HESI EXIT RN V5 EXAM (2024 / 2025) [ NEW All 160 Qs & As Included – Guaranteed Pass A+!!! (All Brand New Q&A )

HESI EXIT RN V5 EXAM (2024 / 2025) [ NEW All 160 Qs & As Included – Guaranteed Pass A+!!! (All Brand New Q&A )

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The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?A) NutritionB) EliminationC) ActivityD) Safety D: Safety
While explaining an illness to a 10 year-old, what should the nurse keep in mind about the cognitive development at this age?A) They are able to make simple association of ideasB) They are able to think logically in organizing factsC) Interpretation of events originate from their own perspectiveD) Conclusions are based on previous experiences B: Think logically in organizing facts
The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first?A) Clear the area of any hazardsB) Place the child on the sideC) Restrain the childD) Give the prescribed anticonvulsant B: Place the child on the side
The nurse is reviewing a depressed client’s history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers toA) Reports of difficulty falling and staying asleepB) Expression of persistent suicidal thoughtsC) Lack of enjoyment in usual pleasuresD) Reduced senses of taste and smell C: Lack of enjoyment in usual pleasures
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be toA) Administer pain medicationB) Suction excessive tracheobronchial secretionsC) Assist client to turn, deep breathe and coughD) Monitor oxygen saturation B) Suction excessive tracheobronchial secretions
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significantfor this client?A) Compulsive behaviorB) Sense of impending doomC) Fear of flyingD) Predictable episodes B) Sense of impending doom
“A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clingsto her and begins to cry. What would be the initial action by the nurse?A) Arrange to change client care assignmentsB) Explain that this behavior is expectedC) Discuss the appropriate use of “”time-out””D) Explain that the child needs extra attention” B) Explain that this behavior is expected
A 15 year-old client with a lengthy confining illness is at risk for altered growth anddevelopment of which task?A) Loss of controlB) InsecurityC) DependenceD) Lack of trust C) Dependence
“Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?A) Sports and games with rulesB) Finger paints and water playC) “”Dress-up”” clothes and propsD) Chess and television programs” A) Sports and games with rules
“The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse isA) “”Eat a balanced diet for your age.””B) “”Increase your intake of protein and Vitamin A.””C) “”Decrease fatty foods from your diet.””D) “”Do not use caffeine in any form, including chocolate.””” “A) “”Eat a balanced diet for your age.”””
“The nurse is assigned to a newly delivered woman with HIV/AIDS. The student asks the nurse about how it is determined that a person has AIDS other than a positive HIV test. The nurse respondsA) “”The complaints of at least 3 common findings.””B) “”The absence of any opportunistic infection.””C) “”CD4 lymphocyte count is less than 200.””D) “”Developmental delays in children.””” “C) “”CD4 lymphocyte count is less than 200.”””
The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is appropriate?A) Offer ice cream every 2 hoursB) Place the child in a supine positionC) Allow the child to drink through a strawD) Observe swallowing patterns D: Observe swallowing patterns
A 23 year-old single client is in the 33rd week of her first pregnancy. She tells the nurse that she has everything ready for the baby and has made plans for the first weeks together at home. Which normal emotional reaction does the nurse recognize?A) Acceptance of the pregnancyB) Focus on fetal developmentC) Anticipation of the birthD) Ambivalence about pregnancy C: Anticipation of the birth
The nurse is planning care for a client with pneumococcal pneumonia. Which of the following would be most effective in removing respiratory secretions?A) Administration of cough suppressantsB) Increasing oral fluid intake to 3000 cc per dayC) Maintaining bed rest with bathroom privilegesD) Performing chest physiotherapy twice a day B: Increasing oral fluid intake to 3000 cc per day

15. The nurse in a well-child clinic examines many children on a daily basis. Which of the following toddlers requires further follow up?A) A 13 month-old unable to walkB) A 20 month-old only using 2 and 3 word sentencesC) A 24 month-old who cries during examinationD) A 30 month-old only drinking from a sip cup D: A 30 month-old only drinking from a sip cup
    Which of the following would be the best strategy for the nurse to use when teaching insulin injection techniques to a newly diagnosed client with diabetes?A) Give written pre and post testsB) Ask questions during practiceC) Allow another diabetic to assistD) Observe a return demonstration D: Observe a return demonstration
    A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?A) Elevate leg on 2 pillowsB) Apply support stockingsC) Apply warm compressesD) Maintain complete bed rest A: Elevate leg on 2 pillows
    A nurse from the surgical department is reassigned to the pediatric unit. The charge nurse should recognize that the child at highest risk for cardiac arrest and is the least likely to be assigned tothis nurse is which child?A) Congenital cardiac defectsB) An acute febrile illnessC) Prolonged hypoxemiaD) Severe multiple trauma C: Prolonged hypoxemia
    A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client toA) A social worker from the local hospitalB) An occupational therapist from the community centerC) A physical therapist from the rehabilitation agencyD) Another client with diabetes mellitus and takes insulin B: An occupational therapist from the community center
    A priority goal of involuntary hospitalization of the severely mentally ill client isA) Re-orientation to realityB) Elimination of symptomsC) Protection from harm to self or others C: Protection from self harm and harm to others
    The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommendA) IsometricB) Range of motionC) AerobicD) Isotonic A: Isometric
    The nurse is teaching parents about the treatment plan for a 2 weeks-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately reportA) Loss of consciousnessB) Feeding problemsC) Poor weight gainD) Fatigue with crying A: Loss of consciousness
    A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse wouldA) Instruct the client to maintain a regular diet the day prior to the examinationB) Restrict the client’s fluid intake 4 hours prior to the examinationC) Administer a laxative to the client the evening before the examinationD) Inform the client that only 1 x-ray of his abdomen is necessary C: Administer a laxative to the client the evening before the examination
    The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What is the priority nursing diagnoses at this time?A) Altered tissue perfusionB) Risk for fluid volume deficitC) High risk for hemorrhageD) Risk for infection D: Risk for infection
    The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them thatA) Circumcision is delayed so the foreskin can be used for the surgical repairB) This procedure is contraindicated because of the permanent defectC) There is no medical indication for performing a circumcision on any childD) The procedure should be performed as soon as the infant is stable Circumcision is delayed so the foreskin can be used for the surgical repair
    The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (A.L.S.). Which finding would the nurse expect?A) ConfusionB) Loss of half of visual fieldC) Shallow respirationsD) Tonic-clonic seizures C: Shallow respirations
    A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse’s best explanation of these findings?A) These side effects are common and should subside in a few daysB) The client is probably having an allergic reaction and should discontinue the drugC) Taking the lithium on an empty stomach should decrease these symptomsD) Decreasing dietary intake of sodium and fluids should minimize the side effects A) These side effects are common and should subside in a few days
    A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?A) Ask the client if he has noticed any bleeding or dark stoolsB) Tell the client to call 911 and go to the emergency department immediatelyC) Schedule a repeat Hemoglobin and Hematocrit in 1 monthD) Tell the client to schedule an appointment with a hematologist A) Ask the client if he has noticed any bleeding or dark stools
    A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA).The nurse knows that a PTCA is theA) Surgical repair of a diseased coronary arteryB) Placement of an automatic internal cardiac defibrillatorC) Procedure that compresses plaque against the wall of thediseased coronary artery to improve blood flowD) Non-invasive radiographic examination of the heart C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow
    For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?A) Institute seizure precautionsB) Weigh the child twice per shiftC) Encourage the child to eat protein-rich foodsD) Relieve boredom through physical activity A) Institute seizure precautions
