
c. A young male with schizophrenia who said voices are telling him to kill his psychiatrist.

A nurse receive a shift report about a male client with Obsessive compulsive disorder (OCD). The nurse does morning rounds and reaches the client while he is repeatedly washing the top of the same table. What intervention should the nurse implement?

a. Encourage the client to be calm and relax for a little while
b. Assist the client to identify stimuli that precipitates the activity.
c. Allow time for the behavior and then redirect the client to other activities.
d. Teach the client thought stopping techniques and ways to refocus.
c. Allow time for the behavior and then redirect the client to other activities.

An adult female client tells the nurse that though she is afraid her abusive boyfriend might one day kill her, she keeps hoping that he will change. What action should the nurse take first?

a. Report the finding to the police department
b. Discuss treatment options for abusive partners
c. Determine the frequency and type of client’s abuse
d. Explore client’s readiness to discuss the situation.
d. Explore client’s readiness to discuss the situation.

A client experiencing withdrawal from the benzodiazepines alprazolam (Xanax) is demonstrating severe agitation and tremors. What is the best initial nursing action?

a. Administer naloxone (Narcan) per PNR protocol
b. Initiate seizure precautions
c. Obtain a serum drug screen
d. Instruct the family about withdrawal symptoms.
b. Initiate seizure precautions

A client has a prescription for lorazepam 2mg for alcohol withdrawal symptoms. Which finding… the client?
a. Blood pressure 149/101
b. Irregular pulse rate of 80
c. Oral temperature is 98.9 F (37.1 C)
d. Pain rated 7 on scale 1-10
a. Blood pressure 149/101

A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg PO for withdrawal symptoms. The client begins to complain of feeling nervous and tells the nurse that her bones are itching. Which finding should the nurse identify as a contraindication for administering the medication?
Blood pressure 90/76 mm Hge

A client is admitted to the hospital after experiencing a brain attack, commonly referred to as a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?
a. Abnormal responses for cranial nerves I and II
b. Persistent coughing while drinking
c. Unilateral facial drooping
d. Inappropriate or exaggerated mood swings
b. Persistent coughing while drinking

Two hours after an abdominal aneurysm repair, a client remains sedated and mechanically ventilated in the post-anesthesia care unit (PACU). Which assessment finding warrants immediate intervention by the nurse?
Systolic blood pressure less than 90 mm Hg.

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