HESI EXIT RN V3 EXAM (2024 / 2025) [ NEW All 160 Qs & As Included - Guaranteed Pass A+!!! (All Brand New Q&A )

HESI EXIT RN V3 EXAM (2024 / 2025) [ NEW All 160 Qs & As Included – Guaranteed Pass A+!!! (All Brand New Q&A )

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

The nurse is has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?A) Nutrition B) Elimination C) ActivityD) Safety 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 perspective D) Conclusions are based on previous experiences They are able to think logically in organizing factsRationale: 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 hazards B) Place the child on the side C) Restrain the childD) Give the prescribed anticonvulsant 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 asleep B) Expression of persistent suicidal thoughtsC) Lack of enjoyment in usual pleasuresD) Reduced senses of taste and smell 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 secretions C) Assist client to turn, deep breathe and coughD) Monitor oxygen saturation 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 significant for this client?A) Compulsive behaviorB) Sense of impending doom C) Fear of flyingD) Predictable episodes 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, clings to her and begins to cry. What would be the initial action by the nurse?A) Arrange to change client care assignments B) Explain that this behavior is expectedC) Discuss the appropriate use of “”time-out””D) Explain that the child needs extra attention” Explain that this behavior is expected
A 15 year-old client with a lengthy confining illness is at risk for altered growth and development of which task?A) Loss of controlB) InsecurityC) DependenceD) Lack of trust 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 play C) “”Dress-up”” clothes and propsD) Chess and television programs” Sports and games with rules
“The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is A) “”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.””” 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.””” 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 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 pregnancy B) Focus on fetal development C) Anticipation of the birthD) Ambivalence about pregnancy 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 day C) Maintaining bed rest with bathroom privilegesD) Performing chest physiotherapy twice a day Increasing oral fluid intake to 3000 cc per day
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 sentences C) A 24 month-old who cries during examinationD) A 30 month-old only drinking from a sip cup 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 tests B) Ask questions during practice C) Allow another diabetic to assistD) Observe a return demonstration 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 pillows B) Apply support stockings C) Apply warm compressesD) Maintain complete bed rest 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 to this nurse is which child? A) Congenital cardiac defectsB) An acute febrile illness C) Prolonged hypoxemiaD) Severe multiple trauma 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 center C) A physical therapist from the rehabilitation agencyD) Another client with diabetes mellitus and takes insulin An occupational therapist from the community center
A priority goal of involuntary hospitalization of the severely mentally ill client isA) Re-orientation to reality B) Elimination of symptomsC) Protection from harm to self or others Protection from harm to self or 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 motion C) AerobicD) Isotonic 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 report A) Loss of consciousnessB) Feeding problems C) Poor weight gainD) Fatigue with crying 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 examination B) 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 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 perfusion B) Risk for fluid volume deficit C) High risk for hemorrhageD) Risk for infection 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 repair B) 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 field C) Shallow respirationsD) Tonic-clonic seizures 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 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 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 defibrillator C) Procedure that compresses plaque against the wall of the diseased coronary artery to improve blood flow D) Non- invasive radiographic examination of the heart 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 Institute seizure precautions
Following mitral valve replacement surgery a client develops PVC’s. The health care provider orders a bolus of Lidocaine followed by a continuous Lidocaine infusion at a rate of 2 mgm/minute. The IV solution contains 2 grams of Lidocaine in 500 cc’s of D5W. The infusion pump delivers 60 micro drops/cc. What rate would deliver 4 mgm of Lidocaine/ minute?A) 60 microdrops/minute B) 20 microdrops/minute C) 30 microdrops/minute D) 40 microdrops/minute 60 microdrops/minute Rationale: 2 gm=2000 mgm2000 mgm/500 cc = 4 mgm/x cc2000x = 2000 x= 2000/2000 = 1 cc of IV solution/minute CC 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 the nurse perform first?A) Review the client’s weight pattern over the yearB) Ask the mother to record her diet for the last 24 hours C) Encourage her to talk about her view of herselfD) Give her several pamphlets on postpartum nutrition Encourage her to talk about her view of herself