    Following mitral valve replacement surgery a client develops PVC’s. The health careprovider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at arate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s ofD5W. Theinfusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/minute?A) 60 microdrops/minuteB) 20 microdrops/minuteC) 30 microdrops/minuteD) 40 microdrops/minute A: 60 microdrops/minute2 gm=2000 mgm2000 mgm/500 cc = 4 mgm/x cc2000x = 2000x= 2000/2000 = 1 cc of IV solution/minuteCC x 60 microdrops = 60 microdrops/minute
    An adolescent client comes to the clinic 3 weeks after the birth of her first baby. She tells the nurse she is concerned because she has not returned to her pre-pregnant weight. Which action should thenurse perform first?A) Review the client’s weight pattern over the yearB) Ask the mother to record her diet for the last 24 hoursC) Encourage her to talk about her view of herselfD) Give her several pamphlets on postpartum nutrition C) Encourage her to talk about her view of herself
    To prevent a valsalva maneuver in a client recovering from an acute myocardialinfarction, the nurse wouldA) Assist the client to use the bedside commodeB) Administer stool softeners every day as orderedC) Administer anti dysrhythmics prn as orderedD) Maintain the client on strict bed rest B) Administer stool softeners every day as ordered
    A 3 year-old had a hip spica cast applied 2 hours ago. In order to facilitate drying, the nurse shouldA) Expose the cast to air and turn the child frequentlyB) Use a heat lamp to reduce the drying timeC) Handle the cast with the abductor barD) Turn the child as little as possibleThe correct answer is A: Expose the cast to air and turn the child frequently A) Expose the cast to air and turn the child frequently
    The nurse is caring for a 13 year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate postoperative period?A) Raise the head of the bed at least 30 degreesB) Encourage ambulation within 24 hoursC) Maintain in a flat position, logrolling as neededD) Encourage leg contraction and relaxation after 48 hours C) Maintain in a flat position, logrolling as needed
    A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts toA) Convince the client that the hospital staff is trying to helpB) Help the client to enter into group recreational activitiesC) Provide interactions to help the client learn to trust staffD) Arrange the environment to limit the client’s contact with other clients C) Provide interactions to help the client learn to trust staff
    The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?A) Unequal leg lengthB) Limited adductionC) Diminished femoral pulsesD) Symmetrical gluteal foldsThe correct answer is A: Unequal leg length A) Unequal leg length
    A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes thisproblem is probably due toA) A cerebral vascular accidentB) Postoperative meningitisC) Medication reactionD) Metabolic alkalosis A) A cerebral vascular accident
    “Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: “”We just don’t know how he caught the disease!”” The nurse’s response is based on an understanding thatA) AGN is a streptococcal infection that involves the kidney tubulesB) The disease is easily transmissible in schools and campsC) The illness is usually associated with chronic respiratory infectionsD) It is not “”caught”” but is a response to a previous B-hemolytic strep infection” “D) It is not “”caught”” but is a response to a previous B-hemolytic strep infection”
    A couple asks the nurse about risks of several birth control methods. What is he most appropriate response by the nurse?A) Norplant is safe and may be removed easilyB) Oral contraceptives should not be used by smokersC) Depo-Provera is convenient with few side effectsD) The IUD gives protection from pregnancy and infection B) Oral contraceptives should not be used by smokers
    “A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breast feed the infants. Which of the following is based on sound rationale?A) “”Nursing will help contract the uterus and reduce your risk of bleeding.””B) “”Breastfeeding twins will take too much energy after the hemorrhage.””C) “”The blood transfusion may increase the risks to you and the babies.””D) “”Lactation should be delayed until the “”real milk”” is secreted.””” “A) “”Nursing will help contract the uterus and reduce your risk of bleeding.”””
    The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?A) Place pillows under the kneesB) Use elastic stockings continuouslyC) Encourage range of motion and ambulationD) Massage the legs twice dailyThe correct answer is C: Encourage range of motion and ambulation C) Encourage range of motion and ambulation
    The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33%normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?A) 3 episodes of vomiting in 1 hourB) Periodic crying and irritabilityC) Vigorous sucking on a pacifierD) No measurable voiding in 4 hours D) No measurable voiding in 4 hours
    “Which response by the nurse would best assist the chemically impaired client to deal with issues of guilt?A) “”Addiction usually causes people to feel guilty. Don’t worry, it is a typical responsedue to your drinking behavior.””B) “”What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?””C) “”Don’t focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs.””D) “”You’ve caused a great deal of pain to your family and close friends, so it will take time to undo all the things you’ve done.””” “B) “”What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?”””
    “A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when “”his eyes rolled upward.”” The nurse recognizes this as what type of side effect?A) Oculogyric crisisB) Tardive dyskinesiaC) NystagmusD) Dysphagia” A) Oculogyric crisis
    Which of the following measures would be appropriate for the nurse to teach the parent of a nine month-old infant about diaper dermatitis?A) Use only cloth diapers that are rinsed in bleachB) Do not use occlusive ointments on the rashC) Use commercial baby wipes with each diaper changeD) Discontinue a new food that was added to the infant’s diet just prior to the rash D: Discontinue a new food that was added to the infant”s diet just prior to the rash
    “A mother brings her 26 month-old to the well-child clinic. She expresses frustration and anger due to her child’s constantly saying “”no”” and his refusal to follow her directions. The nurse explains this isnormal for his age, as negativism is attempting to meet which developmental need?A) TrustB) InitiativeC) IndependenceD) Self-esteem” C) Independence
    Which behavioral characteristic describes the domestic abuser?A) AlcoholicB) Over confidentC) High tolerance for frustrationsD) Low self-esteem D) Low self-esteem
    “Which statement by the client with chronic obstructive lung disease indicates an understanding of the major reason for the use of occasional pursed-lip breathingA) “”This action of my lips helps to keep my airway open.””B) “”I can expel more when I pucker up my lips to breathe out.””C) “”My mouth doesn’t get as dry when I breathe with pursed lips.””D) “”By prolonging breathing out with pursed lips the little areas in my lungs don’t collapse.””” “D: “”By prolonging breathing out with pursed lips my little areas in my lungs don”t collapse.”””
    “During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?A) “”I have constant blurred vision.””B) “”I can’t see on my left side.””C) “”I have to turn my head to see my room.””D) “”I have specks floating in my eyes.””” “C) “”I have to turn my head to see my room.”””
    “A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client was using the mechanism of “”suppression””?A) “”I don’t remember anything about what happened to me.””B) “”I’d rather not talk about it right now.””C) “”It’s all the other guy’s fault! He was going too fast.””D) “”My mother is heartbroken about this.””” “A) “”I don’t remember anything about what happened to me.”””
    While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse’s first action?A) Check vital signsB) Massage the fundusC) Offer a bedpanD) Check for perineal lacerations B: Massage the fundus
    An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?A) Double the birth weightB) Triple the birth weightC) Gain 6 ounces each weekD) Add 2 pounds each month A: Double the birth weight
    On admission to the psychiatric unit, the client is trembling and appears fearful. The nurse’s initial response should be toA) Give the client orientation materials and review the unit rules and regulationsB) Introduce him/herself and accompany the client to the client’s roomC) Take the client to the day room and introduce her to the other clientsD) Ask the nursing assistant to get the client’s vital signs and complete the admission search B) Introduce him/herself and accompany the client to the client’s room
    A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the clientA) Has increased airway obstructionB) Has improved airway obstructionC) Needs to be suctionedD) Exhibits hyperventilation A) Has increased airway obstruction
    “A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?A) “”Focus on your sons’ needs during the first days at home.””B) “”Tell each child what he can do to help with the baby.””C) “”Suggest that your husband spend more time with the boys.””D) “”Ask the children what they would like to do for the newborn.””” “A) “”Focus on your sons’ needs during the first days at home.”””