To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse wouldA) Assist the client to use the bedside commode B) Administer stool softeners every day as ordered C) Administer anti dysrhythmics prn as orderedD) Maintain the client on strict bed rest 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 frequently B) Use a heat lamp to reduce the drying timeC) Handle the cast with the abductor barD) Turn the child as little as possible 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 degrees B) Encourage ambulation within 24 hoursC) Maintain in a flat position, logrolling as neededD) Encourage leg contraction and relaxation after 48 hours 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 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 folds 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 this problem is probably due to A) A cerebral vascular accidentB) Postoperative meningitis C) Medication reactionD) Metabolic alkalosis 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” “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 smokers C) Depo-Provera is convenient with few side effectsD) The IUD gives protection from pregnancy and infection 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.””” 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 daily 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 hour B) Periodic crying and irritability C) Vigorous sucking on a pacifierD) No measurable voiding in 4 hours 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 response due 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 thethings you’ve done.””” 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” 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 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 is normal for his age, as negativism is attempting to meet which developmental need?A) TrustB) InitiativeC) IndependenceD) Self-esteem” Independence
Which behavioral characteristic describes the domestic abuser?A) AlcoholicB) Over confidentC) High tolerance for frustrationsD) Low self-esteem 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.””” By prolonging breathing out with pursed lips the 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.””” 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.””” 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 fundus C) Offer a bedpanD) Check for perineal lacerations 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 weight B) Triple the birth weightC) Gain 6 ounces each weekD) Add 2 pounds each month 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 regulations B) 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 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 obstruction B) Has improved airway obstructionC) Needs to be suctionedD) Exhibits hyperventilation 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.””” 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 hostility C) Reunion wish or fantasyD) Feelings of alienation or isolation Feelings of alienation or isolation
A newborn has been diagnosed with hypothyroidism. In discussing the condition and treatment with the family, the nurse should emphasize A) They can expect the child will be mentally retardedB) Administration of thyroid hormone will prevent problems C) This rare problem is always hereditaryD) Physical growth/development will be delayed 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 advising C) Herbal preparationsD) Witchcraft potions 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 mobility C) Learning, creativity, and judgmentD) Balance, flexibility, and coordination 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 splotchy rash, 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 kinks D) Turn the television off and then assist client to use relaxation techniques 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 shakiness B) Reduced lower leg sensation C) Intense thirst and hungerD) Painful hematoma on thigh Diaphoresis and shakiness
he nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be A) Reduce fear and protect self-esteemB) Minimize anxiety and delay apprehensionC) Avoid conflict and leave unpleasant situationsD) Increase independence and communicate more often 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 gain B) Unchanged urine specific gravity C) Rapid protein excretionD) Decreased blood potassium 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 has A) Achieved developmental milestones at an erratic rateB) Delay in musculoskeletal developmentC) Displayed difficulty with speech developmentD) Delay in achievement of most developmental milestones 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 Mental confusion
Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure togetherwith pulmonary capillary wedge pressure with a pulmonary arterycatheter. This action by the nurse will assess A) Right ventricular pressureB) Left ventricular end-diastolic pressure C) Acid-Base balanceD) Coronary artery stability 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 rinse C) Wash and rinse the bed linens in hot waterD) Use air filters in the furnace system 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 breakdown C) Lubricate the tips of the cannula before insertionD) Maintain sterile technique when handling cannula 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 quickly C) Allow the client the time needed to dressD) Demonstrate methods on how to dress more quickly Allow the client the time needed to dress
The nurse is assessing a 12 year-old who has Hemophilia A. Which finding would the nurse anticipate?A) An excess of red blood cellsB) An excess of white blood cells C) A deficiency of clotting factor VIIID) A deficiency of clotting factors VIII and IX 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 about A) Alcohol use during pregnancyB) Usual nutritional intakeC) Family genetic disorders D) Maternal and paternal ages 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 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 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.””” 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 ) Elevated creatinine phosphokinase (CPK )
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 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 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 pain B) Muscle spasms will be relievedC) Mobility will be managed as toleratedD) Tissue perfusion will be maintained Tissue perfusion will be maintained
The nurse would expect which eating disorder to have the greatest fluctuations in potassium?A) Binge eating disorder B) Anorexia nervosaC) BulemiaD) Purge syndrome 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 problems B) AmenorrheaC) Electrolyte imbalanceD) Blood disorders Amenorrhea
The nurse is planning care for a client with increased intracranial pressure. The best position for this client isA) Trendelenberg B) ProneC) Semi-FowlersD) Side-lying with head flat 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 extremities B) Negative Ortlani responseC) Lengthened leg of affected sideD) Irregular hip symmetry 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 on this assessment data?A) Impaired gas exchange related to acute infection and sputum productionB) Ineffective airway clearance related to sputum production and ineffective cough C) Ineffective breathing pattern related to acute infectionD) Anxiety related to hospitalization and role conflict 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 damage B) Moderate anemiaC) Renal tubule damageD) Growth impairment 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 assignments B) Clarify reasons for current assignments C) Help staff see the complexity of issuesD) Facilitate creative thinking on staffing 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 muscle B) Potential circulatory overloadC) Left ventricular overloadD) Electrolyte imbalance 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) Lethargy B) Agitation C) AtaxiaD) Hearing loss 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.””” 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 neuropathy C) Altered nutrition: less than body requirementsD) Fluid volume excess: ascites 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 restlessness C) Distended neck veinsD) Use of accessory muscles 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 membrane B) Irritability, rhinorrhea, and bulging tympanic membraneC) Diarrhea, retracted tympanic membrane and enlarged parotid glandD) Vomiting, pulling at ears and pearly white tympanic membrane 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 delays C) Prevention of infectionD) Maintenance of adequate nutrition 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 sleep B) Do not allow anyone to smoke in the homeC) Follow recommended immunization scheduleD) Be sure to check infant every one hour 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 collapse B) Reduces the potential for shockC) Reduces the intensity of bladder spasmsD) Prevents bladder atrophy 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 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 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 1 C) Primagravida 1, Para 1D) Gravida 2, Para 1 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 all those 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 asthma D) Impaired gas exchange related to broncho constriction and mucosal edema” 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 recumbent C) Semi-FowlerD) Supine Semi-Fowler
While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?A) Positive Homan’s sign B) Fever and chillsC) Dyspnea and coughD) Sensory impairment Dyspnea and cough
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?A) Jaundice evident at 26 hours B) Hematocrit of 55%C) Serum bilirubin of 12mgD) Positive Coomb’s test Serum bilirubin of 12mg
“The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed (“”knocked out””). After recovering the tooth, the initial response should be toA) Rinse the tooth in water before placing it in the socketB) Place the tooth in a clean plastic bag for transport to the dentistC) Hold the tooth by the roots until reaching the emergency roomD) Ask the child to replace the tooth even if the bleeding continues” Rinse the tooth in water before placing it in the socket
The nurse is caring for a 4 year-old child with a greenstick fracture. In explaining this type of fracture to the parents, the best response by the nurse should be that A) A child’s bone is more flexible and can be bent 45 degrees before breakingB) Bones of children are more porous than adults and often have incomplete breaks C) Compression of porous bones produces a buckle or torus type breakD) Bone fragments often remain attached by a periosteal hinge Bones of children are more porous than adults and often have incomplete breaks