    A 16 year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents isA) Progressive failure to adaptB) Feelings of anger or hostilityC) Reunion wish or fantasyD) Feelings of alienation or isolation D) Feelings of alienation or isolation
    A newborn has been diagnosed with hypothyroidism. In discussing the condition andtreatment with the family, the nurse should emphasizeA) They can expect the child will be mentally retardedB) Administration of thyroid hormone will prevent problemsC) This rare problem is always hereditaryD) Physical growth/development will be delayed B) Administration of thyroid hormone will prevent problems
    A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?A) Holistic healingB) Spiritual advisingC) Herbal preparationsD) Witchcraft potions A) Holistic healing
    In addition to disturbances in mental awareness and orientation, a client with cognitive impairment is also likely to show loss of ability inA) Hearing, speech, and sightB) Endurance, strength, and mobilityC) Learning, creativity, and judgmentD) Balance, flexibility, and coordination C) Learning, creativity, and judgment
    In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchyrash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?A) Take the client’s respirations, blood pressure (BP), temperature and then pupillary responsesB) Place the client into the bed and administer the ordered PRN analgesicC) Check the client for bladder distention and the client’s urinary catheter for kinksD) Turn the television off and then assist client to use relaxation techniques C) Check the client for bladder distention and the client’s urinary catheter for kinks
    The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client complaint calls for immediate nursing action?A) Diaphoresis and shakinessB) Reduced lower leg sensationC) Intense thirst and hungerD) Painful hematoma on thigh A) Diaphoresis and shakiness
    The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would beA) Reduce fear and protect self-esteemB) Minimize anxiety and delay apprehensionC) Avoid conflict and leave unpleasant situationsD) Increase independence and communicate more often A: Reduce fear and protect self-esteem
    In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test?A) Increased edema and weight gainB) Unchanged urine specific gravityC) Rapid protein excretionD) Decreased blood potassium B: Unchanged urine specific gravity
    The nurse is evaluating the growth and development of a toddler with AIDS. The nurse would anticipate finding that the child hasA) Achieved developmental milestones at an erratic rateB) Delay in musculoskeletal developmentC) Displayed difficulty with speech developmentD) Delay in achievement of most developmental milestones D) Delay in achievement of most developmental milestones
    A client was admitted with a diagnosis of pneumonia. When auscultating the client’s breath sounds, the nurse hears inspiratory crackles in the right base. Temperature is 102.3 degrees Fahrenheit orally. What finding would the nurse expect?A) Flushed skinB) BradycardiaC) Mental confusionD) Hypotension C) Mental confusion
    Postoperative orders for a client undergoing a mitral valve replacement includemonitoring pulmonary artery pressure togetherwith pulmonary capillary wedge pressurewith a pulmonary arterycatheter. This action by the nurse will assessA) Right ventricular pressureB) Left ventricular end-diastolic pressureC) Acid-Base balanceD) Coronary artery stability B) Left ventricular end-diastolic pressure
    The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?A) Change the pillow covers every monthB) Wash bed linens in warm water with a cold rinseC) Wash and rinse the bed linens in hot waterD) Use air filters in the furnace system C) Wash and rinse the bed linens in hot water
    A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?A) Determine that adequate mist is suppliedB) Inspect the nares and ears for skin breakdownC) Lubricate the tips of the cannula before insertionD) Maintain sterile technique when handling cannula B) Inspect the nares and ears for skin breakdown
    The nurse is caring for a client with Parkinson’s disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?A) Ask family members to dress the clientB) Encourage the client to dress more quicklyC) Allow the client the time needed to dressD) Demonstrate methods on how to dress more quickly C) Allow the client the time needed to dress
    The nurse is assessing a 12 year-old who has Hemophilia A. Which finding would thenurse anticipate?A) An excess of red blood cellsB) An excess of white blood cellsC) A deficiency of clotting factor VIIID) A deficiency of clotting factors VIII and IX C) A deficiency of clotting factor VIII
    The nurse is assessing a newborn infant and observes low set ears, short palpebral fissures, flat nasal bridge and indistinct philtrum. A priority maternal assessment by the nurse should be to ask aboutA) Alcohol use during pregnancyB) Usual nutritional intakeC) Family genetic disordersD) Maternal and paternal ages A) Alcohol use during pregnancy
    A 2 month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which nursing approach should be the priority?A) Remove protective arm devices one at a time for short periods with supervisionB) Initiate by mouth feedings when alert, with the return of the gag reflexC) Introduce to the parents how to cleanse the suture line with the prescribed protocolD) Position the infant on the back after feedings throughout the day A) Remove protective arm devices one at a time for short periods with supervision
    The new graduate nurse interviews for a position in a nursing department of a large health care agency, described by the interviewer as having shared governance. Which of these statements best illustrates the shared governance model?A) An appointed board oversees any administrative decisionsB) Nursing departments share responsibility for client outcomesC) Staff groups are appointed to discuss nursing practice and client education issuesD) Non-nurse managers supervise nursing staff in groups of units B) Nursing departments share responsibility for client outcomes
    “The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?A) “”What is your reason for wanting such a plan?””B) “”Have you talked with your health care provider about this?””C) “”Let us discuss your rights as a couple.””D) “”Write your ideal plan for the next class.””” “C: “”Let us discuss your rights as a couple.”””
    A client is admitted with the diagnosis of myocardial infarction (MI). Which of the following lab values would be consistent with this diagnosisA) Low serum albuminB) High serum cholesterolC) Abnormally low white blood cell countD) Elevated creatinine phosphokinase (CPK ) D: Elevated CPK (creatinine phosphokinase)
    A client tells the nurse he is fearful of planned surgery because of evil thoughts about a family member. What is the best initial response by the nurse?A) Call a chaplainB) Deny the feelingsC) Cite recovery statisticsD) Listen to the client D: Listen to the client
    A 14 month-old had cleft palate surgical repair several days ago. The parents ask the nurse about feedings after discharge. Which lunch is the best example of an appropriate meal?A) Hot dog, carrot sticks, gelatin, milkB) Soup, blenderized soft foods, ice cream, milkC) Peanut butter and jelly sandwich, chips, pudding, milkD) Baked chicken, applesauce, cookie, milk B: Soup, blenderized soft foods, ice cream, milk
    The RN is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?A) Infant will experience minimal painB) Muscle spasms will be relievedC) Mobility will be managed as toleratedD) Tissue perfusion will be maintained D: Tissue perfusion will be maintained
    The nurse would expect which eating disorder to have the greatest fluctuations in potassium?A) Binge eating disorderB) Anorexia nervosaC) BulemiaD) Purge syndrome C) Bulemia
    When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?A) Digestive problemsB) AmenorrheaC) Electrolyte imbalanceD) Blood disorders B) Amenorrhea
    The nurse is planning care for a client with increased intracranial pressure. The bestposition for this client isA) TrendelenbergB) ProneC) Semi-FowlersD) Side-lying with head flat C) Semi-Fowlers
    While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality?A) Flexion of lower extremitiesB) Negative Ortlani responseC) Lengthened leg of affected sideD) Irregular hip symmetry D: Irregular hip symmetry
    The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based onthis assessment data?A) Impaired gas exchange related to acute infection and sputum productionB) Ineffective airway clearance related to sputum production and ineffective coughC) Ineffective breathing pattern related to acute infectionD) Anxiety related to hospitalization and role conflict B: Ineffective airway clearance related to sputum production and ineffective cough
    A young child is admitted for treatment of lead poisoning. The nurse recognizes that the most serious effect of chronic lead poisoning isA) Central nervous system damageB) Moderate anemiaC) Renal tubule damageD) Growth impairment A) Central nervous system damage
    At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initiallyA) Allow the staff to change assignmentsB) Clarify reasons for current assignmentsC) Help staff see the complexity of issuesD) Facilitate creative thinking on staffing D) Facilitate creative thinking on staffing
    A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due toA) Insufficient oxygenation of the cardiac muscleB) Potential circulatory overloadC) Left ventricular overloadD) Electrolyte imbalance A) Insufficient oxygenation of the cardiac muscle
    A client was re-admitted to the hospital following a recent skull fracture. Which finding requires the nurse’s immediate attention?A) LethargyB) AgitationC) AtaxiaD) Hearing loss A) Lethargy
    “You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which indicates further teaching may be needed by the client?A) “”I will be receiving continuous doses of medication.””B) “”I should call the nurse before I take additional doses.””C) “”I will call for assistance if my pain is not relieved.””D) “”The machine will prevent an overdose.””” “B) “”I should call the nurse before I take additional doses.”””