During the beginning shift assessment of a client with asthma and is receiving oxygen per nasal cannula at 2 liters per minute, the nurse would be most concerned about which unreported finding? A) Pulse oximetry reading of 89%B) Crackles at the base of the lungs on auscultationC) Rapid shallow respirations with intermittent wheezesD) Excessive thirst with a dry cracked tongue Rapid shallow respirations with intermittent wheezes
During the care of aclient with Legionnaire’s disease, which finding would require the nurse’s immediate attention? A) Pleuritic pain on inspirationB) Dry mucus membranes in the mouthC) A decrease in respiratory rate from 34 to 24D) Decrease in chest wall expansion Decrease in chest wall expansion
A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a A) Chest x-rayB) Blood culture C) Sputum cultureD) PPD intradermal test PPD intradermal test
The nurse is assigned to a client with Parkinson’s disease. Which findings would the nurse anticipate?A) Non intention tremors and urgency with voiding B) Echolalia and a shuffling gaitC) Muscle spasm and a bent over postureD) Intention tremor and jerky movement of the elbows Echolalia and a shuffling gait
Which of these statements by the nurse is incorrect to use to reinforce information about cancers to a group of young adults?A)You can reduce your risk of this serious type of stomach cancer by eating lots of fruits and vegetables, limiting all meat, and avoiding nitrate-containing foods.B) Prostate cancer is the most common cancer in American men with results to threaten sexuality and life.C) Colorectal cancer is the second-leading cause of cancer-related deaths in the United States.D) Lung cancer is the leading cause of cancer deaths in the United States. Yet it’s the most preventable ofall cancers. It is recommended that only red meat limited for the prevention of stomach cancer
A 67 year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infraction (MI). The priority nursing diagnosis for this client during the immediate 24 hours isA) Constipation related to immobility B) High risk for infectionC) Impaired gas exchangeD) Fluid volume deficit Impaired gas exchange
“With an alert of an internal disaster and the need for beds, the charge nurse is asked to list clients who are potential discharges within the next hour. Which client should the charge nurse select?A) An elderly client who has had type 2 diabetes for over 20 years, admitted with diabetic ketoacidosis 24 hours agoB) An adolescent admitted the prior night with Tylenol intoxicationC) A middle aged client with an internal automatic defibrillator and complaints of””passing out at unknown times”” admitted yesterdayD) A school age child diagnosed with suspected bacterial meningitis and was admitted at the change of shifts” An elderly client who has had type 2 diabetes for over 20 years, admitted withdiabetic ketoacidosis 24 hours ago
The nurse is assessing a newborn the day after birth. A high pitched cry, irritability and lack of interest in feeding are noted. The mother signed her own discharge against medical advice. What intervention is appropriate nursing care?A) Reduce the environmental stimuli B) Offer formula every 2 hoursC) Talk to the newborn while feedingD) Rock the baby frequently Reduce the environmental stimuli
A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child isA) High risk for infection related to vomitingB) Altered family processes related to chronic illnessC) Fluid volume deficit related to vomitingD) Risk for aspiration related to loss of consciousness Risk for aspiration related to loss of consciousness
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity? * A) BradycardiaB) Lethargy C) IrritabilityD) Vomiting Bradycardia
“A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the “”evil eye.”” The nurse should communicate to other personnel that the appropriate approach is toA) Touch the baby after looking at him B) Talk very slowly while speaking to him C) Avoid touching the childD) Look only at the parents” Touch the baby after looking at him
A client is admitted for COPD. Which finding would require the nurse’s immediate attention?A) Nausea and vomitingB) Restlessness and confusion C) Low-grade fever and coughD) Irritating cough and liquefied sputum Restlessness and confusion
A young adult male has been diagnosed with testicular cancer. Which of these statements by this client would need to be explored by the nurse to clarify information? A) This surgical procedure involves removing one or both testicles through a cut in the groin. My lymph nodes in my lower belly also may be removed.B) I have a good chance to regain my fertility later. However if I am concerned, I can have my sperm frozen and preserved (cryopreserved) before chemotherapy. C) If I have cancer at stage 3 it means I have less involvement of the cancer.D) After the surgical removal of a testicle, I can have an artificial testicle (prosthesis) placed inside my scrotum. This artificial implant has the weight and feel of a normal testicle. If I have cancer at stage 3 it means I have less involvement of the cancer.
A newly appointed nurse manager is having difficulties with time management.Which advice from an experienced manager should the new manager do initially? A) Set daily goals and establish priorities for each hour and each day.B) Ask for additional assistance when you feel overwhelmed.C) Keep a time log of your day in hourly blocks for at least 1 week.D) Complete each task before beginning another activity in selected instances. Keep a time log of your day in hourly blocks for at least 1 week.