    When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?A) Risk for injury: hemorrhageB) Risk for injury related to peripheral neuropathyC) Altered nutrition: less than body requirementsD) Fluid volume excess: ascites A) Risk for injury: hemorrhage
    The nurse is caring for a client with left ventricular heart failure. Which one of the following assessments is an early indication of inadequate oxygen transport?A) Crackles in the lungsB) Confusion and restlessnessC) Distended neck veinsD) Use of accessory muscles B) Confusion and restlessness
    On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the RN anticipate finding?A) Periorbital edema, absent light reflex and translucent tympanic membraneB) Irritability, rhinorrhea, and bulging tympanic membraneC) Diarrhea, retracted tympanic membrane and enlarged parotid glandD) Vomiting, pulling at ears and pearly white tympanic membrane B) Irritability, rhinorrhea, and bulging tympanic membrane
    A child with Tetralogy of Fallot visits the clinic several weeks before planned surgery. The nurse should give priority attention toA) Assessment of oxygenationB) Observation for developmental delaysC) Prevention of infectionD) Maintenance of adequate nutrition A) Assessment of oxygenation
    When teaching new parents to prevent Sudden Infant Death Syndrome (SIDS) what is the most important practice the nurse should instruct them to do?A) Place the infant in a supine or side lying position for sleepB) Do not allow anyone to smoke in the homeC) Follow recommended immunization scheduleD) Be sure to check infant every one hour A) Place the infant in a supine or side lying position for sleep
    A client is admitted with a distended bladder due to the inability to void. The nurse obtains an order to catheterize the client knowing that gradual emptying is preferred over complete emptying because itA) Reduces the potential for renal collapseB) Reduces the potential for shockC) Reduces the intensity of bladder spasmsD) Prevents bladder atrophy B) Reduces the potential for shock
    The nurse is assessing a client with a deep vein thrombosis. Which of the following signs and/or symptoms would the nurse anticipate finding?A) Rapid respirationsB) DiaphoresisC) Swelling of lower extremityD) Positive Babinski’s sign C) Swelling of lower extremity
    A 6 year-old female is diagnosed with recurrent urinary tract infections (UTI). Which one of the following instructions would be best for the nurse to tell the caregiver?A) Increase bladder tone by delaying voidingB) When laundering clothing, rinse several timesC) Use plain water for the bath, shampooing hair lastD) Have the child use antibacterial soaps while bathing C) Use plain water for the bath, shampooing hair last
    A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client’s obstetric history by the nurse?A) Para 2, Gravida 1B) Nulligravida 2, Para 1C) Primagravida 1, Para 1D) Gravida 2, Para 1 D) Gravida 2, Para 1
    “On admission to the hospital a client with an acute asthma episode has intermittent nonproductive coughing and a pulse oximeter reading of 88%. The client states, “”I feel like this is going to be a bad time this admission. I wish I would not have gone into that bar with allthose people who smoke last night.”” Which nursing diagnoses would be most important for this client?A) Anxiety related to hospitalizationB) Ineffective airway clearance related to potential thick secretionsC) Altered health maintenance related to preventative behaviors associated with asthmaD) Impaired gas exchange related to broncho constriction and mucosal edema” D) Impaired gas exchange related to broncho constriction and mucosal edema
    A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?A) ProneB) Dorsal recumbentC) Semi-FowlerD) Supine C) Semi-Fowler

Suicide precautions are initiated for a child admitted to the mental health unit following an intentional narcotic overdose. After a visitor leaves, the nurse finds a package of cigarettes in the client’s room. Which intervention is most important for the nurse to implement? Remove cigarettes for the client’s room
A family member of a frail elderly adult asks the nurse about eligibility requirements for hospice care. What information should the nurse provide? (Select all that apply.)A.)A client must be willing to accept palliative care, not curative care.B.)The healthcare provider must project that the client has 6 months or less to live.C.)The client must be diagnosed with clinical depression D.)The client must be of sound mind A,B
A client with atrial fibrillation receives a new prescription for dabigatran. What instruction should the nurse include in this client’s teaching plan? Avoid use of nonsteroidal ant-inflammatory drugs (NSAID).
An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first? Digoxin
The nursing staff on a medical unit includes a registered nurse (RN), practical nurse (PN), and an unlicensed assistive personnel (UAP). Which task should the charge nurse assign to the RN? Supervise a newly hired graduate nurse during an admission assessment.
While teaching a young male adult to use an inhaler for his newly diagnosed asthma, the client stares into the distance and appears to be concentrating on something other than the lesson the nurse is presenting. What action should the nurse take? Ask the client what he is thinking about at his time.
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.)Administer PRN nebulizer treatment.B.)Obtain 12 lead electrocardiogram.C.)Monitor continuous oxygen saturation.D.) Lay the client in the prone position A,B,C
The nurse caring for a 3-month-old boy one day after a pylorotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the nurse take? Administer a prescribed analgesia for pain.
A 4-year-old with acute lymphocytic leukemia (ALL) is receiving a chemotherapy (CT) protocol that includes methotrexate (Mexate, Trexal, MIX), an antimetabolite. Which information should the nurse provide the parents about caring for their child? Use sunblock or protective clothing when outdoors.
Two days after admission a male client remembers that he is allergic to eggs, and informs the nurse of the allergy. Which actions should the nurse implement? SATAA.) Tell the client that its a mild reaction B.)Notify the food services department of the allergy.C.)Enter the allergy information in the client’s record.D.)Add egg allergy to the client’s allergy arm band. B,C,D
The rapid response team’s detects return of spontaneous circulation (ROSC) after 2 min of continuous chest compressions. The client has a weak, fast pulse and no respiratory effort, so the healthcare provider performs a successful oral, intubation. What action should the nurse implement? Perform bilateral chest auscultation.
After administering an antipyretic medication. Which intervention should the nurse implement? Encouraging liberal fluid intake
A client with hyperthyroidism is being treated with radioactive iodine (I-131). Which explanation should be included in preparing this client for this treatment? Describe radioactive iodine as a tasteless, colorless medication administered by the healthcare provider
After a colon resection for colon cancer, a male client is moaning while being transferred to the Postanesthesia Care Unit (PACU). Which intervention should the nurse implement first? Determine client’s pulse, blood pressure, and respirations
The nurse is caring for a group of clients with the help of a licensed practical nurse (LPN) and an experienced unlicensed assistive personnel (UAP). Which procedures can the nurse delegate to the UAP? (Select all that apply)A.)Take postoperative vital signs for a client who has an epidual following knee arthroplastyB.)Collect a sputum specimen for a client with a fever of unknown originC.)Ambulate a client who had a femoral-popliteal bypass graft yesterday A,B,C
A male client with cirrhosis has ascites and reports feeling short of breath. The client is in semi Fowler position with his arms at his side. What action should the nurse implement? Raise the head of the bed to a Fowler’s position and support his arms with a pillow
A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. Which action should the nurse implement next? Administer the analgesic as requested
The nurse uses the parkland formula (4ml x kg x total body surface area = 24 hours fluid replacement) to calculate the 24-hours IV fluid replacement for a client with 40% burns who weighs 76kg. How many ml should the client receive? (Enter numeric value only.) 12160
A client with leukemia undergoes a bone marrow biopsy. The client’s laboratory values indicate the client has thrombocytopenia. Based on this data, which nursing assessment is most important following the procedure?A.)Observe aspiration site.B.)Assess body temperature C.)Monitor skin elasticityD.)Measure urinary output A
An 18-year-old female client is seen at the health department for treatment of condylomata acuminate (perineal warts) caused by the human papillomavirus (HPV). Which intervention should the nurse implement? Reinforce the importance of annual papanicolaou (Pap) smears.
A client admitted to the psychiatric unit diagnosed with major depression wants to sleep during the day, refuses to take a bath, and refuses to eat. Which nursing intervention should the nurse implement first? Establish a structured routine for the client to follow.
A client with history of bilateral adrenalectomy is admitted with a week, irregular pulse, and hypotension. Which assessment finding warrants immediate intervention by the nurse? Ventricular arrhythmias.
The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? Instruct the mother to change the child’s diaper more often.
A resident of a long-term care facility, who has moderate dementia, is having difficulty eating in the dining room. The client becomes frustrated when dropping utensils on the floor and then refuses to eat. What action should the nurse implement? Encourage the client to eat finger foods.
A client is receiving mesalamine 800 mg PO TID. Which assessment is most important for the nurse to perform to assess the effectiveness of the medication? Bowel patterns
While in the medical records department, the nurse observes several old medical records with names visible in waste container. What action should the nurse implement? Contact the medical records department supervisor.
A 16-year-old adolescent with meningococcal meningitis is receiving a continuous IV infusion of penicillin G, which is prescribed as 20 million units in a total volume of 2 liters of normal saline every 24 hr. The pharmacy delivers 10 million units/ liters of normal saline. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only. If rounding is required, round to the nearest whole number.) 83
While visiting a female client who has heart failure (HF) and osteoarthritis, the home health nurse determines that the client is having more difficulty getting in and out of the bed than she did previously. Which action should the nurse implement first? Submit a referral for an evaluation by a physical therapist.
A client has an intravenous fluid infusing in the right forearm. To determine the client’s distal pulse rate most accurately, which action should the nurse implement? Submit a referral for an evaluation by a physical therapist.
A child is admitted to the pediatric unit diagnosed with sickle cell crisis. When the nurse walks into the room, the unlicensed assistive personnel (UAP) is encouraging the child to stay in bed in the supine position. Which action should the nurse implement? Reposition the client with the head of the bed elevated.