“The nurse and a student nurse are discussing the specific points about infants born to HBsAg-positive mothers. Which of these comments by the student indicates a need for clarification of information?A) “”The infant will get the hepititis B vaccine (HepB) and the hepatitis B immune globulin within 12 hours at birth at separate injection sites.””B) “”The second dose can be given at 1 to 2 months of age.””C) “”The third dose should be given at least 16 weeks from the second dose.””D) “”The last dose in the series is not to be given before age 24 weeks.””” the third dose should be given at least 16 weeks from the second dose
A 74 year-old male is admitted due to inability to void. He has a history of an enlarged prostate and has not voided in 14 hours. When assessing for bladder distention, the best method for the nurse to use is to assess forA) Rebound tendernessB) Left lower quadrant dullnessC) Rounded swelling above the pubisD) Urinary discharge Rounded swelling above the pubis
“Which one of the following statements, if made by the client, indicates teaching about Inderal (propranolol) has been effective?A) “”I may experience seizures if I stop the medication apruptly.””B) “” I may experience an increase in my heart rate for a few weeks.”” C) “” I can expect to feel nervousness the first few weeks.””D) “” I can have a heart attack if I stop this medication suddenly.””” I can have a heart attack if I stop this medication suddenly
A 6 month-oldinfant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents toA) Gently rub the skin with a cotton swab to relieve itchingB) Place the favorite books and push-pull toys in the cribC) To check every few hours for the next day or 2 for swelling in the baby’s feetD) Turn the baby with the abduction stabilizer bar every 2 hours To check every few hours for the next day or 2 for swelling in the baby’s feet
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?A) Right ventricle, left ventricle, right atrium, left atrium B) Left ventricle, right ventricle, left atrium, right atrium C) Right atrium, right ventricle, left atrium, left ventricle D) Right atrium, left atrium, right ventricle, left ventricle Right atrium, right ventricle, left atrium, left ventricle
The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?A) Confront the nurse about the suspicions in a private meetingB) Schedule a staff conference, without the nurse present, to collect information C) Consult the human resources department about the issue and needed actionsD) Counsel the employee to resign to avoid investigation Consult the human resources department about the issue and needed actions
The nurse would teach a client with Raynaud’s phenomenon that it is most important toA) Stop smoking B) Keep feet dry C) Reduce stressD) Avoid caffeine Stop smoking
The nurse is caring for a client with status epileptics. The most important nursing assessment of this client is A) Intravenous drip rateB) Level of consciousness C) Pulse and respirationD) Injuries to the extremities Level of consciousness
A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to noteA) High proteinB) Clear colorC) Elevated sed rateD) Increased glucose High protein
“The hospital is planning to downsize and eliminate a number of staff positions as a cost-saving measure. To assist staff in this change process, the nurse manager is preparing for the “”unfreezing”” phase of change. With this approach and phase the nurse manager shouldA) Discuss with the staff how to deal with any defensive behaviorB) Explain to the unit staff why change is necessaryC) Assist the staff during the acceptance of the new changesD) Clarify what the changes mean to the community and hospital” Explain to the unit staff why change is necessary
Which of these tests with frequency would the nurse expect to monitor for the evaluation of clients with poor glycemic control in persons aged 18 and older?A) A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than 3-month intervalsB) A glycosylated hemoglobin is to be obtained at least twice a yearC) A fasting glucose and a glycosylated hemoglobin is to be obtained at 3 months intervals after the initial assessmentD) A glucose tolerance test, a fasting glucose and a glycosylated hemoglobin should be obtained at 6-month intervals after the initial assessment A glycosylated hemoglobin (A1c) should be performed during an initial assessment and during follow-up assessments, which should occur at no longer than three-month intervals
“At a routine health assessment, a client tells the nurse that she is planning a pregnancy in the near future. She asks about preconception diet changes. Which of the statements made by the nurse is best?A) “”Include fibers in your daily diet.””B) “”Increase green leafy vegetable intake.”” C) “”Drink a glass of milk with each meal.””D) “”Eat at least 1 serving of fish weekly.””” Increase green leafy vegetable intake
“A client comes into the community health center upset and crying stating “”I will die of cancer now that I have this disease.”” And then the client hands the nurse a paper with one word written on it: “”Pheochromocytoma.”” Which response should the nurse state initially?A) Pheochromocytomas usually aren’t cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid).B) This problem is diagnosed by blood and urine tests that reveal elevated levels of adrenaline and noradrenaline.C) Computerized tomography (CT) or magnetic resonance imaging (MRI) are used to detect an adrenal tumor.D) You probably have had episodes of sweating, heart pounding and headaches.” Pheochromocytomas usually aren”t cancerous (malignant). But they may be associated with cancerous tumors in other endocrine glands such as the thyroid (medullary carcinoma of the thyroid).