155. After six days on a mechanical ventilator, a male client is extubated and place on 40% oxygen via face mask. He is awake and cooperative, but complaining of a severe sore throat. While sipping water to swallow a medication, the client begins coughing, as if strangled. What intervention is most important for the nurse to implement? Hold oral intake until swallow evaluation is done.
     The nurse is interacting with a female client who is diagnosed with postpartum depression. Which finding should the nurse document as an objective signs of depression? (Select all that apply)A.)Interacts with a flat affect.B.)Avoids eye contact.C.)Makes dull eye contact D.)Has a disheveled appearance. A,B,D
     A client in the postanesthesia care unit (PACU) has an eight (8) on the Aldrete postanesthesia scoring system. What intervention should nurse implement? Transfer the client to the surgical floor.
     In caring for the body of a client who just died, which tasks can be delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)A.)Place personal religious artifacts on the body.B.)Attach identifying name tags to the body.C.)Follow cultural beliefs in preparing the body.D.) Inform the family A,B,C
     An adult male reports the last time he received penicillin he developed a severe maculopapular rash all over his chest. What information should the nurse provide the client about future antibiotic prescriptions? Be alert for possible cross-sensitivity to cephalosporin agents.
     “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?” The client’s need for pain medication should be determined.
     A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention should the nurse implement? (Select all that apply.)A.)Monitor abdominal girth.B.)Increase oral fluid intake to 1500 ml daily.C.)Report serum albumin and globulin levels.D.)Provide diet low in phosphorous.E.)Note signs of swelling and edema. A,C,E
     During discharge teaching, the nurse discusses the parameters for weight monitoring with a client who was recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge? Report weight gain of 2 pounds (0.9kg) in 24 hours
     Which problem, noted in the client’s history, is important for the nurse to be aware of prior to administration of a newly prescribed selective serotonin reuptake inhibitor (SSRI)? Aural migraine headaches.
     When implementing a disaster intervention plan, which intervention should the nurse implement first?A.)Initiate the discharge of stable clients from hospital unitsB.)Identify a command center where activities are coordinatedC.)Assess community safety needs impacted by the disasterD.)Instruct all essential off-duty personnel to report to the facility B
     “The nurse is evaluating a client’s symptoms, and formulates the nursing diagnosis, “”high risk for injury due to possible urinary tract infection.”” Which symptoms indicate the need for this diagnosis?” Fever and dysuria.
     A client is admitted with metastatic carcinoma of the liver, ascites, and bilateral 4+ pitting edema of both lower extremities. When the client complains that the antiembolic stocking are too constricting, which intervention should the nurse implement? Maintain both lower extremities elevated on pillows.
     A client with muscular dystrophy is concerned about becoming totally dependent and is reluctant to call the nurse to assist with activities of daily living (ADLs). To achieve maximum mobility and independence, which intervention is most important for the nurse to include in the client’s plan of care? Teach family proper range of motion exercises.
     The nurse is teaching a postmenopausal client about osteoporosis prevention. The client reports that she smokes 2 packs of cigarettes a day and takes 750 mg calcium supplements daily. What information should the nurse include when teaching this client about osteoporosis prevention? Postmenopausal women need an intake of at least 1,500 mg of calcium daily.
     When evaluating a client’s rectal bleeding, which findings should the nurse document? Color characteristics of each stool.
     The nurse is auscultating a client’s lung sounds. Which description should the nurse use to document this sound?A.)High pitched or fine crackles.B.)Rhonchi C.)High pitched wheeze D.)Stridor A
     An adult male is admitted to the emergency department after falling from a ladder. While waiting to have a computed tomography (CT) scan, he requests something for a severe headache. When the nurse offers him a prescribed does of acetaminophen, he asks for something stronger. Which intervention should the nurse implement? Explain the reason for using only non-narcotics.
     The nurse is managing the care of a client with Cushing’s syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply) Weigh the client and report any weight gain.Report any client complaint of pain or discomfort.Note and report the client’s food and liquid intake during meals and snacks.
     Ten years after a female client was diagnosed with multiple sclerosis (MS), she is admitted to a community palliative care unit. Which intervention is most important for the nurse to include in the client’s plan of care? Medicate as needed for pain and anxiety.
     An increased number of elderly persons are electing to undergo a new surgical procedure which cures glaucoma. What effect is the nurse likely to note as a result of this increases in glaucoma surgeries? Decrease prevalence of glaucoma in the population.
     The nurse is caring for a client who is entering the second stage of labor. Which action should the nurse implement first? Convey to the client that birth is imminent.
     To evaluate the effectiveness of male client’s new prescription for ezetimibe, which action should the clinic nurse implement? Remind the client to keep his appointments to have his cholesterol level checked.
     Diagnostic studies indicate that the elderly client has decreased bone density. In providing client teaching, which area of instruction is most important for the nurse to include? Fall prevention measures.
     “A young adult client is admitted to the emergency room following a motor vehicle collision. The client’s head hit the dashboard. Admission assessment include: Blood pressure 85/45 mm Hg, temperature 98.6 F, pulse 124 beat/minute and respirations 22 breath/minute. Based on these data, the nurse formulates the first portion of nursing diagnosis as “” Risk of injury”” What term best expresses the “”related to”” portion of nursing diagnosis?A.)InfectionB.)Increase intracranial pressureC.)ShockD.)Head Injury.” C
     An older male client with history of diabetes mellitus, chronic gout, and osteoarthritis comes to the clinic with a bag of medication bottles. Which intervention should the nurse implement first? Identify pills in the bag.
     A male client who was diagnosed with viral hepatitis A 4 weeks ago returns to the clinic complaining of weakness and fatigue. Which finding is most important for the nurse to report to the healthcare provider? New onset of purple skin lesions.
     In assessing a client twelve hours following transurethral resection of the prostate (TURP), the nurse observes that the urinary drainage tubing contains a large amount of clear pale pink urine and the continuous bladder irrigation is infusing slowly. What action should the nurse implement? Ensure that no dependent loops are present in the tubing.
     The healthcare provider prescribes the antibiotic Cefdinir (cephalosporin) 300mg PO every 12 h for a client with postoperative wound infections. Which feeds should the nurse encourage this client to eat?A.)Yogurt and/or buttermilk.B.)Avocados and cheese C.)Green leafy vegetablesD.)Fresh fruits A
     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 depress for the past several month 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 tell the staff and other client that he is superman and he can fly. C
     In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client’s appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis? Anxiety related to fear of suffocation.
     A client with a cervical spinal cord injury (SCI) has Crutchfield tongs and skeletal traction applied as a method of closed reduction. Which intervention is most important for the nurse to include in the client’s a plan of care? Provide daily care of tong insertion sites using saline and antibiotic ointment
     A client arrives on the surgical floor after major abdominal surgery. What intervention should the nurse perform first? Determine the client’s vital sign.
     A client is admitted to the emergency department with a respiratory rate of 34 breaths per minute and high pitched wheezing on inspiration and expiration, the medical diagnosis is severe exacerbation of asthma. Which assessment finding, obtained 10 min after the admission assessment, should the nurse report immediately to the emergency department healthcare provider? No wheezing upon auscultation of the chest.
     The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation? During acute illness
     A 350-bed acute care hospital declares an internal disaster because the emergency generators malfunctioned during a city-wide power failure. The UAPs working on a general medical unit ask the charge nurse what they should do first. What instruction should the charge nurse provide to these UAPs? Tell all their assigned clients to stay in their rooms.