A client with chronic congestive heart failure should be instructed to contact the home health nurse if which finding occurs?A) Weight gain of 2 pounds or more in a 48 hour period B) Urinating 4 to 5 times each dayC) A significant decrease in appetiteD) Appearance of non-pitting ankle edema Weight gain of 2 pounds or more in a 48 hour period
he nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia byA) Inserting a fenestrated catheter with a whistle tip without suctionB) Completing suction pass in 30 seconds with pressure of 150 mm HgC) Hyper oxygenating with 100% O2 for 1 to 2 minutes before and after each suction passD) Minimizing suction pass to 60 seconds while slowly rotating the lubricated catheter Hyper oxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass
A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be toA) Suggest 3 to 4 warm sitz baths per dayB) Cleanse the genitalia twice a day with soap and water C) Spray warm water over genitalia after urinationD) Apply heat or cold to lesions as desired Suggest 3 to 4 warm sitz baths per day
Which finding would be the most characteristic of an acute episode of reactive airway disease? A) Auditory gurglingB) Inspiratory laryngeal stridor C) Auditory expiratory wheezingD) Frequent dry coughing Auditory expiratory wheezing
Which tasks, if delegated by the new charge nurse to a unlicensed assistive personnel (UAP), would require intervention by the nurse manager? A) To help an elderly client to the bathroom.B) To empty a foley catheter bag.C) To bathe a woman with internal radon seeds.D) To feed a 2 year-old with a broken arm. To bathe a woman with internal radon seeds.
An 82 year-old client is prescribed eye drops for treatment of glaucoma. What assessment is needed before the nurse begins teaching proper administration of the medication?A) Determine third party payment plan for this treatment B) The client’s manual dexterityC) Proximity to health care servicesD) Ability to use visual assistive devices The client’s manual dexterity
The nurse uses the DRG (Diagnosis Related Group) manual toA) Classify nursing diagnoses from the client’s health history B) Identify findings related to a medical diagnosisC) Determine reimbursement for a medical diagnosisD) Implement nursing care based on case management protocol Determine reimbursement for a medical diagnosis
The community health nurse has been following the care for an adolescent with a history of morbid obesity, asthma, hypertension and is 22 weeks in to a pregnancy. Which of these lab reports sent to the clinic need to be called to the teens health care provider within the next hour?A) Hemoblobin 11 g/L and calcium 6 mg/dlB) Magnesium 0.8 mEq/L and creatinine 3 mg/dl C) Blood urea nitrogen 28 and glucose 225 mg/dlD) Hematocrit 33% and platelets 200,000 Magnesium 0.8 mEq/L and creatinine 3 mg/dl
“The nurse has identified what appears to be ventricular tachycardia on the cardiac monitor of a client being evaluated for possible myocardial infarction. The first action the nurse would perform is toA) Begin cardiopulmonary resuscitationB) Prepare for immediate defibrillationC) Notify the “”Code”” team and health care providerD) Assess airway breathing and circulation” Assess airway breathing and circulation
To prevent keratitis in an unconscious client, the nurse should apply moisturizing ointment to theA) Finger and toenail quicks B) EyesC) Perianal areaD) External ear canals Eyes
The nurse is caring for a child with cystic fibrosis. The nurse would anticipate that the child would be deficient in which vitamins?A) B, D, and KB) A,D,andKC) A, C, and D D) A, B, and C A,D,andK
“The nurse is teaching a 27 year-old client with asthma about management of their therapeutic regime. Which statement would indicate the need for additional instruction?A) “”I should monitor my peak flow every day.””B) “”I should contact the clinic if I am using my medication more often.””C) “”I need to limit my exercise, especially activities such as walking and running.””D) “”I should learn stress reduction and relaxation techniques.””” I need to limit my exercise, especially activities such as walking and running
While caring for a child with Reye’s Syndrome, the nurse should give which action the highest priority? A) Monitor intake and outputB) Provide good skin careC) Assess level of consciousnessD) Assist with range of motion Assess level of consciousness
A newborn presents with a pronounced cephalic hematoma following a birth in the posterior position. Which nursing diagnosis should guide the plan of care?A) Pain related to periosteal injuryB) Impaired mobility related to bleedingC) Parental anxiety related to knowledge deficitD) Injury related to inter cranial hemorrhage Parental anxiety related to knowledge deficit
A confused client has been placed in physical restraints by order of the health care provider. Which task could be assigned to an unlicensed assistive personnel (UAP)?A) Assist the client with activities of daily living B) Monitor the clients physical safetyC) Evaluate for basic comfort needsD) Document mental status and muscle strength Assist the client with activities of daily living