     The healthcare provider changes a client’s medication prescription from IV to PO administration and double the dose. The nurse notes in the drug guide that the prescribed medication, when given orally, has a high first-pass effect and reduce bioavailability. What action should the nurse implement? Administer the medication via the oral route as prescribed
     “A client refuses to ambulate, reporting abdominal discomfort and bloating caused by “”too much gas buildup”” the client’s abdomen is distended. Which prescribed PRN medication should the nurse administer?” Simethicone (Mylicon)
     The public nurse health received funding to initiate primary prevention program in the community. Which program the best fits the nurse’s proposal?A.)Lead screening for children in low-income housing. B.)Case management and screening for clients with HIVC.)Regional relocation center for earthquake victims D.)Vitamin supplements for high-risk pregnant women. D
     When assessing and adult male who presents as the community health clinic with a history of hypertension, the nurse note that he has 2+ pitting edema in both ankles. He also has a history of gastroesophageal reflex disease (GERD) and depression. Which intervention is the most important for the nurse to implement? A.)Arrange to transport the client to the hospitalB.)Instruct the client to keep a food journal, including portions size.C.)Review the client’s use of over the counter (OTC) medications. D.)Reinforce the importance of keeping the feet elevated. C
     An older client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sound. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96`F, heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure(MAP) 64 mmHg and central venous pressure (CVP) 7 mmHg. Serum laboratory findings include: hemoglobin 6.5 grams/dl, platelets 6o, 000, and white blood cell count (WBC) 3,000/mm3. Based on these findings this client is at greatest risk for which pathophysiological condition?A.)Multiple organ dysfunction syndrome (MODS)B.)Disseminated intravascular coagulation (DIC)C.)Chronic obstructive disease.D.)Acquired immunodeficiency syndrome (AIDS) A
     A man expresses concern to the nurse about the care his mother is receiving while hospitalized. He believes that her care is not based on any ethical standards and ask what type of care he should expect from a public hospital. What action should the nurse take? Provide the man and his mother with a copy of the Patient’s Bill of Rights
     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 protocolB.)Initiate seizure precautionsC.)Obtain a serum drug screenD.)Instruct the family about withdrawal symptoms. B
     The nurse is caring for a client who is taking a macrolide to treat a bacterial infection. Which finding should the nurse report to the healthcare provider before administering the next dose?A.)JaundiceB.)Nausea C.)FeverD.)Fatigue A
     A client with Alzheimer’s disease (AD) is receiving trazodone (Desyrel), a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the client’s mood and sleep patterns are improved, but there is no change in cognitive ability. How should the nurse respond to this information?A.)Explain that it may take several weeks for the medication to be effectiveB.)Confirm the desired effect of the medication has been achieved.C.)Notify the health care provider than a change may be needed.D.)Evaluate when and how the medication is being administered to the client. B
     A client with diabetic peripheral neuropathy has been taking pregabalin (Lyrica) for 4 days. Which finding indicates to the nurse that the medication is effective?A.)Reduced level of painB.)Full volume of pedal pulses C.)Granulating tissue in foot ulcerD.)Improved visual acuity A
     A group of nurse-managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization’s budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?A.)How many departments can use this equipment?B.)Will the equipment require annual repair?C.)Is the cost of the equipment reasonable?D.)Can the equipment be updated each year? A
     “While receiving a male postoperative client’s staples de nurse observe that the client’s eyes are closed and his face and hands are clenched. The client states, “”I just hate having staples removed””. After acknowledgement the client’s anxiety, what action should the nurse implement?A.)Encourage the client to continue verbalize his anxietyB.)Attempt to distract the client with general conversation C.)Explain the procedure in detail while removing the staplesD.)Reassure the client that this is a simple nursing procedure.” B
     A male client is admitted for the removal of an internal fixation that was inserted for the fracture ankle. During the admission history, he tells the nurse he recently received vancomycin (vancomycin) for a methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which action should the nurse take? (Select all that apply.) A.)Collect multiple site screening culture for MRSAB.)Call healthcare provider for a prescription for linezolid (Zyrovix)C.)Place the client on contact transmission precautionsD.)Obtain sputum specimen for culture and sensitivity E.)Continue to monitor for client sign of infection. A,C,E
     A vacuum-assistive closure (VAC) device is being use to provide wound care for a client who has stage III pressure ulcer on a below-the- knee (BKA) residual limb. Which intervention should the nurse implement to ensure maximum effectiveness of the device? Ensure the transparent dressing has no tears that might create vacuum leaks
     “The nurse is developing the plan of care for a client with pneumonia and includes the nursing diagnosis of “”Ineffective airway clearance related to thick pulmonary secretions.”” Which intervention is most important for the nurse to include in the client’s plan of care?” Increase fluid intake to 3,000 ml/daily
     The nurse plans to collect a 24- hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?A.)Clearance around the meatus, discard first portion of voiding, and collect the rest in a sterile bottleB.)Urinate at specific time, discard the urine, and collect all subsequent urine during the next 24 hours. C.)For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect catheterized specimens. D.)Urinate immediately into a urinal, and the lab will collect specimen every 6 hours, for the next 24 hours. D
     The nurse is preparing to administer a histamine 2-receptor antagonist to a client with peptic ulcer disease. What is the primary purpose of this drug classification? Decreases the amount of HCL secretion by the parietal cells in the stomach
     The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug’s effectiveness? Hemoglobin A1C (HbA1C) reading less than 7%
     The nurse assesses a client with new onset diarrhea. It is most important for the nurse to question the client about recent use of which type of medication?A.)AntibioticsB.)AnticoagulantsC.)AntihypertensiveD)Anticholinergics A
     A neonate with a congenital heart defect (CHD) is demonstrating symptoms of heart failure (HF). Which interventions should the nurse include in the infant’s plan of care?A.)Give O2 at 6 L/nasal cannula for 3 repeated oximetry screens below 90%B.)Administer diuretics via secondary infusion in the morning onlyC.)Evaluate heart rate for effectiveness of cardio tonic medicationsD.)Use high energy formula 30 calories/ounce at Q3 hours feeding via softnipplesE.)Ensure Interrupted and frequent rest periods between procedures. A,C,D,E
     The nurse is caring for a 4-year-old male child who becomes unresponsive as his heart rate decreases to 40 beats/minute. His blood pressure is 88/70 mmHg, and his oxygen saturation is 70% while receiving 100% oxygen by non-rebreather face mask. In what sequence, from first to last, should the nurse implement these actions? (Place the first action on top and last action on the bottom.)Administer epinephrine 0.01 mg/kg intraosseous (IO)Start chest compressions with assisted manual ventilationsReview the possible underlying causes for bradycardiaApply pads and prepare for transthoracic pacing 1. Start chest compressions with assisted manual ventilations2. Administer epinephrine 0.01 mg/kg intraosseous (IO)3. Apply pads and prepare for transthoracic pacing4. Review the possible underlying causes for bradycardia
     An elderly male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions he is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has foul odor. These findings suggest that his client is experiencing which condition?A.)Psychotic episodeB.)DepressionC.)DementiaD.)Delirium D
     A preschool-aged boy is admitted to the pediatric unit following successful resuscitation from a near-drowning incident. While providing care to child, the nurse begins talking with his preadolescent brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. What action should the nurse take? Ask the older brother how he felt during the incident.