“A client is scheduled to have a blood test for cholesterol and triglycerides the next day. The nurse would tell the clientA) “”Be sure and eat a fat-free diet until the test.””B) “”Do not eat or drink anything but water for 12 hours before the blood test.””C) “”Have the blood drawn within 2 hours of eating breakfast.””D) “”Stay at the laboratory so 2 blood samples can be drawn an hour apart.””” Do not eat or drink anything but water for 12 hours before the blood test
A client who is terminally ill has been receiving high doses of an opiod analgesic for the past month. As death approaches and the client becomes unresponsive to verbal stimuli,what orders would the nurse expect from the health care provider?A) Decrease the analgesic dosage by half B) Discontinue the analgesicC) Continue the same analgesic dosageD) Prescribe a less potent drug Continue the same analgesic dosage
Which of these clients would the triage nurse request for the health care provider to examine immediately?A) A 5 month-old infant who has audible wheezing and gruntingB) An adolescent who has soot over the face and shirtC) A middle-aged man with second degree burns over the right handD) A toddler with singed ends of long hair that extends to the waist A 5 month-old infant who has audible wheezing and grunting
“An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for trachea esophageal fistula. The mother asks:””When can the tube can be used for feeding?”” The nurse’s best response would be which of these comments? A) Feedings can begin in 5 to 7 days.B) The use of the feeding tube can begin immediately. C) The stomach contents and air must be drained first.D) The incision healing must be complete before feeding.” The stomach contents and air must be drained first.
A pre-term baby develops nasal flaring, cyanosis and diminished breath sounds on one side. The provider’s diagnosis is spontaneous pneumothorax. Which procedure should the nurse prepare for first? A) Cardiopulmonary resuscitationB) Insertion of a chest tube C) Oxygen therapyD) Assisted ventilation Insertion of a chest tube
The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?A) Extreme fatigue B) Increased appetite C) Intense itchingD) Constipation Extreme fatigue
The nurse is teaching a client with atrial fibrillation about the use of Coumadin (warfarin) at home. Which of these should be emphasized to the client to avoid?A) Large indoor gatherings B) Exposure to sunlight C) Active physical exerciseD) Foods rich in vitamin K Foods rich in vitamin K
A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy?A) Intraventricular hemorrhage B) Retinopathy of prematurity C) Bronchial pulmonary dysplasiaD) Necrotizing enterocolitis Retinopathy of prematurity
A nurse manager is using the technique of brainstorming to help solve a problem. One nurse criticizes another nurse’s contribution and begins to find objections to the suggestion. The nurse manager’s best response is toA) Let’s move on to a new action that deals with the problem.B) I think you need to reserve judgment until after all suggestions are offered. C) Very well thought out. Your analytic skills and interest are incredible.D) Let’s move to the ‘what if…’ as related to these objections for an exploration of spin off ideas. Let’s move to the ‘what if…’ as related to these objections for an exploration of spin off ideas.
The nurse is caring for an acutely ill 10 year-old client. Which of the following assessments would require the nurses immediate attention?A) Rapid bounding pulseB) Temperature of 38.5 degrees Celsius C) Profuse DiaphoresisD) Slow, irregular respirations Slow, irregular respirations
“A child is diagnosed with poison ivy. The mother tells the nurse that she does not know how her child contracted the rash since he had not been playing in wooded areas. As the nurse asks questions about possible contact, which of the following would the nurse recognize as highest risk for exposure?A) Playing with toys in a back yard flower gardenB) Eating small amounts of grass while playing “”farm””C) Playing with cars on the pavement near burning leavesD) Throwing a ball to a neighborhood child who has poison ivy” Playing with cars on the pavement near burning leaves
The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?A) Weight reduction B) Stress management C) Physical exerciseD) Smoking cessation Smoking cessation
“The nurse is caring for a 5 year-old child who has the left leg in skeletal traction. Which of the following activities would be an appropriate diversional activity?A) Kicking balloons with right legB) Playing “”Simon Says””C) Playing hand held gamesD) Throw bean bags” Playing hand held games
The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?A) Expiratory wheezes B) Blurred visionC) AcitesD) Dilated pupils Acites

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