     Following an esophagogastroduodenoscopy (EGD) a male client is drowsy and difficult to arouse, and his respiration are slow and shallow. Which action should the nurse implement? Select all that apply.A.)Prepare medication reversal agentB.)Check oxygen saturation levelC.)Apply oxygen via nasal cannula D.)Initiate bag- valve mask ventilation. E.)Begin cardiopulmonary resuscitation A,B,C
     The nurse is planning preoperative teaching plan of a 12-years old child who is scheduled for surgery. To help reduce the child anxiety, which action is the best for the nurse to implement?A.)Give the child syringes or hospital mask to play it at home prior to hospitalization. B.)Include the child in pay therapy with children who are hospitalized for similarsurgery.C.)Provide a family tour of the preoperative unit one week before the surgery is scheduled.D.)Provide doll an equipment to re-enact feeling associated with painful procedures. C
     Which intervention should the nurse implement during the administration of vesicant chemotherapeutic agent via an IV site in the client’s arm? Assess IV site frequently for signs of extravasation
     When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occurA.)Resume normal physical activityB.)Drink electrolyte fluid replacementC.)Give a dose of regular insulin per sliding scale D.)Measure urinary output over 24 hours. C
     The nurse is teaching a group of clients with rheumatoid arthritis about the need to modify daily activities. Which goal should the nurse emphasize?A.)Protect joint functionB.)Improve circulationC.)Control tremors D.)Increase weight bearing A
     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. What percentage of body surface area should the nurse document in the electronic medical record (EMR)?A.)9 %B.)18 %C.)36 %D.)45 % C
     A client with hyperthyroidism is receiving propranolol (Inderal). Which finding indicates that the medication is having the desired effect?A.)Decrease in serum T4 levelsB.)Increase in blood pressureC.)Decrease in pulse rateD.)Goiter no longer palpable C
     An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation?A.)Consistently applies TED hose before getting dressed in the morning.B.)Frequently elevated legs thorough the day.C.)Inspect the leg frequently for any irritation or skin breakdown D.)Completely stop cigarette/ cigar smoking. D
     A community health nurse is concerned about the spread of communicable diseases among migrant farm workers in a rural community. What action should the nurse take to promote the success of a healthcare program designed to address this problem? Establish trust with community leaders and respect cultural and family values
     The nurse performs a prescribed neurological check at the beginning of the shift on a client who was admitted to the hospital with a subarachnoid brain attack (stroke). The client’s Glasgow Coma Scale (GCS) score is 9. What information is most important for the nurse to determine?A.)The client’s previous GCS scoreB.)When the client’s stroke symptoms startedC.)If the client is oriented to timeD.)The client’s blood pressure and respiration rate A
     The charge nurse in a critical care unit is reviewing clients’ conditions to determine who is stable enough to be transferred. Which client status report indicates readiness for transfer from the critical care unit to a medical unit? Chronic liver failure with a hemoglobin of 10.1 and slight bilirubin elevation
     Based on principles of asepsis, the nurse should consider which circumstance to be sterile?A.)One inch- border around the edge of the sterile field set up in the operating roomB.)A wrapped unopened, sterile 4×4 gauze placed on a damp table top. C.)An open sterile Foley catheter kit set up on a table at the nurse waist level D.)Sterile syringe is placed on sterile area as the nurse riches over the sterile field. C
     An unlicensed assistive personnel (UAP) reports that a client’s right hand and fingers spasms when taking the blood pressure using the same arm. After confirming the presence of spams what action should the nurse take? A.)Ask the UAP to take the blood pressure in the other armB.)Tell the UAP to use a different sphygmomanometer.C.)Review the client’s serum calcium levelD.)Administer PRN antianxiety medication. C
     A 56-years-old man shares with the nurse that he is having difficulty making decision about terminating life support for his wife. What is the best initial action by the nurse?A.)Provide an opportunity for him to clarify his values related to the decision B.)Encourage him to share memories about his life with his wife and familyC.)Advise him to seek several opinions before making decisionD.)Offer to contact the hospital chaplain or social worker to offer support. A
     A client is being discharged home after being treated for heart failure (HF). What instruction should the nurse include in this client’s discharge teaching plan?A.)Weigh every morningB.)Eat a high protein dietC.)Perform range of motion exercisesD.)Limit fluid intake to 1,500 ml daily A
     A woman just learned that she was infected with Heliobacter pylori. Based on this finding, which health promotion practice should the nurse suggest? Encourage screening for a peptic ulcer
     A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? Teach tracheal suctioning techniques
     A child with heart failure is receiving the diuretic furosemide (Lasix) and has serum potassium level 3.0 mEq/L. Which assessment is most important for the nurse to obtain?A.)Daily intake of foods rich in potassium.B.)Cardiac rhythm and heart rate.C.)Hourly urinary outputD.)Thirst ad skin turgor. B
     The nurse note a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client? A.)Encourage the client’s family to visit more oftenB.)Schedule a daily conference with the social workerC.)Encourage the client to participate in group activities D.)Engage the client in a non-threatening conversation. D
     A client with rheumatoid arthritis (RA) starts a new prescription of etanercept (Enbrel) subcutaneously once weekly. The nurse should emphasize the importance of reporting problem to the healthcare provider?A.)HeadacheB.)Joint stiffnessC.)Persistent feverD.)Increase hunger and thirst C
     The nurse is assessing an older adult with type 2 diabetes mellitus. Which assessment finding indicates that the client understands long- term control of diabetes?A.)The fating blood sugar was 120 mg/dl this morning.B.)Urine ketones have been negative for the past 6 monthsC.)The hemoglobin A1C was 6.5g/100 ml last weekD.)No diabetic ketoacidosis has occurred in 6 months. C
     An older male client is admitted with the medical diagnosis of possible cerebral vascular accident (CVA). He has facial paralysis and cannot move his left side. When entering the room, the nurse finds the client’s wife tearful and trying unsuccessfully to give him a drink of water. What action should the nurse take? Ask the wife to stop and assess the client’s swallowing reflex
     A 13 years-old client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects home aspirate specimens for culture and sensitivity and applies a cast to the adolescent’s lower leg. What action should the nurse implement next?A.)Administer antiemetic agentsB.) Bivalve the cast for distal compromise C.)Provide high- calorie, high-protein dietD.)Begin parenteral antibiotic therapy D
     The nurse is preparing a community education program on osteoporosis. Which instruction is helpful in preventing bone loss and promoting bone formation? Recommend weigh bearing physical activity
     A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next? Administer the analgesic as requested
     A male client receives a thrombolytic medication following a myocardial infarction. When the client has a bowel movement, what action should the nurse implement?A.)Send stool sample to the lab for a guaiac test B.)Observe stool for a day-colored appearance.C.)Obtain specimen for culture and sensitivity analysisD.)Asses for fatty yellow streaks in the client’s stool. A
     The mother of a child with cerebral palsy (CP) ask the nurse if her child’s impaired movements will worsen as the child grows. Which response provides the best explanation? Brain damage with CP is not progressive but does have a variable course
     During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first? Respiratory apnea of 30 seconds
     In early septic shock states, what is the primary cause of hypotension?A.)Peripheral vasoconstrictionB.)Peripheral vasodilationC.)Cardiac failureD.)A vagal response B
     A client diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide (Amphogel) is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider’s attention?A.)Aspirin, low doseB.)Furosemide (lasix)C.)Enalapril (vasote)D.)Allopurinol (Zyloprim) D
     A male client’s laboratory results include a platelet count of 105,000/ mm3 Based on this finding the nurse should include which action in the client’s plan of care?A.)Cluster care to conserve energyB.)Initiate contact isolationC.)Encourage him to use an electric razorD.)Asses him for adventitious lung sounds C
     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 IIB.)Persistent coughing while drinkingC.)Unilateral facial drooping D.)Inappropriate or exaggerated mood swings B
     At 1615, prior to ambulating a postoperative client for the first time, the nurse reviews the client’s medical record. Based on date contained in the record, what action should the nurse take before assisting the client with ambulation:A.)Remove sequential compression devices.B.)Apply PRN oxygen per nasal cannula.C.)Administer a PRN dose of an antipyretic.D.)Reinforce the surgical wound dressing. A
     Which assessment finding for a client who is experiencing pontine myelinolysis should the nurse report to the healthcare provider?A.)Sudden dysphagiaB.)Blurred visual fieldC.)Gradual weaknessD.)Profuse diarrhea A
     A client is scheduled to receive an IW dose of ondansetron (Zofran) eight hours after receiving chemotherapy. The client has saline lock and is sleeping quietly without any restlessness. The nurse caring for the client is not certified in chemotherapy administration. What action should the nurse take?A.)Ask a chemotherapy-certified nurse to administer the ZofranB.)Administer the Zofran after flushing the saline lock with salineC.)Hold the scheduled dose of Zofran until the client awakensD.)Awaken the client to assess the need for administration of the Zofran. B
     When providing diet teaching for a client with cholecystitis, which types of food choices the nurse recommend to the client?A.)High proteinB.)Low fatC.)Low sodiumD.)High carbohydrate. B
     A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse?A.) Jaundice skin toneB.)Muffled heart soundsC.)Pitting peripheral edemaD.)Bilateral scleral edema B
     When entering a client’s room, the nurse discovers that the client is unresponsive and pulseless. The nurse initiate CPR and Calls for assistance. Which action should the nurse take next?A.)Prepare to administer atropine 0.4 mg IVPB.)Gather emergency tracheostomy equipmentC.)Prepare to administer lidocaine at 100 mg IVPD.)Place cardiac monitor leads on the client’s chest. D
     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. What intervention should the nurse implement?A.)Replace the IV site with a smaller gauge.B.)Redress the abdominal incisionC.)Leave the lights on in the room at night.D.)Apply soft bilateral wrist restraints. B
     An adult male client is admitted to the emergency room following an automobile collision in which he sustained a head injury. What assessment data would provide the earliest that the client is experiencing increased intracranial pressure (ICP)?A.)LethargyB.)Decorticate posturingC.)Fixed dilated pupilD.)Clear drainage from the ear. A
     In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? A.)Prepare the client to independently treat their disease process B.)Reduce healthcare costs related to diabetic complicationsC.)Enable clients to become active participating in controlling the disease processD.)Increase client’s knowledge of the diabetic disease process and treatment options. C
     To reduce staff nurse role ambiguity, which strategy should the nurse manager implemented? A.)Confirm that all the staff nurses are being assigned to equal number of clients.B.)Review the staff nurse job description to ensure that it is clear, accurate, and recurrent.C.)Assign each staff nurse a turn unit charge nurse on a regular, rotating basis.D.)Analyze the amount of overtime needed by the nursing staff to complete assignments. B
     The nurse is assisting a new mother with infant feeding. Which information should the nurse provide that is most likely to result in a decrease milk supply for the mother who is breastfeeding?A.)Supplemental feedings with formulaB.)Maternal diet high in proteinC.)Maternal intake of increased oral fluidD.)Breastfeeding every 2 or 3 hours. A
     Which assessment is more important for the nurse to include in the daily plan of care for a client with a burned extremity?A.)Range of MotionB.)Distal pulse intensityC.)Extremity sensationD.)Presence of exudate B
     An elderly client with degenerative joint disease asks if she should use the rubber jar openers that are available. The nurse’s response should be based on which information about assistive devices?
     When assessing a 6-month old infant, the nurse determines that the anterior fontanel is bulging. In which situation would this finding be most significant?A.)CryingB.)Straining on stoolC.)VomitingD.)Sitting upright. D
     A client with angina pectoris is being discharge from the hospital. What instruction should the nurse plan to include in this discharge teaching?A.)Engage in physical exercise immediately after eating to help decrease cholesterol levels. B.)Walk briskly in cold weather to increase cardiac outputC.)Keep nitroglycerin in a light-colored plastic bottle and readily available.D.)Avoid all isometric exercises, but walk regularly. D
     What is the priority nursing action when initiating morphine therapy via an intravenous patient-controlled analgesia (PCA) pump?A.)Initiate the dosage lockout mechanism on the PCA pumpB.)Instruct the client to use the medication before the pain becomes severeC.)Assess the abdomen for bowel sounds. D.)Assess the client ability to use a numeric pain scale A
     While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first?
     The nurse receives a newborn within the first minutes after a vaginal delivery and intervenes to establish adequate respirations. What priority issue should the nurse address to ensure the newborn’s survival?A.)Heat lossB.)HypoglycemiaC.)Fluid balanceD.)Bleeding tendencies A
     The fire alarm goes off while the charge nurse is receiving the shift report. What action should the charge nurse implement first?
     A 60-year-old female client asks the nurse about hormones replacement therapy (HRT) as a means preventing osteoporosis. Which factor in the client’s history is a possible contraindication for the use of HRT?
     “A male client, who is 24 hours postoperative for an exploratory laparotomy, complains that he is “”starving”” because he has had no “”real food”” since before the surgery. Prior to advancing his diet, which intervention should the nurse implement?”
     The nurse working in the psychiatric clinic has phone messages from several clients. Which call should the nurse return first?
     During change of shift, the nurse reports that a male client who had abdominal surgery yesterday increasingly confused and disoriented during the night. He wandered into other clients rooms, saying that there are men in his room trying to hurt him. Because of continuing disorientation and the client’s multiple attempts to get of bed, soft restrains were applied at 0400. In what order should the nurse who is receiving report implement these interventions? (Arrange from first action on top to last on the bottom).Assign unlicensed assistive personnel to remove restrains and remain with clientAssess the client’s skin and circulation for impairment related to the restrainsContact the client’s surgeon and primary healthcare providerEvaluate the client’s mentation to determine need to continue the restrains
     A mother brings her 3-year-old son to the emergency room and tells the nurse the he has had an upper respiratory infection for the past two days. Assessment of the child reveals a rectal temperature of 102 F. he is drooling and becoming increasingly more restless. What action should the nurse take first?
     After receiving the first dose of penicillin, the client begins wheezing and has trouble breathing. The nurse notifies the healthcare provider immediately and received several prescriptions. Which medication prescription should the nurse administer first?
     Two clients ring their call bells simultaneously requesting pain medication. What action should the nurse implement first?
     A client receives a new prescription for simvastatin (Zocor) 5 mg PO daily at bedtime. What action should the nurse take?
     Which client should the nurse assess frequently because of the risk for overflow incontinence? A client Who is confused and frequently forgets to go to the bathroom
     While monitoring a client during a seizure, which interventions should the nurse implement? (Select all that apply)A.)Move obstacle away from clientB.)Monitor physical movementsC.)Observe for a patent airway D.)Record the duration of the seizure A,B,C,D
     A male client with a long history of alcoholism is admitted because of mild confusion and fine motor tremors. He reports that he quit drinking alcohol and stopped smoking cigarettes one month ago after his brother died of lung cancer. Which intervention is most important for the nurses to include in the client’s plan of care? A.)Determine client’s level current blood alcohol level.B.)Observe for changes in level of consciousness.C.)Involve the client’s family in healthcare decisions.D.)Provide grief counseling for client and his family. B
     An older adult female admitted to the intensive care unit (ICU) with a possible stroke is intubated with ventilator setting of tidal volume 600, PlO2 40%, and respiratory rate of 12 breaths/minute. The arterial blood gas (ABG) results after intubation are PH 7.31. PaCO2 60, PaO2 104, SPO2 98%, HCO3 23. To normalize the client’s ABG finding, which action is required?A.)Report the results to the healthcare provider.B.)Increase ventilator rate.C.)Administer a dose of sodium carbonate.D.)Decrease the flow rate of oxygen. B
     The mother of the 12- month-old with cystic fibrosis reports that her child is experiencing increasing congestion despite the use of chest physical therapy (CPT) twice a day, and has also experiences a loss of appetite. What instruction should the nurse provide?A.)Perform CPT after meals to increase appetite and improve food intake.B.)CPT should be performed more frequently, but at least an hour before meals.C.)Stop using CPT during the daytime until the child has regained an appetite.D.)Perform CPT only in the morning, but increase frequency when appetite improves. B
     The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension?
     A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (HbA1c) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale with insulin aspart q6h are prescribed. What action should the nurse include in this client’s plan of care?A.)Fingerstick glucose assessment q6h with mealsMix bedtime dose of insulin glargine with insulin aspart sliding scale doseB.)Review with the client proper foot care and prevention of injury C.)Do not contaminate the insulin aspart so that it is available for iv useD.)Coordinate carbohydrate controlled meals at consistent times and intervals E.)Teach subcutaneous injection technique, site rotation and insulin management A,B,D,E
     Which problem reported by a client taking lovastatin requires the most immediate fallow up by the nurse?A.)Diarrhea and flatulence B.)Abdominal cramps C.)Muscle pain D.)Altered taste C
     While assessing a client’s chest tube (CT), the nurse discovers bubbling in the water seal chamber of the chest tube collection device. The client’s vital signs are: blood pressure of 80/40 mmHg, heart rate 120 beats/minutes, respiratory rate 32 breaths/minutes, oxygen saturation 88%. Which interventions should the nurse implement? SATAA.)Provide supplemental oxygenB.)Auscultate bilateral lung fieldsC.)Administer a nebulizer treatmentD.)Reinforce occlusive CT dressingE.)Give PRN dose of pain medication A,B,D
     Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client’s wrist restraints to the movable portion of the client’s bed frame. What action should the nurse take before leaving the room?A.)Ensure that the knot can be quickly released.B.)Tie the knot with a double turn or square knot.C.)Move the ties so the restraints are secured to the side rails.D.)Ensure that the restraints are snug against the client’s wrist. A
     Oral antibiotics are prescribed for an 18-month-old toddler with severe otitis media. An antipyrine and benzocaine-otic also prescribed for pain and inflammation. What instruction should the nurse emphasize concerning the installation of the antipyrine/benzocaine otic solution?A.)Place the dropper on the upper outer ear canal and instill the medication slowly.B.)Warm the medication in the microwave for 10 seconds before instilling.C.)Keep the medication refrigerated between administrations.D.)Have the child lie with the ear up for one to two minute after installation. D
     An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide?A.)Limit the intake of high calorie foods.B.)Eat meals at the same time daily.C.)Maintain a low protein diet.D.)Restrict daily fluid intake. D
     The nurse inserts an indwelling urinary catheter as seen in the video what action should the nurse take next?A.)Remove the catheter and insert into urethral openingB.)Observe for urine flow and then inflate the balloon.C.)Insert the catheter further and observe for discomfort.D.)Leave the catheter in place and obtain a sterile catheter. D